After its recent electronic health record (EHR) transition, a hypothetical health system found itself struggling to implement computerized physician order entry (CPOE) across its 10 hospitals and 3,400 employed, contracted, and community-based physicians. Older physicians were frustrated with the technology while other physicians were unhappy with what they perceived to be an extra administrative burden for medication orders. The productivity of physicians (and the nurses who were supporting them) was trending poorly, and the patient experience was suffering due to delays in service.
To address these challenges, the CEO asked leaders to uncover what was delaying the adoption of CPOE by rounding on direct reports. During rounding, leaders touch base with employees who report to them for five to 10 minutes—typically on a monthly basis—to learn the following:
At first, the leaders were skeptical that rounding could help increase the number of physicians using CPOE. They had been rounding on direct reports for some time and physician engagement had not yet improved. But after the leaders refined their approach to rounding, they were pleasantly surprised.
The goals of rounding are to strengthen relationships, create approachability, assess process improvement opportunities, and demonstrate appreciation. As this health system learned, rounding can also be used to help an organization identify and resolve barriers to organizationwide goals, such as CPOE adoption. Here are four ways this health system adapted rounding to meets its needs.
Target questions around specific organizationwide priorities. Many leaders at this health system had been rounding on direct reports for four years. They were bored with the standard rounding questions, and staff weren’t responding with much actionable information. Because CPOE was a high organizational priority, leaders decided to make CPOE the focus of their rounding questions for a period of time, which ended up energizing the process.
For example, instead of asking, “What’s working well today?” they asked, “What’s working well with the CPOE implementation?” With this line of questioning, leaders learned that changes made to the standard order sets streamlined the process for ordering labs. In the past, physicians had to sort through many similar codes, so errors required patient blood re-draws, which was a huge dissatisfier.
Rather than asking, “Who can I reward and recognize?” They asked, “Who’s done a nice job with CPOE this week?” When the CFO rounded on the director of IT in this way, the director responded, “Dr. Menendez really went the extra mile to resolve some of the CPOE challenges we’ve been having with the hospitalists.”
Also, leaders learned that when staff didn’t have a response to a rounding question, they needed to be more specific and set an expectation for an appropriate response next time.
For example, when one employee said she couldn’t think of anyone to recognize, her leader said, “Sarah, I understand no one comes to mind, but let me rephrase the question: It doesn’t have to be a big deal, just something simple that made you smile or made your day go better. If you still can’t think of anyone right now, please think about who you can mention next time I round.”
Follow up on findings. When the CNO rounded on her nursing directors and asked about CPOE, she learned that the pharmacy was struggling to fill orders on time because it was spending so much time problem-solving orders that were entered incorrectly by physicians. However, the CNO did not act on this information in a timely manner. So physicians continued to be frustrated with delayed pharmacy orders and complicated order sets.
Once the CNO was coached on how to document her findings using a rounding log, she could then bring objective results to the CPOE team for action. The CPOE team members met with the pharmacy and the therapeutic team to review and simplify some of the standard order sets to make the order entry easier for physicians.
Next, the CNO posted a stoplight report—a close-the-loop document—to keep everyone posted on progress towards resolution of each type of CPOE order entry challenge as recorded on the rounding logs. Issues that had been addressed were highlighted in green, those that were pending were highlighted in yellow, and recommendations that were not adopted after review were highlighted in red.
Maintain a consistent schedule. Leaders discovered that rounding wasn’t occurring consistently. When they drilled down to find out why, some directors and managers said they just couldn’t find the time. Even when rounding opportunities were scheduled, they were frequently bumped because of last-minute meeting changes and other emergencies.
Sometimes rounding became a lengthy, unstructured hallway conversation focused on putting out a fire instead of on proactive strategies for improvement. As a result, the organization was experiencing pockets of high physician engagement where leaders were rounding consistently and low engagement where rounding was sporadic.
To resolve this, they decided to incorporate rounding into every one-on-one monthly supervisory meeting. The CEO modeled the new approach with his direct reports; he added five- to 10- minute rounding sessions as a standing agenda item at the opening of these meetings. When he learned about process design issues with CPOE, he asked the CIO to track these as a priority item with the vendor.
Find a time that works for staff. Some leaders had difficulty rounding on frontline staff who were constantly moving between patient rooms or various locations throughout the health system. Instead of chasing down staff, leaders set an expectation by saying, “I need to round on you next week, so please page me when you have five minutes to accomplish this.” They also capitalized on spontaneous moments when staff arrived with a concern or question to complete the round.
For example, one director of case management was approached by a frustrated case manager who couldn’t complete a durable medical equipment referral for a patient because of a malfunctioning computer. The director responded by saying, “That’s really important. I want you to have the tools and equipment you need to do your job, so let me get that fixed. And while you’re here, do you have five minutes I can round on you to find out about other processes or systems we need to address?”
Using these four tactics to improve the quality and quantity of rounding across the organization helped the health system improve CPOE compliance significantly among its physicians over a three-month period. Leaders also began to experience the rewards of consistently high physician engagement as measured by their physician and patient satisfaction surveys and more proactive partnership in problem solving with hospital leaders organizationwide.
Lyn Ketelsen, RN, is senior coach leader and national speaker for Studer Group, Gulf Breeze, Fla., and a member of HFMA’s McMahon Illini Chapter.
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