Dear Director: I’ve heard about rounding, but what exactly am I supposed to do—and why am I doing it?
Although I’ve blocked out most of the memories of my 3rd year med student internal medicine clerkship, the concept of going door to door checking on patients in the morning (and sometimes in the evening) is obviously a requirement for effective patient care. Sir William Osler was the first to bring 3rd year med students to the wards, started the first medicine residency, and is often credited with coining the term “rounds.” As residents at Johns Hopkins, we heard how Osler would take his students and residents from room to room “around” the Dome of the original hospital, teaching, quizzing, and challenging them to learn more. As an ER doc, I may check on patients in the ED or update them, but I don’t make the multi-hour rounds anymore (fortunately). Hospital leadership has taken the idea of medical patient rounds and turned them into their own beneficial activity, and as an ED director, I find rounding on docs, staff, and patients a critical tool to help manage the ED.
Where to Round
Long before I heard the term “executive rounding,” I used to wander around the ED and talk to docs as an excuse to get off my computer and escape my cubicle (office). It was really meaningful to me when a full-time urgent care doc told me how much he appreciated me coming over to talk to him and help fix “his” problems. Now that I’ve studied rounding, I better understand the different nuances and purposes of it.
While I’ll get into the actual questions and conversations shortly, it’s important to understand on whom to concentrate your focus. First, there’s ER rounding. I round on my docs and advanced practice providers in the ED on a very regular basis. But I also talk to the nurses. From time to time, I’ll also round on patients. Outside of the ED, there’s huge value in what I’ll call GI rounds. Actually, this is spending time in the doctor’s lounge (free food and coffee) to “round” on our colleagues in other departments. I do this less formally than how I round in the ED, but the bottom line is that I want to hear feedback and issues from docs outside the department before they go to administration. It’s also a good idea to take advantage of the time before or after meetings like MEC or other multidisciplinary meetings (critical care, STEMI, stroke) to talk to the other docs who attend. Though not as informal as the doctor’s lounge, it’s an excellent opportunity to talk about how things are going with them and the ED. Finally, there’s rounding in the C-suite. How easy this is may depend on the culture of your hospital and whether you can access your administration by an open door policy or bumping into them in the hallway. But an extra lap around the C-suite before or after a meeting in the boardroom or another conference room there can have benefits as well. When I’m rounding in the C-suite, I usually talk a little more about the ED accomplishments or give status updates on projects and then ask if there’s anything they’ve heard or anything I can do for them.
Executive rounding has become a proven technique to improve staff and patient satisfaction. Although most, if not all, ER chairs still work clinically, I suspect that my shifts run a little smoother than many of my docs. As a chair, I probably get less pushback from the hospitalists, get scribes with a little more experience, and get a little more help from the nurses. I also believe I work under the “magical chair white cloud” that accompanies chairs on their shifts, but that hasn’t been proven yet. Therefore, rounding on my docs, gives me a better understanding of what’s going on at the front lines. As a whole, rounding helps me and other leaders understand what’s important to staff and where they have frustrations. I also get to hear directly from patients with my administrator ear (although they get that ear when they call to complain) rather than my clinical ear. Even as a clinician, I find that rounding, observing, and spending extra time in the ED outside of my shifts, helps me to evaluate our processes with a different perspective. And for leaders who don’t work clinically (hospital administrators and perhaps nursing leadership), they can see processes in real time.
Observing and listening is key, and I’ve often been impressed by listening to my docs talk to patients and their families from outside the curtain. On rare occasions, I may listen and be able to offer some feedback afterwards about how to handle a difficult question or issue. Effective rounding makes you talk to everyone in your group/department, and while I have a handful of people I talk to on a daily basis, ultimately, rounding improves communication between all staff and the leadership team. It also allows you to show your thanks and appreciation for the work they’re doing. Keep in mind, walking around taking notes may freak out your staff, so if you’ve never officially rounded before, be sure to let your staff know via short conversations or email that you’re doing it to help get feedback to make the ER a better place for staff and patients.
How to Round
There are too many days where I’m running from meeting to meeting or stuck doing something on my computer. Therefore, it’s best to treat rounding as a scheduled activity and block time on your calendar. While I like to walk through the ER every day, official rounding should take place regularly. It’s important to watch, listen, and talk to everyone. Effective rounding should include documentation, note taking (including a spread sheet to document when you’re talking to each of your docs), and follow up.
Questions to Ask
Your questions and the conversation will vary depending on whom you’re rounding on. For your providers and nurses, consider the following:
- What’s working well today?
- What problems are you experiencing today? (By the 5th day in a row when you hear CT turnaround time or boarding, you’ll know what inter-department meetings to set up.)
- Do you have all the tools you need to do your job? (What supplies aren’t stocked and what otoscope is broken may surprise you.)
- Anyone to recognize? (This is great for adding to any daily/weekly email you send out to your group).
- Any other thoughts or comments?
At my site, our nurse management team now does more of the patient rounding than I do. At one point, as we were trying to turn around our patient experience scores, we had a senior doc round on 10 patients a day (We see about 180 a day, so I realize this is a small percentage, but it was a good way to get some real time info on our docs from the patient’s perspective). I did a lot of this rounding and while I often felt like a manager at a fine steak restaurant, the patients really appreciated it. I think it was one of several things we did that resulted in us meeting our patient sat target.
I find that rounding on patients is a great way to check/verify that your providers are doing the behaviors you’re trying to reinforce to your team, such as handing out business cards, explaining the ED process and how long the visit will take, and making sure the patient is comfortable.
Other questions to ask patients:
- How is your care today?
- Is the team responsive to your needs?
- Do you know who is caring for you today? Did the doctor give you a business card?
- Is there anything I can do for you?
Rounding is a critical administrative tool that should be a part of every medical director’s armamentarium. Talking to our providers is easy, but allow yourself some time to get comfortable talking to nurses and patients with this format. As the conversations become easier, following up and making improvements based on feedback is what helps get the ED to its next performance level.