This case study first appeared in the report Committed to Safety: Ten Case Studies on Reducing Harm to Patients by Douglas McCarthy and David Blumenthal, M.D.
Organization. Concord Hospital is a 295-bed, not-for-profit community hospital, located in Concord, N.H. It treats 250 patients per year in its cardiac surgery program.
Objective and intervention. In its report, To Err Is Human, the Institute of Medicine recommended that hospitals include pharmacists on physician rounds on patient care units as a strategy for improving medication safety. Building on this recommendation, a cardiac care team at Concord Hospital instituted a program of multidisciplinary collaborative rounds at the patient's bedside that included all members of the care team along with the patient and his or her family. The goal is to create a more informed care team and patient, providing additional opportunities to identify and prevent potential errors and to rapidly mitigate the effects of any errors that do occur.
Date of implementation. A cardiac care team led by Paul Uhlig, M.D., began meeting in 1999 to collaboratively plan improvements in patient care.
Process of change. The entire cardiac surgery care team (including the surgeon, bedside nurse, nurse practitioner or physician assistant, social worker, counselor, clinical and home care coordinators, pharmacist, dietician, therapists, and rehabilitation specialists) conducts a 10-minute daily briefing at every patient's bedside. The briefing is led by the nurse practitioner following a structured communication protocol developed by an expert in human factors science. The process is focused on developing and recapping the patient's care plan, reviewing patient progress and needs, and clarifying team responsibilities. Patients and family members are educated about the process in advance and are encouraged to actively participate by stating their concerns. Participation of patients and family members tends to increase each day.
To promote medication safety, the pharmacist reads the scheduled medications for the day and addresses any questions raised by the patient, family, or care team. The pharmacist maintains a monitoring sheet with notes from rounds along with pertinent lab work and home medication reconciliation. This provides continuity among different pharmacists who may participate on rounds from day to day.
The team addresses anything that has gone wrong in the care process—called "system glitches" rather than mistakes to encourage their identification and avoid the stigma of individual blame. System glitches are documented, patterns are identified, and corrective actions taken. The team participates in biweekly system rounds, which provide a forum for discussing team goals and progress and for addressing system-level concerns.
Results. Following implementation, mortality rates declined by more than half, to 2.1 percent, compared with an expected rate of 4.8 percent based on risk-adjusted data from the Northern New England Cardiovascular Study Group (Uhlig et al. 2002) (Figure 5). Practice patterns and culture became more collaborative and providers, based on a quality of work life survey, expressed greater satisfaction with the process than with traditional rounds (Figure 6). Patients reported high levels of satisfaction on surveys. Family members informally expressed their appreciation at not having to worry about what was happening with their loved ones. They also reported that exposure to the process made them much more proactive in all their medical encounters.
Lessons learned. The Concord Hospital team discovered that bedside briefings allowed them to meet patients' needs more effectively and that relatively simple changes can have a dramatic impact on outcomes, said surgeon Dr. Paul Uhlig, M.D. Although it is not possible to tease out the specific causes of the mortality improvement, the patient-centered nature of the collaborative round suggests that patient safety can be improved as part of a broader intervention that improves quality and patient experience generally.
The rounds became a means of reorienting the care team toward a "collaborative culture of interaction" in which everyone feels they can safely make observations and suggestions that increase error detection and reporting, said Dr. Uhlig. Physician leadership in "flattening the hierarchy" set the tone for collaboration that promotes respectful interactions among the entire team.
Concord Hospital's experience with collaborative rounds demonstrates that "health care's greatest resource for improvement is the desire of practitioners to do the best for their patients," said Dr. Uhlig. Collaborative rounds may have originally seemed a waste of staff time, but they actually increased efficiency since they reduced each member's need to communicate with one another and the patient separately.
Replication and related results. Collaborative rounds have been adopted in cardiac surgery units at several other institutions including North Shore Medical Center in Salem, Mass.; University of Cincinnati Hospital; the Mayo Clinic; and in pediatric surgery at Women and Children's Hospital of Buffalo, N.Y. Multidisciplinary rounds also have been adopted in ICUs and other units of hospitals participating in Institute for Healthcare Improvement collaboratives. Surgeons and clinicians instituting multidisciplinary rounds report improved patient care, increased patient and family satisfaction, and shortened lengths of stay (personal communications with Michael Caty, Walter Merrill, and Thomas Vander Salm 2004). Results include the following:
- A controlled trial reported slightly shorter average length of stay (0.6 day) compared with usual care and savings of $1,409 per patient associated with of the use of collaborative team rounds at MetroHealth Medical Center, an academic hospital in Cleveland, Ohio (Curley et al. 1998).
- A noncontrolled study of ICUs in two teaching hospitals and one nonteaching hospital found a correlation between nurse reports of collaborative decision-making and better patient outcomes, including fewer deaths or ICU readmissions (Baggs et al. 1999).
- Two controlled studies have found that involving pharmacists on team rounds in an ICU at Massachusetts General Hospital, Boston, and on a general medical ward at Henry Ford Hospital, Detroit, reduced the rate of preventable adverse drug events by 66 percent and 78 percent, respectively (Leape et al. 1999; Kucukarslan et al. 2003). This resulted in an estimated $270,000 annual savings associated with elimination of 58 adverse drug events in the ICU.
The collaborative rounds approach has been the subject of a simulation study at the Harvard Center for Integration of Medicine and Information Technology, to understand the particular cognitive, physical, and social elements that create success and to determine how these elements of the collaborative rounds process can be enhanced and replicated in everyday practice. Dr. Uhlig said this work is demonstrating "the untapped potential to use social science to transform human practice."
Implications. Efforts to improve patient safety can dovetail with other improvements in the quality of patient care. Through the process of multidisciplinary collaborative rounds, improving patient safety fit hand-in-hand with making care more patient- and family-centered. Future research should measure the impact of multidisciplinary rounds on reducing adverse events and how the participation of pharmacists contributes to this outcome. Barriers are chiefly cultural, often due to reluctance of physicians to re-orient to a less hierarchical power structure, according to Dr. Uhlig. This may be overcome by emphasizing the benefits to the physician of achieving improved outcomes. An organizational change of this nature must be supported by hospital management, emphasizing the need to embed specific process changes in broader organizational culture.
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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.