P4A091: A Quality Improvement Initiative to Standardize and Improve Family Centered Rounds Through Use of Best-practice Checklists

Purpose/Objectives: Family Centered Rounds (FCR) best-practice communication checklists have been shown to improve patient and family satisfaction, communication, and patient safety (1,2). No reliable local data existed at our institution regarding the quality of FCR, and anecdotal reports suggested wide variability in FCR practice on our pediatric hospital medicine (PHM) service. Our project aimed to increase the percentage of best-practice FCR checklist items completed on our PHM service by 50% over 5 months.

Design/Methods: An interdisciplinary team used the Model for Improvement to collect baseline data, identify key drivers, and implement PDSA cycles. We chose 8 best-practice checklist items to target (Figure 1). Data was collected by direct observation of FCR on the pediatric hospital medicine service using a structured assessment tool developed by the QI team reflecting evidence-based FCR best practices. In addition, we assessed family engagement during FCR using a previously published tool (3) and administered a Likert-scale survey assessing family satisfaction for each observed FCR. Our primary outcome was the percentage of checklist items completed per FCR opportunities with secondary outcome measures of family engagement and satisfaction. Our primary balancing measure was rounding length. Our interventions included FCR best practice education (medical students, residents, nurses, and attendings), FCR information sheets placed in families’ admission folders, visual checklist reminders, and targeted FCR teaching at the start of rounds. Continuous weekly data review of primary outcome and completion rates of individual checklist items were plotted on statistical process control charts to evaluate for special cause variation or trends requiring further investigation.

Results: We observed 145 FCR encounters. Baseline data showed that we completed an average of 48% of FCR checklist items. At baseline, the lowest completion rates were seen in C1 (18%), C2 (25%), C6 (18%), C8 (0%). The highest completion rates were seen in C3 (87.5%), C4 (100%), C5 (100%), and C7 (75%). After focused interventions, we saw increases in completion rates of C1 (70%), C2 (65%), and C6 (49%). Our primary outcome demonstrated a positive center line shift from 48% to 64% (Figure 2). Median round length was unchanged and rounding length did not increase with greater inclusion of checklist items. Sub-group analysis demonstrated that completion of C1 during FCR led to significantly greater active family engagement behaviors and higher family-reported scores of shared decision making during FCR.

Conclusion/Discussion: We increased completion rates of best-practice FCR checklist items by 33%, particularly in prompting family for updates/questions at the start of the discussion, prompting nurses for updates/questions at bedside, and discussing contingency planning without increasing length of rounding. Future PDSA cycles will work to focus on reinforcing best-practice checklists with new rotators, addressing disparities in FCR outcomes seen in English versus Spanish FCRs, and increasing nursing presence at bedside.