ROUNDING FOR OUTCOMES:
How to Increase Employee Retention and Drive Higher Patient Satisfaction
By Barbara Hotko, R.N., M.P.A., Studer Group Coach
When I recently asked a room full of health care employees, "How many of you who have left an organization did so because of your supervisor?," the majority of them raised their hands. This is very typical.
Most employees don't leave an organization because of pay or benefits—or even because they want to leave the health care industry. The number one reason they leave—39% of employees1— is because they have a poor relationship with their supervisor. What staff want in a leader is approachability; to work "shoulder to shoulder"; tools and equipment to do their jobs well; appreciation; efficient systems; and opportunities for professional development.
These desires are highly correlated to the 12 questions developed by the Gallup Organization in its 1998 landmark study of 80,000 managers to determine drivers for productivity, profitability, employee retention and customer satisfaction.2
Understanding what employees want and how to give it to them—or explaining why it can't be provided—has never been more important. In October 2003, 58% of CEOs rated personnel shortages as one of their top three concerns in a survey by the American College of Healthcare Executives. And as the health care industry struggles with an epic nursing shortage3, more than 4,000 nurse respondents in a Press-Ganey & Associates study said the most important way that executives can boost nurse satisfaction in the future is to provide "support to adapt to change in the organization." They also ranked "recognition for excellent performance" as most highly correlated to recruiting friends to the organization.4
In our experience coaching more than 400 health care organizations at Studer Group, Rounding for Outcomes is the single best way to raise employee satisfaction, loyalty, and ultimately attract and retain high performing employees. It's a practice that helps employees feel they have purpose, are doing worthwhile work, and are making a difference. It increases employee retention by providing that which is important to them.
And just as Rounding for Outcomes has a great impact on staff, rounding on patients also improves clinical outcomes; promotes patient safety; increases efficiency; raises patient satisfaction; and decreases length of stay. It's so important that Studer Group considers it the first and most fundamental skill set for leaders and includes it as Volume 1 in its Must HavesSM Video Series. (See below)
What is Rounding for Outcomes?
Rounding for Outcomes is the consistent practice of asking specific questions of key stakeholders—leaders, employees, physicians and patients—to obtain actionable information. Just as physicians round on patients, senior leaders can round in their divisions; unit leaders can round on their staff; leaders can round on ancillary departments they serve; and nurse leaders can round on patients.
The focus of questions during rounding are to:
► Build relationships (e.g. "How is your family?" "Did your daughter graduate last week?")
► Harvest "wins" to learn what is going well, what is working, and who has been helpful (e.g. "Are there any physicians I need to recognize today?")
► Identify process improvement areas ("What systems can be working better?")
► Repair and monitor systems to ensure chronic issues have been resolved (i.e. "Do you have the tools and equipment to do your job?" or even more specifically: "How long did it take you to find an IV pump today?")
► Ensure that key behavior standards in the organization are "hardwired" (or being consistently executed) to reward those who are following the standards and coach those who are not.
Relationship-building questions during rounding build communication at all levels of an organization because they demonstrate to employees that leaders care about them as people… one of the top indicators of a strong workplace according to Gallup. (See "Gallup's 12 Questions.")
Because many health care employees tend to notice what is wrong or not working—instead of what is right and working—it's particularly important to ask questions that look for the positive. While diagnosing what's wrong is critical to ensuring quality clinical outcomes in patients, it serves as an obstacle in an organization's effort to create a positive work culture, so we must build in opportunities to notice what's right.
Rounding provides an opportunity for leaders to collect and pass on recognition for physicians and staff who have been helpful. This in turn creates increasing momentum and turns the Healthcare FlywheelSM for better service, higher retention, improved quality, stronger financials, and growth.
Rounding also validates that key behaviors which promote a safe environment for patients are hardwired in the organization. Presently, all JCAHO-accredited organizations are surveyed for implementation of the 2004 National Patient Safety Goals (NPSGs), which include seven goals and 13 specific requirements designed to prevent the occurrence of medical errors in health care organizations. The NPSGs highlight problematic areas and describe evidence-based solutions.
Several of these requirements (e.g. using at least two patient identifiers when administering medications; reading back a telephone or verbal order to ensure accuracy; involving patients in marking their surgical sites; and timely response to clinical alarm systems) require consistent practice by all members of the health care team to be effective in preventing medical errors. Rounding on patients to validate that these practices have occurred—and then rewarding and recognizing the practitioners who demonstrate these behaviors—will result in this consistent practice.
“According to a study by the Murphy Leadership Institute, about 35% of all hospital employees’ time is spent on wasteful work.”
Identifying areas for process improvement (and consistent follow-up) demonstrates for employees that leaders walk the talk…that they are committed to providing the tools and equipment to do the job in the most efficient way possible. According to a study by the Murphy Leadership Institute, about 35% of all hospital employees' time is spent on wasteful work, including: inefficient shift-to-shift or departmental reports; locating equipment; waiting for physicians; meetings that last too long; interruptions by telephone calls; and completing multiple forms for the same task.
By identifying and preventing employee frustrations and delays, organizations increase staff productivity and communication. In this way, rounding can provide a quick return on investment by reducing medically unnecessary days due to inefficiencies (e.g. test not completed in a timely manner; treatment not started on the day ordered, prep not followed, patient activity orders not initiated). In fact, when senior leaders rounded at Pekin Hospital (Pekin, IL) they learned that two hospital departments had not been billing for half of a certain test procedure for years because each assumed the other was doing it, a billing loss of $400,000 annually according to CEO Doug Wilson.5
Rounding for Higher Patient Satisfaction
In a study of one million emergency department patients6, the authors found that the most important consideration of patients in recommending an emergency department was the degree to which staff cared about them as a person. (For patients, receiving quality clinical care is a baseline expectation.) This provides such an important opportunity for us to help our staff connect back to purpose, worthwhile work and making a difference.
While many organizations struggle with issues related to pain management, response to call lights, attention to personal needs, and increasing their sensitivity to patients' inconvenience, rounding is a powerful way to shape the experience for patients and increase patient perception of care. Try:
► Positively cuing patients. Instead of focusing on the negative by saying, "Are you having any problems?" say, "We want to ensure you get very good care here at Caring Heart General. Please let me know if there's anything you need. I have time."
► Help patients understand the quality of the care they are receiving by introducing staff skill sets and "managing up"7 physicians (e.g. "Hello Mr. Johnson. I'm Tina Smith, your phlebotomist. I want you to know that I've performed this procedure 50 times a day for the past 10 years and have been specially trained here at Caring Heart. Or: "I see Dr. Johnson is your cardiologist. You're so fortunate. He is one of our very best.")
► Ask the patient for names of staff who have been helpful to them so you can collect and deliver these compliments personally. I remember speaking to one nurse about a patient who had nothing but complaints. She persevered by asking, "Isn't there anyone I might recognize who did a good job for you?" and was rewarded with the name of an employee who was particularly kind. This is how we help create good memories for our patients.
► Set expectations. Tell patients during rounding when you will return and do so. (An excellent visual cue for service and quality is a clock face. Draw one on a white board in patient rooms or purchase inexpensive "I'll be back at…" clock faces.) This is particularly key for managing pain for patients who often watch the second—not the minute—hand of a clock when waiting for the next dose of pain medication. (A side note: Studer Group has found that effective rounding on patients will decrease call lights by two-thirds, creating more time for staff to deal with real emergencies.)
Sometimes I meet great leaders who really take rounding to the next level. Dr. Steven Lockhart, M.D., Ph.D., Medical Director, Surgical Services at California Pacific Medical Center (CPMC) in San Francisco, CA recognizes that patients are ambassadors to the medical center through their referrals and service as volunteers. When Dr. Lockhart rounds, he invites patients to attend meetings of CPMC's patient satisfaction team so staff can hear what WOWed them and what didn't.
At Sharp Chula Vista Medical Center in San Diego, patient satisfaction soared on one unit from 52% to 92% in nine months where it has remained high. Why? Sherri Fitzgerald, RN, Manager of 3 East, hardwired rounding with a checklist. She ensured that rounding was scheduled on her calendar; often took an ancillary leader on rounds with her (e.g. plant operations, engineering, housekeeping); fixed things at the patient bedside or followed up with service recovery when she couldn't; and had a plan when rounding on patients. In other words, since it was her goal to round on 100% of her patients daily, she rotated key questions that focused on call lights, attention to personal needs, and pain management. She also consistently rewarded and recognized staff based on patient feedback during her rounds.
Because rounding was hardwired, Sherri's unit at Sharp Chula Vista Hospital sustained the gains—in the top 1% of nursing units nationwide for patient satisfaction (Press-Ganey)— even while she was on leave for four months battling cancer. Sherri's unit also works well as a cohesive team, with under 10% employee turnover.
We find the most successful organizations—those whose patient satisfaction is rising steadily and remaining high—are those who have hardwired Rounding for Outcomes with unit managers, physicians, ancillary leaders, senior leaders and patients. The rewards are tangible. How will you take rounding to the next level in your organization?
Barbara Hotko, R.N., M.A. brings more than 30 years experience in health care administration and nursing to her coaching and has trained hundreds of leaders at hospitals, health systems, medical practices and emergency departments nationwide on effective Rounding for Outcomes.
1 Hardwiring Excellence by Quint Studer, based on comparable hospitals.
2 First Break All the Rules: What the World's Greatest Managers Do Differently by Marcus Buckingham & Curt Coffman, 1999, Simon & Schuster
3 The U.S. Bureau of Labor Statistics has projected demand for RNs at 2.9 million in 2012.
4 Press Ganey Associates 2003 study of 4,699 nurses at 36 hospitals.
5 HealthLeaders Magazine, "Making the Rounds," March 2004.
6 "America's Emergency Departments: One Million Patients Issue ‘Report Card,'" Press-Ganey, July 2000.
7 "Managing up" is Studer Group terminology for eliminating a "we/they" culture by positioning physicians, colleagues, and supervisors positively to others in the organization and to patients (e.g. using reward, recognition and introducing clinician skill sets to patients.)