Intervention Title: Registered Nurses Participate in Presenting Their Patients During Morning Rounds – Massachusetts General Hospital, Boston, Mass.
Goal: Eliminate competition for bedside charts and increase nurse participation in patient rounds by formalizing a role for the nurse in rounds.
Innovation: What began as an exploration of how to ensure that nurses and other staff had ready access to patient charts (known as “green books” at Massachusetts General Hospital) evolved into a way in which registered nurses could take a more active, visible role during rounds.
Result: Because physicians, medical students, interns and residents are not scrambling to review patient vitals and other information before morning rounds, the green books now remain at patients' bedsides, where they may be easily accessed and updated by nurses and others who are providing direct care.
Institution: Massachusetts General Hospital55 Fruit StreetBoston MA 02114P: (617) 726-2000
From the C-Suite:“Formalizing a defined role where the nurse presents the current patient status on patient care rounds has heightened collaboration and communication between nurses and physicians on White 10. This change has created a care environment that promotes progress toward quality, safety and patient satisfaction goals.”
Jeanette Ive Erickson, R.N., M.S., F.A.A.N.Senior Vice President for Patient Care & Chief Nurse
Profile: Massachusetts General Hospital is a 900-bed, inner-city, teaching medical center that has more than 46,000 inpatient admissions and nearly 1.5 million outpatient visits each year.
Clinical areas affected:
- General medicine unit
- Medical students
- Nurses' aides
- Patient care associates
Timeline: The innovation spanned four to five weeks, from idea generation to rollout.
Contact: Amanda Stefancyk, R.N., M.S.N., M.B.A.Nursing Director, White 10, General MedicineP: (617) email@example.com
Innovation implementation: Like many hospitals and health systems in the United States, Massachusetts General Hospital is on its way to becoming fully electronic, but the facility is not there yet. In the interim, the hospital's green books, which contain patients' vital signs, input/output, medication lists and more, are in high demand among physicians, nurses, patient care associates and many others.
Between the hours of 6 a.m. and 8 a.m. each day, house staff would typically review the books as they prepared for morning rounds, making these same materials unavailable to staff who needed to enter patients' latest vital signs and bedside labs.
The need to ensure access to the green books sparked a cultural change on the White 10 unit at Massachusetts General Hospital that provided nurses with a more active and defined role during morning rounds.
The team on a 20-bed, general medicine unit implemented a new approach to rounds in which the registered nurse caring for the patient participated in presenting the patient's vital signs, lab results, intake and output results, and other critical information to the rest of the team.
The end result is that nurses and others have access to books and can record information about their patients as it becomes available rather than jotting patient notes down in other notebooks and on random pieces of paper and rerecording it in the green books later. An additional and equally important end result is that the nurse plays a direct role in the rounding process.
Advice and lessons learned:
- An active role in rounds means an engaged provider. An active, defined nursing role in rounds sets the stage for the nurse to contribute essential patient information to the plan of care. It also validates the facility's commitment to a multidisciplinary care model. What could be more important in a setting where a largely new graduate workforce is establishing its practice?
- Introduce new processes to all new members of the team. Massachusetts General learned that it needed to reintroduce the nurse presenting concept each time residents rotated and a new team of residents and interns were assigned to the unit. Each group warmed up to the approach, but it took time to accept a new way of doing things.
Cost/benefit estimate: While no cost savings have been calculated, there have been time savings. Prior to nurses presenting during rounds, physicians typically spent up to an hour pre-rounding to ensure that they were fully up to speed on each patient. Now extra time can be spent on providing patient care rather than on information gathering.