Considerations for Pediatric Leader Rounding

Leader rounding allows staff to proactively connect with patients and families. It fosters unit communication and reinforces a commitment to family-centered care and excellence in patient experience. Along with identifying opportunities for improvement, leader rounding also provides a way to recognize individual staff members who receive positive patient feedback.

At NRC Health, we recognize that pediatric environments pose a unique challenge to the traditional leadership rounding model. In pediatric settings, leaders must assess when it’s appropriate to round, who to round on, and how to tailor the conversation to the patient and family needs. Rounding technology should empower leaders to make these decisions during leader rounds.

Consider the following questions as you build your leader rounding program for pediatrics:

What time is appropriate to round on each unit? 

Many facilities are designating a “sacred hour” as a time for leaders to round on patients (and employees) prohibiting meetings or other activities that pull leaders off their units. Finding a single time that aligns with the workflow on each individual unit is nearly impossible. Sometimes the needs of acute care adult units take priority over the needs in the Women’s and Children’s tower or units.

Nearly every leader can tell you their most “productive” time of day. If the sacred hour falls during that time, attention to other responsibilities may suffer. If planned rounding intervals overlap with peak times for medications or physician visits, leader rounds may represent distractions or interruptions that impact patient safety and satisfaction. It also doesn’t make sense to round in some pediatric areas when parents or family are not present. Find a time that works for your patients and schedule and put it on your calendar.

What are the expectations for rounding when parents or family members are not present? 

Most pediatric areas are positioned for parents to stay 24/7 with their child, if desired. But even if they want to stay, some parents have obligations at work or other small children at home who need their time and attention. If parents are not present, it may not be appropriate for leaders to attempt a round on children or adolescents, or different question sets may be needed. Leader questions can be leveled for children or written to focus on family rounds instead.

Leaders may need to use the leader round to assess the environment for safety risks or to audit staff compliance with standardized processes or expectations. Environmental assessments may vary depending on the level of care, i.e. critical care versus general pediatrics, or the unique risks or processes being used.

Are there considerations for leader rounding when staff members are working arm-in-arm with parents? 

No one cares more about the safety and care of sick children than their parents. Using leader rounds to capture the observations or impressions of parents who see staff members in action is an often-overlooked opportunity. Adding customized questions to leader rounds that invite candid feedback from parents can uncover care trends or concerns that would otherwise go unnoted. This is especially important when children are admitted for long periods of time.

Rounding in the absence of parents is also an opportunity to validate key nursing practices such as bedside shift report, white board documentation, central line care, skin assessment and infection prevention.

How do we tailor the frequency and content of questions for leader rounding for long-term patients?

Not all “long-term patients” are created equal and that is especially true in pediatrics. Critically ill neonates and infants have very different safety needs from older children and adolescents. The comfort and satisfaction of their parents is the primary goal. Mapping the care and concerns for critically ill children and their parents over time can guide the development of a leader rounding program that anticipates their needs at each phase of care. Content, frequency, and response types may all need to be periodically revised.

Leader rounding in pediatrics presents an opportunity to build a better experience by respecting the needs of the whole family, demonstrating empathy and caring, maintaining trust and opening lines of communication. Using these and other techniques make it possible to build a sustainable and impactful nurse leader rounding program in pediatric settings.

At NRC Health, we partner with our hospitals to understand the unique needs of their patient populations to customize solutions for each unit. Our approach, along with insightful analytics and support for process improvement, empower NRC Health users to accelerate goal achievement in patient experience, staff engagement, and consistency of care.

Recognizing that your primary focus during leadership rounding will be on effectively engaging the family to gain insights into their child’s healthcare experience is a pivotal component in establishing a meaningful leadership rounding routine. This diverges from the conventional leadership rounding approach, which primarily centers around engaging the adult patient when they are capable of participating.

One of the most significant hurdles can be pinpointing a moment when the family is available. Inquire with any healthcare provider at a children’s hospital, and they will affirm that family members are not consistently present. Various factors can keep families away from the bedside, and even when they are present, it’s crucial to identify a suitable time for conducting rounds that accommodates their availability.

Organizations that have had success with rounding on children tend to have a multi-modal approach to leadership rounds. First, they try to visit the family in-person as the primary way to engage the family. If your organization does grand physician rounds with family, try to connect with the family briefly to learn what their schedule is for the day and either connect with them after grand rounds or plan for another date and time to talk. Second, some organizations may reach out with a phone call and email to connect with the family at a time convenient for both parties.

Some organizations shy away from using the phone as a means to doing a leadership round because they are worried family will think something has gone wrong. Change the stigma around phone calls to be something that is seen as proactive and not an indication of a decline in the patient’s condition. Advertise your leadership rounding process early and often so family can expect a phone call if a connection in person can’t happen.

Organizations should evaluate the appropriateness of conducting leadership rounds on pediatric patients based on the patient’s age. Some organizations may opt to have a clear policy that leadership rounding must be done only when family is present.

Others may decide that rounding on older pediatric populations without a parent involved would be acceptable. Having a policy will give your rounders clear guidance on if they should seek out family if they are not present or are free to engage the older pediatric patient.

The frequency of leadership rounding required to achieve high patient satisfaction scores is not a one-size-fits-all answer and may vary depending on various factors such as the size of the unit, the patient population, and the specific goals and priorities of the organization.

The first question to answer when establishing a leader rounding goal is to determine your end game: are you seeking to influence every patient’s experience through this process or do you hope to obtain first hand feedback from a random sample size to learn, grow and improve upon?

If your goal is to impact patient satisfaction scores individually then it’s important that every patient be visited by a leader during their stay. If you aim to use the results of rounding more for process improvement, therefore implementing interventions based on the feedback from rounds to move the needle on HCAHPS then a lower frequency or target could be set.

We have seen some organizations establish rounding goals based on how many staff are available to round each day and the time commitment expected for rounds. For instance, if you have three leaders each day to do rounds, each will spend one hour rounding, and the round is expected to take 10 minutes. In this case, you would have a unit-based goal of rounding on 18 patients a day. If the unit holds 24 patients, they may end up rounding on about 75% of the census each day if the unit is full.

Children’s hospitals frequently provide a wide array of supplemental services aimed at enhancing the well-being of their young patients. While we advise maintaining a primary focus on rounding questions related to the outcomes of HCAHPS key drivers or quality/safety initiatives, there is merit in occasionally inquiring with families about their awareness of, or interest in, additional child and family support services for their child. This approach can effectively boost engagement with these services and ultimately elevate patient satisfaction levels. Some examples may be: chaplain, service dog, child-life services, reiki therapy, parent support groups, and tutoring.

As evident, children’s hospitals exhibit both commonalities and distinctions when compared to adult healthcare settings concerning the approach to leadership rounding on patients. When initiating your leader rounding program, it is advisable to remain adaptable and willing to adjust the process or approach based on the feedback received from your rounding team. With time, you’ll discover the optimal blend of decisions that align with your organization’s specific needs.

The epiphany that nearly all medical-surgical patients are awake, alert, and able to actively participate in a leader round is a valid reason to consider alternative rounding models and compliance goals for these leaders. Time studies might help to estimate the average time to complete a purposeful round by a leader. A ten-question rounding menu that includes 2-3 questions for admission, 3-4 questions for stable patients, and 3-4 for patients heading home can maximize leader rounding time and allow for all data to be tracked and analyzed in one platform.

Alternative questions for patients who stay beyond the average length of stay for the unit could be provided in a separate question set, because longer lengths of stay create a greater risk of safety harm events or patient dissatisfaction. These patients might become the priority when leader rounding time is limited. Compliance goals for leaders must consider all these factors. Even criteria for documenting rounding attempts and environmental assessments might need to be re-evaluated.

Another key process in the care of medical-surgical patients is communication with family and friends. Alert and awake patients often will have many visitors and the healthcare team must explore ways to engage these valuable resources to support both safety and patient satisfaction during the stay. Family members want to keep an eye on their loved one, but they also want to help. By orienting them to assist with comfort measures like fresh iced water, warm blankets, and snacks can save staff time. Teaching them how to safely ambulate a patient by using a gait belt keeps the patient safer and starts the process for safe ambulation after the patient returns home. Engaging visitors early in the process furthers the trust of the team to care for their loved one’s safety.

Using the friends and family portal makes it easy for others to check on the patient securely over any internet connection when they can’t be at the hospital. Reinforcing the availability of the portal, what information it contains, and how to use it is an important part of a leader round. Rounding on visitors can provide valuable information based on their observations, ideas, and needs as well as their use and satisfaction with the portal. When completing post-discharge satisfaction surveys, patients are often influenced by the perceptions of family members, so this is an important population to keep in mind.

Each Medical-surgical unit is a unique microcosm of practice and services within the division of acute care. They differ from each other and they differ from critical care, cardiology, women’s and children’s or rehabilitation. It is very important to plan leader workload and activities around that uniqueness to prevent leader burnout and turnover, and to position leaders to successfully support their team and the patients they serve.

1Becker’s Hospital Review (2013), Patient-Driven Care Beats Patient-Centered Care: Here’s Why.  Downloaded 12/09/2019 from https://www.beckershospitalreview.com/quality/patient-driven-care-beats-patient-centered-care-here-s-why.html