Ward Rounds - Ideas for Making Them Better

Originally published in Sitaram Bhartia Blog (July 9, 2015):

Author: Abhishek Bhartia 
Director, Sitaram Bhartia Institute of Science and Research

"A leader must be able to define an ideal state and get people enthused about moving towards it" said Dr Prab Prabhakar, a consultant paediatric neurologist at the Great Ormond Street Hospital (GOSH), as we sat down together in my office. I had met Dr Prabhakar a few months ago in London and was pleased that he was taking a day out of his vacation in India to visit us.

"Would you feel comfortable raising an issue if you noticed something wasn't quite right? How do we, as doctors, learn to see things from the patient's perspective? How do you develop a culture where you feel responsible for what happens in the whole hospital, not just your unit?" These were some of the questions he asked members of our paediatric unit before hearing a presentation on ongoing quality improvement work in the department.

Before long we were in the auditorium to hear his talk on improving ward rounds. Dr Prabhakar related examples from his actual ward rounds at GOSH.

LISTEN and SILENT have the same alphabets

"A 3.5 year old child with a serious genetic immune disease had been admitted to the hospital over the weekend and I had to see him on Monday to talk to the family about the possible causes of the current acute deterioration; the differential diagnosis included three possible reasons.... How long do you think this consultation is going to take?" asked Dr Prabhakar.

Estimates from the audience ranged from 20 minutes to a full hour.

"It took me 2 and half hours!" said Dr Prabhakar. "I thought it would take between 30-45 minutes. But no one had told me that both parents were lawyers. The father had a notebook and was documenting everything. The parents had already put in a complaint against the hospital. And most importantly the father was depressed! How can you ever prepare for this?"

"In the first one hour I hardly spoke."

"Should I have just given them the differential diagnosis and told them about the tests that need to be done? Is it my responsibility to listen to their complaints? Should I have terminated this conversation and simply told them about the neurological condition of the child?"

"I think the one hour I spent was the golden hour. It said to them that this doctor cares, he is willing to give his time to listen. If I had stopped them and told them what I had to say, I bet nothing would have gone in. Because I took 2.5 hours on Monday, it took me 15 minutes on Tuesday, 10 minutes on Wednesday, and on Friday before I left it took only 5 minutes. By Wednesday and Thursday the writing stopped! Not so with other specialists - writing is still going on, still having one hour conversations."

"What I learnt is you never know what you are going to encounter. But by taking time to listen to the family, the narrative from their point of view, hearing their story, their anger, and their feelings, we can meet our fundamental duty of empathizing with them and clearly communicating what we were trying to say."

You have to go where the mother is to be heard

The next case that Dr Prabhakar picked was of an 18 year old single mother with a seriously ill child in the hospital. She sat withdrawn on her chair, unaware that her child had lost half his brain.

"She is sitting in a place of safety, where she knows what is happening, she doesn't know what is happening in the rest of the room. We can't talk to her from this space, we have to go to her, acknowledge she is in a different place. Looking someone in the face is quite a powerful thing to do."

Taking responsibility for decisions as a team

As a third case, Dr Prabhakar discussed a 3 year old who had come in for an angiogram. This child had an experimental treatment and now was now suffering serious side effects that had left him blind and unable to walk without help. He was needle phobic; all he knew was that people held his hand and then there was a big poke. The healthcare team had sited a canula after much screaming and shouting and 10 minutes later the child had pulled out. Dr Prabhakar had to decide whether they needed to re-site the canula?

He decided that they didn't need the canula! And he asked why they had put in a canula in the first place? The decision had been taken by a colleague five months ago, in different circumstances, and this time around there was no one senior to check the plan before executing!

"How do you communicate and take responsibility for such decisions as a team?" asked Dr Prabhakar, highlighting an important problem in care delivery in hospitals.

Placing equal importance on showing respect as on making a clinical diagnosis

What struck me most about Dr Prabhakar was how he embodied the qualities of an ideal consultant - he seemed to be not just an expert clinician but also outstandingly empathetic towards the patient, family, staff, junior doctors and colleagues. I found myself thinking that this was different from how even some of our best doctors come across in India. While clinical skills for diagnosing diseases and performing procedures are often highly developed in our better consultants, their ability to communicate and empathize with different stakeholders often leaves much scope for improvement. This may be because of high pressure of volumes in teaching hospitals and as Dr Rinku Sen Gupta Dhar, consultant obstetrician-gynaecoligst, pointed out, "It's hard to display compassion when you have to see 45-50 patients in two hours in the OPD". But undoubtedly there are other reasons too. Prof Vinod Paul, head of paediatrics at AIIMS said, it could be related to how we select doctors - relying on multiple-choice questions. And Dr Prabhakar pointed out, it could be because "we have never been told that showing respect to a man from a village is as important as finding a mitral stenosis murmur."

The dignity of the consultant that Dr Prabhakar displayed in his examples was made possible not just by his personal qualities but by being in a system that permitted such behaviours to be practised. If medicine has to live up to the expectations of its stakeholders - patients, families, doctors, and others - senior consultants will have to provide clinical leadership that values courtesy and care as much as diagnosis and treatment.

Related Links:
ACS National Surgical Quality Improvement Program - Pediatric
2. ACSQHC - Patient and Consumer-Centered Care
3. AHRQ - AHRQ Releases New Guide to Help Hospitals Engage Patients and Families in Their Health Care
4. AHRQ PSNet - The Role of the Patient in Safety
5. BCPSLS - Patient's View: Seeing safety through the eyes of families at BC Children's Hospital
6. Beth Daley Ullem - Biography
7. Bridgekeeper - Partnerships for Quality Healthcare
8. CAPHC - Knowledge Exchange Network (KEN) - Patient and Family Centred Care
9. CAPS - Advancing Patient and Family Engagement
10. CHA - 4 Quality Improvement Ideas Hospitals Can Implement - Improving Rounds with Communications Interventions
11. CHA - Children's Hospitals Offer Safety Tips for Patient Families During National Patient Safety Awareness Week
12. CHEO - Patient Safety Ambassadors Program and Family-activated Rapid Response Team
13. Children's Hospitals' Solutions for Patient Safety (SPS) - For Patients & Families
14. Children's Hospitals' Solutions for Patient Safety (SPS) - Hospital Resources
15. Cincinnati Children's - Implementing Patient- and Family-Centered Rounds
16. Cincinnati Children's - Increasing Patient Satisfaction by Moving Nursing Shift Report to the Bedside
17. Cincinnati Children's - MyChart - An Online Tool for Patients
18. Cincinnati Children's - Record Keeping and Forms - "All About Me Questionnaire"
19. CPSI - Member Videos and Stories
20. Danish Society for Patient Safety - Projects - Hello Healthcare
21. DFCI - Establishing Patient- and Family-Centered Care
22. Emmi Solutions healthcare communications - White Papers
23. Empowered Patient Coalition - Patient Education
24. Engaging Patients.org - Best Practices - Patient Engagement in Action Archive
25. Engaging Patients.org - Chrissie Blackburn
26. Health Care Blog - A Safety Checklist for Patients
27. Health Foundation - Patient Safety Briefing Film (to help patients look after themselves while in hospital) 
Hospital Impact - Patient Experience Defines Quality of Care
Hospital Impact - Respect: The Foundation for Quality Care
30. HPI - Resources - Rounding to Influence
31. HPOE/HRET/AHA - A Leadership Resource for Patient and Family Engagement Strategies
32. HSC Safety Forum Paediatric Collaborative - You Know Your Child Best poster
33. IHI - Person- and Family-Centered Care
34. IHI - Delivering Great Care: Engaging Patients and Families as Partners
35. IHI - Encouraging Patient Engagement and Participation
36. Imagine Project - Meet James (Jim) Conway - Imagine Project Special Guest Speaker
37. iMedicalApps 'Our Journey in the Hospital' app helps parents with children in the hospital
38. I-PASS Handoff Study - I-PASS Materials
39. IPFCC - Organizations Advancing Patient- and Family-Centered Care
40. IPFCC - Profiles of Change
41. IPFCC - Profiles of Patient and Family Advisors and Leaders - Margaret Murphy
42. IPFCC - Resources/Roadmaps - Advancing the Practice of Patient- and Family-Centered Care in Hospitals
43. IPFCC - Tools/Checklists - Tools to Foster the Collaboration with Patient and Family Advisors
44. John's Hopkins Children's Center - Better at the Bedside
45. John's Hopkins Children's Center - Patient and Family Centered Care
46. John's Hopkins Children's Center - Patient Safety Initiatives
47. Joint Commission - Speak Up: Prevent Errors in your Child's Care
48. Josie King Foundation - For Patients and Families
49. Justin's HOPE - Pediatric Safety Project
50. Louise H. Batz Patient Safety Foundation - Free Guides
51. Making it Safer Together (MiST) Paediatric Patient Safety Collaborative
52. Meds IQ - Sharing QI Resources for Paediatric Medication Safety - Supporting Patients
53. MIPS - It's Safe to Ask
54. MIPS - Patient Engagement
55. MIPS - Self-Advocacy for Everyone - S.A.F.E. Toolkit
56. National Pediatric Readiness Project (PRP) - Ensuring Emergency Care for all Children - Pediatric Readiness Toolkit
57. NHS Choices - Children in Hospital
58. NHS England - Children and Young people's patient safety expert group
59. NHS England - Patient Involvement - Transforming Participation in Health and Care
60. NHS England - Patient Safety
61. NHS Institute for Innovation and Improvement - Transforming Patient Experience
62. NICHQ - Patient and Family Engagement
63. NPSF - Education and Resources - For Patients and Families
64. NPSF - LLI Reports - Safety Is Personal: Partnering with Patients and Families for the Safest Care
65. Patient's Checklist - 10 Simple Hospital Checklists to Keep You Safe, Sane and Organized
66. Patients for Patient Safety Canada (PFPSC) - Resources
67. PIPSQC Blog - Bridging People and Places in Pediatrics
68. PIPSQC Blog - Don't just stand there - #ReACT! ReACT - the Respond to Ailing Children Tool 
PIPSQC Blog - I-PASS in Critical Care
70. PIPSQC Blog - Partnering with Parents to Save Children's Lives
71. PIPSQC Links - For Patients and Families
72. PIPSQC Presentations - Pediatricians Partnering with Patients and Families to Save Lives
73. PIPSQC Presentations - Protecting Children from Harm in Pediatrics - Lessons Learned from Parents
74. Partnership for Patients (PfP) - Patient and family Engagement
75. Partnership for Patients (PfP) - Resources - Patient and Family Engagement
76. PfP Resource Center - Patient and Family Engagement
77. PfP Resource Center - Pediatric Safety
78. PCORI - Bringing I-PASS to the Bedside: A Communication Bundle to Improve Patient Safety and Experience
79. PSQH - Patient- and Family - Centered Care: Advancing Quality and Safety with Bedside Rounding
80. P.U.L.S.E. - Education - Patient Safety Tips
81. RCPCH - Parent and Carer Resources
82. RCPCH - Quality Improvement and Clinical Audit
83. Re-ACT - the Respond to Ailing Children Tool - External Links
84. Re-ACT - the Respond to Ailing Children Tool - Parent/Carer Engagement
85. Roadmap for Patient and Family Engagement in Healthcare
86. Roadmap for Patient and Family Engagement in Healthcare - Resources
87. Safe Patient Resource Center - 20 Tips to Help Prevent Medical Errors in Children
88. SafeCare - Capacity Building - Patient Poster 
Situation Awareness for Everyone (S.A.F.E) Programme
90. Society for Participatory Medicine - Resources for Providers
91. TMIT - SafetyLeaders - CareBoards
92. UK Sepsis Trust - Acute Paediatric Toolkit - Paediatric Sepsis Six
93. U-M Health System - Patient and Family Centered Care (PFCC)
94. Virginia Mason - Virginia Mason CEO: Respect for people is essential for quality health care
95. Virginia Mason Blog - Deep cultural connection: Respect for people + patient safety
96. Virginia Mason Blog - Does respecting co-workers make patients safer?
97. Virginia Mason Blog - Respect for People: Building Block for Engaged Staff, Satisfied Patients
98. WHO - Patients for Patient Safety
99. WHO - Patient Safety - A-Z Index
100. WHO - Patient Safety - Implementing Change  

Related Publications:
ACSQHC - NSQHS Standard 1: Governance for Safety and Quality in Health Service Organisations
2. ACSQHC - NSQHS Standard 2: Partnering with Consumers
3. AHRQ - Guide to Patient and Family Engagement in Hospital Safety and Quality
4. But I told you she was ill! The role of families in preventing avoidable harm in children
5. Changes in Medical Errors after Implementation of a Handoff Program
6. Concepts for the Development of a Customizable Checklist for Use by Patients
7. CPSI - Harm to Healing: Partnering with Patients Who Have Been Harmed
8. Developing and evaluating the success of a family activated medical emergency team: a quality improvement report
9. Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report
10. Family-initiated dialogue about medications during family-centered rounds
11. Heart of Healing: When things go wrong in care - The family perspective
12. HPI - Rounding to Influence
13. HPOE/HRET/AHA - A Leadership Resource for Patient and Family Engagement Strategies
14. IAPO - Addressing Global Patient Safety Issues - An Advocacy Toolkit for Patients' Organizations
15. IHI - Partnering with Patients and Families to Design a Patient-and-Family-Centered health Care System
16. IHI - Planetree Patient-Centered Care Improvement Guide
17. Implementation of a "second victim" program in a pediatric hospital 
MHA Keystone Center - Michigan Hospital Resource Guide to Patient and Family Engagement
19. NPSF - Safety Is Personal: Partnering with Patients and Families for the Safest Care
20. NPSF - Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care
21. Patient Complaints and Adverse Surgical Outcomes
22. Patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families
23. Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians
24. Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect
25. RCPCH - Not Just a Phase - a guide to the participation of children and young people in health services
26. Roadmap for Patient and Family Engagement in Healthcare
27. SickKids - Involving children and families and promoting patient safety through the implementation of a nursing shift handover toolkit (Abstract #5521)
28. Targeted Interventions Improve Shared Agreement of Daily Goals in the Pediatric Intensive Care Unit
29. Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws
30. Virginia Mason - Leadership Journey in Health Care: Virginia Mason's Story
31. WHO - Patient Safety Tool kit
32. WHO - Exploring Patient Participation in Reducing Health Care Related Safety Risks