Family-Centered Rounds Requires an Equity Oriented Approach Free

Family-centered rounds (FCR) have been a pillar in family- and patient-centered care for hospitalized children for the past 2 decades. FCR provides several benefits to patients, families, and the medical teams and staff that take care of them. Ideally, FCR brings patients, families, and care team members together to optimize communication and develop a shared mental model. FCR facilitates the modeling of family-centered education for trainees, promotes patient safety, and may contribute to more efficient discharge times.^1,2  However, despite the widespread adoption of FCR, practice variation and process variability exist within and across pediatric institutions. Several barriers contribute to these practice differences, including concerns regarding the impact of FCR on efficiency and workflow, challenges coordinating nursing attendance, quality trainee education, and institutional buy-in, and variability in family or caregiver presence and participation.^3,4  Additionally, FCR is not immune to the influences of inequitable practices within health care systems that disproportionately impact patients and families who are systematically excluded and disenfranchised.⁵ 

In this issue of Hospital Pediatrics, Lopez et al highlight efforts to increase bedside rounding on patients admitted to the general pediatric teams using quality improvement (QI) and change management theory in response to a decrease in bedside rounds during the coronavirus disease 2019 pandemic.⁶  The authors identified patients and families as key stakeholders and used surveys, meetings, and focus groups to obtain input from members of the Family Advisory Council and the Youth Advisory Council. The team used surveys to elicit the perspectives of residents and attending physicians on their perceptions of bedside rounds and the impact of bedside rounds on workflow, teaching, and communication. The primary outcome measure was an average weekly percentage of bedside rounds, which was defined as a resident and attending discussing assessment and plan at the patient’s bedside regardless of caregivers’ presence. After the collection of 2 months of baseline data, the team performed 12 plan-do-study-act (PDSA) cycles that mapped to 3 key drivers: knowledge, culture, and logistics. They saw an increase in the percentage of bedside rounds performed from 18% to 86% after PDSA cycle 2 on team number 1 and from 7% to 54% on the remaining hospital medicine teaching teams. The team’s secondary outcome measure was the percentage of caregiver attendance on rounds, which was defined as caregiver present at the bedside, via phone, or virtual visit. While the percentage of caregivers who participated in rounds via phone or virtually is not clear, the team’s approach was inclusive and equity-oriented. They reported an increase from 66% to 100% after PDSA cycle 2.

The study has several strengths. The authors had an admirable and lofty goal of shifting the culture of their organization and cultivating an environment that promoted bedside rounding on the general pediatric inpatient teams. The team’s approach to the work underscores the premise that the success of QI efforts is often contingent on the incorporation of change management strategies. This approach is of particular importance as health systems support improvement initiatives in partnership with frontline staff and on the tail of the coronavirus disease 2019 pandemic that only exacerbated workforce turnover and burnout.⁷  The use of change management strategy by the team promoted the sustainability of interventions by incorporating the trainees and attending physicians early in the process, making key stakeholders the main facilitators of operational change. The QI initiative was trainee-led, likely a major contributing factor to the overall success of the improvement team. The choice to do initial PDSA cycles on the inpatient team most ideal for efficient bedside rounding (ie, senior resident teams with patients isolated to a single unit) was a wise decision. Finally, the team worked closely with frontline staff who were stakeholders in this project and identified important balancing measures (eg, time spent in the room, resident and attending perceptions of bedside rounds).^4,8 

The authors highlighted several study limitations that may have been mitigated by the inclusion of “quality FCR” as a key driver, which in turn may have spurred a different approach to measurement and broadened the scope of interventions. One notable limitation was the primary outcome measure, the occurrence of rounds physically at the bedside by attending physicians and residents, that served as a proxy for FCR. Although FCR has many components, the link between the patient’s family and the medical team is the foundational dyad, and hence, the act of bedside rounding alone is not a true reflection of the core tenets of the quality of FCR. In addition, although the initial stakeholder assessments included Family Advisory Council and Youth Advisory Council members, the demographic information of these individuals was not reported. The authors do highlight the engagement of families who use a language other than English (LOE), which is an important step toward addressing language and communication barriers relevant to the effective implementation of FCR for this population. Equitable implementation of FCR for this population may entail reframing efficiency balancing measures; more time spent with LOE families during FCR is appropriate and often necessary. The authors elicited initial stakeholder perspectives from patients, families, residents, and attending physicians but only elicited the perceptions of the medical staff throughout the course of the QI initiative. Ideally, the QI team would have created opportunities for ongoing assessment of rounding quality by all key stakeholders, including patients, families, and nursing staff, to identify gaps and potential interventions.

The authors call out several barriers to FCR, including negative perceptions of FCR by members of the care team, as well as a lack of family awareness of the practice of FCR.⁹  However, additional barriers that impact the implementation of quality and equitable FCR should be considered and include (1) suboptimal communication between the medical team and caregivers, (2) communication laden with medical jargon which is more likely to affect those who use a LOE for health care discussions without access to reliable use of interpreters and those with low health literacy, (3) a lack of empowerment among caregivers to participate, and (4) inadequate engagement of caregivers who are unable to be physically present at the bedside during rounds.^5,10  These barriers, which are rooted in social and structural determinants of health, including racism and discrimination, disproportionately impact patients and families from systematically excluded and disenfranchised backgrounds. Thus, these patients and families are more likely to be affected by inadequate or inappropriate facilitation of FCR, which may contribute to inequities in length of stay, cost, patient safety measures, and health outcomes.^5,11  Of note, the authors only included patients whose caregivers were present at the bedside in the denominator of the primary outcome measure. As a result, this practical, yet narrow approach was a missed opportunity for the team to test innovative solutions that address barriers to FCR for families who are unable to be physically at the bedside during rounds.

Lopez et al outlined a successful, innovative, and trainee-driven QI initiative to improve bedside rounds. However, the effective implementation of FCR in pediatric health care systems in a manner that promotes equity remains elusive. Institutions should support additional improvement efforts to optimize and standardize rounds that center on all patients and families. Opportunities abound and include supporting processes that (1) facilitate the proactive scheduling of FCR and visibility of rounding order, (2) leverage technology that allows families and other care team members to join FCR virtually, (3) ensure the reliable use of interpreters to support families with LOE, and (4) support adjustments in traditional workflows to bridge communication gaps between patients, families, and the care team. These efforts will require a culture shift, one that truly views all 6 components of quality care (safe, effective, efficient, patient and family-centered, timely, and equitable) as complementary rather than opposing core values.¹²