Now, I would like to introduce our speaker to kick off the series for us today. Dr. Toni Sesta is a founding partner of Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for over 25 years. Her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations with measures of patient satisfaction, quality of life, and short and long-term clinical perceptions and outcomes. Thank you for being here with us this morning, Dr. Sesta, and we invite you to go ahead and get us started. Well, thank you, Lindsay. Good morning, everybody. I'm just watching the tally, Lindsay, of how many people are logging on, and that's exciting. We have quite a big group today, whoo-hoo, yeah, so it's always exciting, and yes, as Lindsay said, we're going to do five parts this time again for our Beyond Basics, and you know, these topics, I'm sure you've looked through our agenda, and you may think these topics aren't connected to each other, but they really are, and I hope a lot of you have also taken our Basic Boot Camp so that you can see how we're building on those topics that we went over in Basic Boot Camp. If not, that's okay. Each one of these can stand alone as well as be integrated with other information you've already received. So we're going to kick it off, as Lindsay said, with bedside rounds or walking rounds, you may think of it as. I have been noticing as I speak to case managers across the country that more hospitals are starting to move in this direction. I've been talking about walking rounds for a very long time and typically get some bit of resistance because folks maybe have tried walking rounds and it didn't work or it takes too long or any of the above, you know, issues, and then it kind of falls by the wayside, sort of reminds me of the UR committee where we try and nobody comes and it falls apart. So if we do walking rounds correctly, if we follow the structure and do the pieces that we'll discuss today, it should move you in a very positive direction. At the same time, maybe you have some kind of rounds right now. Maybe you have rounds that are in a conference room or at the nursing station and we'll talk a bit about those, but those are not considered best practice and I'm sure you can appreciate the reasons why they're not considered best practice and we'll talk about what falls into a best practice structure for rounds. Don't get me wrong. I know that this is a challenge and can be difficult to kick off, but once you get it going and it's a well-oiled machine, as they say, I think you're going to find that people embrace it and don't want to go back to the way things were. So I can't believe we're going back to 2009 when the Joint Commission came out with their national patient safety goals and goal number two was to improve the effectiveness of communication among caregivers. In my mind, one of the fundamentally important pieces of working with an interdisciplinary team is communication and that's why I start off with this because communication is enhanced so greatly by walking rounds or bedside rounds and really those hand in glove with this patient safety goal. Communication, communication, absolutely, and then care coordination. Some of you may have the title care coordinator. I see that a lot. I could give you the history on that, but we'll talk about that another time. But care coordination and communication, again, they go hand in glove and they are critical to your ability to do all the things that you are required to do in terms of managing length of stay, in terms of reducing cost of care, communicating with your patient and family in terms of patient education and all the other pieces of case management and, of course, to get the hospital paid. I don't want to leave that one out. So when you think about care coordination and communication, you want to say to yourself that this involves deliberately organizing patient care activities and sharing information among all the participants concerned with the patient's care to achieve safer and more effective care. Now, if the team is not coming together, if you don't have that meeting where everybody is joined together to discuss what's going on with the patient, patient care activities, if you will, and information, this is a very difficult thing to do. So they go on to say this means that the patient's needs are known ahead of time. So as case managers, we want to be prospective when we think about how we do this, how we communicate, and it should be communicated at the right time to the right people. And this information then is used to provide safe, appropriate, and effective care to the patient. So you begin to see how communication, and it sounds logical and obvious, but so many times we neglect to perform an excellent communication structure between our caregivers. And in a couple of weeks, we're going to talk about transitions in care. And you'll see some of this information today is going to apply when we talk about transitions because there are a lot of issues that bedside rounds and good communication address in terms of that as well. Again, then in 2010, the Joint Commission came out with the requirement to have standardized handoff protocols. So how many of you, as you are listening today, have a standardized process for handoffs? And for us in case management, our handoffs are not just discharge. We may be transferring a patient from the ED up to the ICU, from the ICU to the floor, and so on and so forth. Those are all opportunities to have a good handoff or to allow things to fall through the cracks. So it's the transition of care as well as the transition of patient-specific information. So not only are you transferring that patient, okay, this is not my patient anymore, this is your patient, and here is the information that you are going to need to continue to care for that patient. One of the classics I'm sure you've all experienced is the patient has, let's say, an MRI in the community and then subsequently goes to the emergency department and what happens? Of course, the physician in the emergency department repeats that MRI. So common, right? Well, that just creates higher cost, obviously, but also a lack of continuous care and really a waste of resources. So a good handoff protocol per the Joint Commission is that this can only be achieved through effective communication, verbal and or written. I just thought this was amazing. A typical teaching hospital may perform 4,000 handoffs every day, and that's of course all the variety of providers, all of us who take care of patients, but that's an awful lot of opportunities for things to fall apart. Handoffs aren't simple. They're actually quite complex. So it could be communication during change of shift, between care providers, handoffs, records, information tools, anything that assists in communication between care providers about that patient's care. It's a mechanism for transferring information, primary responsibility. That's the other one. Remember, when you transfer your patient, you're transferring information and you're transferring primary responsibility. So you want the person receiving that patient to have as much information as they should have to adequately and continuously care for that patient. It also can be from one person to another, a single person, or to a team and all the team members. So we're going to talk about how you script some of these things in a little bit, but you want to make sure all of that critical information is transferred in that handoff. And again, that can be a little bit cumbersome. So having some kind of a structure and a tool to help you do that makes a world of difference. It's also been shown that when we don't have effective handoffs, this can result in more errors. These may not relate directly to us, but it's just, I thought, interesting enough to talk about for a minute. Healthcare has evolved. We've become more specialized, more clinicians. The more clinicians, the more handoffs. And so things are much more complicated than they have been in the past. And when that handoff either doesn't take place, which is not that uncommon, or it's not done in the best manner possible, this can contribute to gaps in care, breaches or failures in patient safety. It's been demonstrated to be attributed to medication errors, wrong site surgery, and even patient death. So it's not something, certainly, to take lightly. So because of these complex environments that we all work in, it can be very difficult. Just think if you have, let's say, 15 patients, and you've got to communicate information to a couple of, maybe three or four physicians, if you're not working with a hospitalist team. Maybe then to a staff nurse, back and forth, a physical therapist. I mean, you know how many team members you have to deal with, and if it's not one team but multiple and different people, you could spend your whole day just doing that. And the second bullet I thought was also interesting. Nursing units may transfer or discharge 40 to 70 percent of their patients every day, thereby increasing the frequency of handoffs encountered daily and the number of possible breaches at each transition point. So for us, we're the discharge planners, so all those discharges mean we have a handoff out into the community. And one of the things I just want to put in your mind is let's not forget our primary care providers. If a patient is going home, I think sharing a summary of information to that patient's primary care provider is important. So I want you to think beyond just the nursing home, the rehab, home care, but think about also patients going home-home without home care and that primary care provider or specialist who's going to be picking up that case. All right, I'm going to take a sip here. All right. Bumbled handoffs, yep, they certainly do happen. They can lead, as we were just discussing, to a host of patient safety problems. Just surgeons reported that they found communication breakdowns were a contributing factor in 43 percent of incidents, and two-thirds of these were communication issues, and those were related to handoffs. So you can begin to see it's not a small issue. The use of sign-out sheets for communication between physicians is a common practice, yet one study found errors in 67 percent of the sheets. I think that's because it's done quickly and not with a lot of thought or care. Now, how many of you, if you're going off on a Friday, you're not working over the weekend, I know a lot of case managers will write up some stuff for whoever's covering on the weekend since most of us have what we call skeleton crews on the weekend, and so you're giving sort of quick, very quick summaries. If there's any way you can leave a verbal report, I think that translates more effectively than a written piece of paper, but again, there's logistical issues with that as well. And they noted that there were missing allergies and weights and incorrect medication information. Another study focusing on near-misses and adverse events involving novice nurses, the nurse identified handoffs as a concern, particularly related to incomplete or missing information. And I really do think that that's not because we don't want to include the information, we either don't have a structured way to do that, or we just rush through seeing it as a task that just has to get done, and that, of course, can be problematic, as we've seen. The other thing I like to talk about is chasing after team members. Now, if you're not meeting with the team in an organized fashion, like walking rounds is our topic today, then you will find yourself chasing after the staff nurse, the physician, maybe it's a community-based physician, maybe it's a hospitalist, chasing after the physical therapist, you know what I'm saying. And so this can create all kinds of havoc, and what a waste of your time having to chase after all these different people. So you've got specialists also, as we see in the second bullet, and contacting the correct health care provider can also be a problem. I thought this was interesting. One study found that only 42 percent of nurses could identify the physician responsible for the patient in their care. Another study highlights the potential gaps in communication among health care providers transferring information. Now, you're probably thinking about that community-based provider who's not going to be there for rounds, and that is an issue, and I recognize that that's an issue for many of you. You might have some hospitalist units, you may have floating hospitalists, and then you've got some community-based physicians, and so those will be your challenge. Okay, so the Joint Commission also gave us some implementation expectations for you to have those effective handoffs. So you want to have interactive communication, allowing for the opportunity for questioning between the giver and receiver of patient information. Now, think about those of you who are currently doing rounds in the nursing station or have done rounds in the nursing station. Oh, my gosh, I remember as I do consulting, and I remember standing in one of the hospitals I was working with, standing in the nursing station while they were doing rounds, well, I couldn't even hear what they were saying, I couldn't concentrate. The phone was ringing, people were talking, the telemetry monitors were beeping, you know, all kinds of stuff going on that really disrupts your ability to have a give and take of information during that process. So that's one of the many reasons why we don't want to do rounds in the nursing station. You do want to give up-to-date information regarding the patient's care, treatments and services, their condition, and any recent or anticipated changes. So as we're going to get to scripting in a little while, just remember these are some of the pieces that you want to have hardwired. So it could be during rounds or any other handoff, and what I do recommend is that you have a standardized handoff tool. You don't want to stand there scratching your head and thinking, okay, what do I need to include in my summary, my handoff summary? If you just use a structured tool where you have the most important information included, it saves you time and it reduces the likelihood of things not being included that should be. And then as you're communicating, you want to have a process for verification of the received information. So you want to have repeat back or read back as necessary and appropriate. The receiver of the handoff information should have an opportunity to review the patient's historical data that might include previous care treatments or services, if those are relevant. You know, if the patient had their appendix out in 1949, not really relevant to the current situation, perhaps. Again, those interruptions during handoffs should be limited to minimize the possibility that information would fail to be conveyed or would be forgotten, you know, so maybe you catch half of what the person is saying and then you kind of drift away as you're listening to that telephone ring and ring and ring. So one of the other things I frequently see and absolutely don't want you to do is mush or integrate, mush is a very technical term, mush or integrate what we call walking or interdisciplinary care rounds with any other kinds of rounds that might be done on your unit. So one of those, of course, is change of shift rounds for the Department of Nursing and I've also seen, you know, case managers attend those rounds. I don't think that's value added for you, it takes up time and probably you'd be better served having those discussions in an interdisciplinary walking rounds format because they're going to talk about things that aren't necessarily relevant to case management. So you know, this is your traditional interchange and it's your staff nurses and there are some pieces of what those nurses are going to share that should transition over to your interdisciplinary rounds but not all of it. And so you don't want to put them together and you don't want them to replace those interdisciplinary care rounds either. Teaching rounds, if you're in a teaching hospital, you're going to see lots of teaching rounds and that is, those teaching rounds, I'm trying to think of how to say this nicely but teaching rounds is the most common way that I've seen that what we call walking or interdisciplinary rounds get integrated with teaching rounds and a hospital I worked with maybe two years ago, the case manager said to me, we cannot have rounds. It takes three hours. It takes four hours. I said, what are we talking about? Why is it taking three or four hours? Well, it was morphed with teaching rounds and again, to stand there as a case manager for that length of time listening to, you know, an attending physician teaching house staff is really, again, not value added for you. So, you know, we see teaching rounds in lots of parts of the hospital. That is not something we want combined with those interdisciplinary rounds. You're going to hear all sorts of in-depth clinical information and I'm sure many of you have had that experience as have I. And then another one is patient care conferences. So yeah, these are an adjunct or a supplement, if you will, to walking rounds because what will happen sometimes in walking rounds, the team will identify the need perhaps for additional time to discuss something in more depth. And I gave you just some examples here, end of life, family barriers or other discharge delay issues that may have come up that you're not going to stand in the hall and have a big discussion with. You're going to take that offline and you're going to have that conversation with, you know, the team members that need to have that discussion. Sometimes you'll have patient care conferences that include family members or family caregivers when you've gotten into some issues that have to, again, be discussed with the family. And again, that's not something you're going to do on rounds. Okay. So those are all the examples of all the other kinds of rounds, kinds of meetings, all kinds of other ways in which handoffs occur, information is shared. But our focus today is interdisciplinary walking rounds slash bedside rounds. This is your most important, in my mind, care coordination strategy. It's a real-time exchange of information. So when you're rounding in the morning, you're able to meet with the entire team and you're going to have that real-time exchange in an environment in which everybody can participate. So the goals and plan of care for each patient are clear to all the team members, so we don't have, you know, the physician going in and saying one thing and the case manager going in and saying something else because they didn't know the physician had given that patient conflicting information. It's formal and it's organized, so it's not a catch-as-catch-can kind of thing. It's not like, well, if you have time, come to rounds. It should be mandatory for team members to participate. It also, and we'll talk more about this, increases the efficiency and safety of patient care. So the Joint Commission sees this as best practice, so does the Institute of Medicine, and they really encourage hospitals to perform the kind of rounds that we're going to be talking about today. So it's a mechanism for interdisciplinary collaboration. The one that I think is so valuable is decision support at the patient care level. So while the team is eyeball to eyeball and there is an issue or you want to progress care, that decision can be made as a team real-time. I mean, that to me is all the money right there. And you can incorporate evidence-based management processes as well as you do this. So maybe you're thinking, why walking rounds? Why bedside rounds? Why can't we just do this thing in a quiet place like in a conference room? Well, you surely could, but again, there is more value added in really going to the bedside. So all the team members caring for the patient can offer individual expertise and contribute to patient care. So when I observe rounds, sometimes I see the case manager or the social worker standing in the background, and when I talk to them, they say, oh, I don't really have anything important or necessary to share with the team, so I'm just listening. Well, that's not true. You do have a lot of information that you can and should bring to the interdisciplinary team. You want to contribute as well as receive information. You have the disciplines together to coordinate care, and then the team sees the patient. That's the important piece of those walking rounds or bedside rounds is that the team sees the patient, and the patient sees the team. Hello, right? That's really critical. Patients are delighted. I have to tell you, having participated or observed rounds many, many times, patients love it. Now, you may be thinking about a surgical patient, and the surgical team goes in. Well, that's the surgical team, not the interdisciplinary team, so that's a little bit different, and that's usually a quick in and out of the patient room, so we're talking way beyond that. That communication is enhanced among and between those team members. Again, Institute for Healthcare Improvement, IHI, which I'm sure you've heard of, and the Joint Commission consider walking rounds best practice, so when you're surveyed, they're going to look to see how you do this. Cuyahoga Valley Medical Center in South Carolina, this is a little bit old, but I think it's still important. They did a survey of rounds. The patients and nurses were surveyed to see if they were satisfied with the rounds. The patient comments were positive, and I have to tell you, these are consistent comments that we see from patients relative to walking bedside rounds. Quote, I didn't realize there were so many people involved in my care. Quote, I have an opportunity to ask questions. I actually got to talk to my doctor. An opportunity to ask questions and talk to the physician are important, and I think it's also very impressive when that patient sees how many people are working together on their behalf. Now, there were some mixed reviews from the nurses. Nurses reported they were better informed about the daily plan of care from all the disciplines, because if you think about it, each discipline caring for that patient is going to have their own professional plan for that day, and what you want to do is you want to make sure that all those disparate plans cohese together for that patient. The nurse hears what the physician tells the patient, as I was alluding to earlier, oh my gosh, so many times what happens is the physician goes in and says, oh, you can stay till tomorrow, and then the nurse or the case manager goes in and says, okay, we're discharging you today. Well, my doctor said I could stay till tomorrow. You know that one. They've also found that calls from the nurses to physicians decreased. Well, sure, if you can ask your questions face-to-face, you're going to have less need to call that physician throughout the day, and the rounds were time-consuming for the nurse. We're going to talk about that, because there's no reason for that to happen. That's a structural problem in the way they put their rounds together that can certainly be avoided. The Center for Patient Safety put this out, old paradigm, I know you'll be able to figure it out. Just get it done the best way you can. A new paradigm, in order to have consistent results, we must do things the same way every time. So, variation in processes leads to errors, and so you want to have standardized work. You want to have standardized rounds, standardized handoffs, and again, these will reduce errors and problems. The other piece of this, when we talk about care coordination, we're also talking about patient flow, or how the patient transitions, let's say, through the acute care continuum. So maybe they come in through the ED, and then they're going to move through that acute care continuum toward discharge. So this is critical to your patient flow, because it helps reduce any barriers or delay issues, because you're addressing them real-time. Again, it's not report. Reporting rounds or bedside rounds should focus on the inpatient plan of care, expected outcomes of care, barriers to care, transitions in the hospital, and the discharge plan. So, as case managers, we may know what those barriers are. We should know what the preliminary discharge destination is going to be. We have lots of information that we need and want to share with the interdisciplinary team that helps everybody understand. If you're going to have a discharge delay, the rest of the team should know that. It shouldn't just come as a surprise at some other point in time. The daily hospitalists, we're going to talk about hospitalists also during this series, but this is interesting. This is a publication for hospitalists. So they publish their daily game plan from the hospitalist's point of view. Hospitalists typically lead multidisciplinary teams. Okay, I think that's true. In hospitals without hospitalists, or when a hospitalist just starting out defers to a nurse leader, where it makes sense for nurses or case managers to take the lead. As I was saying earlier, when you don't have a hospitalist, or in this case, maybe that hospitalist isn't prepared to lead rounds, somebody else can certainly take over those rounds. In the absence of a hospitalist and a community-based physician, well, the case manager, maybe the charge nurse, may have to take that role over, although they're certainly not going to have all that clinical information that that physician would have. The hospitalists like that mornings, either before or after new admissions have been processed, seems to work best. That way, discharges can be handled after rounds. I don't know that we, I don't agree necessarily that we should structure our timeframe before or after new admissions, because admissions don't come in in one big block, typically. So I would have to disagree on that one point from the hospitalist. So as we've been saying, we have two points of rounds in terms of focus, coordination of care, and communication. So for coordination of care, we have coordination among the disciplines. So we're going to coordinate that care through our communication and sharing of information. We're going to review the patient's current status, clarify the goals for our patient and desired outcomes. And those outcomes are not just for discharge, but they should be daily outcomes as well. And we're going to look at some examples of those and then create a comprehensive plan of care. So to encapsulate this, I like to think of it as what happened yesterday, what needs to happen today, and what needs to happen to move that patient toward discharge. Very simple. On the communication side of rounds focus, you're going to identify safety risks because you've gone to the bedside. You're going to identify those daily goals. You may provide some very quick patient education. And you're going to have a consistent approach by all the team members in terms of what is communicated. And again, I think that's pretty important. So if you are considering developing walking bedside rounds or you are trying to maybe fix up rounds that you already have, there are some key things that you want to bear in mind. Identify or refine your goals for rounds. What is it you're trying to accomplish with your rounds? You want to create a structure. You want to stick with that structure. So as I said earlier, this should be mandatory and it should be hardwired in the sense that the structure that you've got is the same structure every time. You also want to have a leader. So there should be a leader. Maybe it is a hospitalist. The hospitalist leader, when they know they're going to be off, should make arrangements for someone else to take their place. And maybe it's the charge nurse. But it shouldn't be that everybody shows up on Monday and the hospitalist is on vacation and nobody knew. So you want to make sure that there's good handoff from the leaders as well. Take a standard time. This is also really important. You don't want to just go, okay, everybody, let's meet for rounds and everybody is fumbling around. They need to know that the rounds are at a specific time so we can be ready for rounds at that time and be prepared with all the information that we have to have. You also want to engage the patient and family. I think this is one of the major reasons why this has become best practice because patients and families get pulled into the process, pulled into the communication, education, and pulled into an understanding of what's going on with their family member or friend. And then also you want to think about how you will measure success as you go forward with your rounds. Who would be the key members of the rounding team? I put the minimum folks here that should attend rounds and really is minimum. So you want to have your staff nurse, your physician, whomever that might be, hopefully, and the case manager. So that is really the rock bottom, if you will, folks who should be on your rounds. Of course, you want to add other people like a physical therapist, if that's relevant, or a respiratory therapist, anybody else, any other discipline that's relevant to the care of that particular patient. Now we didn't get to it yet, but we're going to talk about huddles in a moment. So just remember that slide 25 gives you the appropriate staffing for huddles. So the huddle is a shortened version of rounds that takes place in the afternoon, and these would be the key members of huddles. But they're the minimum staff for rounds, and I hope that makes sense. What makes effective communication on ROUNDS? First of all, everybody has to do their homework and be clear and complete in what information they're sharing. It should be brief. Again, using talking points or using scripting will help to keep the information brief and relevant, and it should be timely, meaning it should happen in an appropriate period of time, not three hours, that's for sure. Communication and teamwork on ROUNDS can help you in so many different ways. Not all of these are measurable, but they will be tangible to the members of the team. Errors can certainly go down. Now, that's one that you could measure. Minimizing strain among the team members. Think about not having to run around looking for different people throughout the day. Because you're talking together, because you're meeting together, you're building trust as a team. The team can learn to be more adaptable because you're hearing from the other disciplines and what their issues may be or their daily goals may be, and so the team can adapt to issues that may come up. This strengthens the team and improves the effectiveness of the team. So there really is no downside to doing this. In fact, you will finally have a true interdisciplinary team that is effective and works well together. So there are some key structural points for you to consider. You want to assign leadership, as we've discussed. You want to select your team participants from the interdisciplinary team appropriate to the unit's clinical specialty. So if you're a cardiac unit, as an example, you may want to have a specialist, perhaps, perhaps not. If it's a respiratory care unit, you want to have respiratory therapy. If you're neurosurgery, orthopedics, you're going to want to have physical therapists. So you want to think that through in terms of the clinical specialty. You want to make sure you have all the relevant disciplines represented. Each time you go to the bedside, you're going to restate the focus of your rounds very quickly to the patient and family, and then you're going to develop your daily care goals. Daily care goals are really important. If you're thinking about managing care and you're thinking about managing length of stay and care coordination, you can't really do that unless you know what you're trying to accomplish for that patient each day. And so it should be two things, the goals for the day and the goals for the stay. So you're going to have daily goals, and then you're going to have the things that need to be accomplished for a safe and appropriate discharge. You want to document those goals, and they should be documented in a couple of places in the medical record. And a lot of the EMRs now have a component built in for rounds, which I think is really great because one of the big difficulties is documentation of rounds. And frankly, if you don't document it, it's like it didn't happen, as we all know. So having a streamlined, easy way to document is really important as well. But you can also put your goals on that whiteboard in the patient room. Remember, the whiteboard is for communication of information to the patient and family. I've seen some hospitals where they start to use the whiteboard to communicate among team members. That's really not the purpose of that whiteboard in the patient's room. It's for us to communicate to the patient and family. And one of the best ways or best elements to communicate to the patient and family are those daily goals and maybe even some discharge goals. And so you're going to have that daily feedback among the team members to refine the goals and reset them if you need to do that. So maybe something didn't happen like it was supposed to happen, and so you have to either augment the care delivery or extend the expectation of when that goal will be accomplished. So here's some examples of daily goals. Discontinue oxygen by 4 p.m. Wean off vasopressors by midnight. Mobilize the patient to walk 20 feet. Obtain patient agreement for hospice referral. So some of these, maybe the first two belong to the staff nurse, one belongs to the physical therapist, and one to case management or social work. So you see how they kind of all go together. IHI, Institute for Healthcare Improvement, which for many years now has been considered a leader in terms of patient safety, patient quality of care, and so forth, also, as we said, believes in patient rounds being best practice. So what they're recommending is if you have some kind of rounds now, well, why don't you leverage parts? So maybe you do do rounds in the nurse's station. Well, you can take that and transition that into a true walking round structure rather than just starting from scratch because people may resent that, you know. Well, we already have rounds. Okay, well, let's see which pieces of our existing rounds can be salvaged. If you're piloting your rounds, seek a unit where you think you're going to have success and you have willing participants. Maybe you have a hospitalist who's raising their hand or a nurse leader who's raising their hand and saying, please let us start, and that does happen. Start small. Test small and often. So maybe, you know, you start with one part of your unit. Test it out and see how it goes and modify if you need to do so. Choose one process to focus on at a time. So maybe it's time management. Maybe it's scripting and what folks are saying. You know, it could vary significantly. Again, you want to develop and document a daily goal, at least one daily goal for each of your patients. It could be certainly more than one, as we just saw. Probably will be more than one, but at least one. Use a short, simple tool to help guide rounds. Again, that structure is important. Eventually, you may not need that anymore, but particularly in the beginning, when people aren't quite sure how to navigate this thing, some kind of a tool to help guide the rounds can be helpful. Again, some support staff sometimes. I mean, we certainly don't want to take the time of pastoral care to come to every round. First of all, they can't be on every round on every unit, but you may have one unit in particular where you've got some patient issues and you may ask them to attend. Track your interventions. Get feedback. Hear from everybody how it's going, because that's the only way you're going to figure out how to make it better. Segmenting rounds. Remember, we talked about Catawba Hospital and the nurses felt the rounds took too long. Well, segmenting rounds is how you address that issue. So let's say, I'm just thinking, let's say we have a 15-bed unit. I know that probably doesn't exist, but let's just say we have a 15-bed unit and the staff nurse has five patients. So for those 15 beds, we have three staff nurses. Well, we certainly don't want those three staff nurses just to have to listen to all 15 patients. That's, I don't want to say a waste of time, but it's not the best use of their time. So we do something called segmenting. So we're going to start with Nurse A's five patients and then Nurse A can move on and do what she's doing and we're going to then move on to Nurse B's five patients and so forth. So you're using the staff nurse as your frame of reference in that case. And if you think about it, if you're looking at one to two minutes per patient and staff nurse A has five patients at the most, you're asking for 10 minutes of the staff nurse's time in this example, 10 minutes. And think of all the information that that staff nurse will receive that will help streamline her care too and save her time. So 10 minutes devoted to this will save a lot of time. So that's how you get around some of these time issues that we hear so much about. And again, getting back to our cardiac unit, you may have a specialty physician. I've had units where we had a heart failure specialist, almost like a heart failure hospitalist, on the cardiac unit. So you might want to segment those patients so that those patients can be discussed with that physician. That's also another way to do it that can be extremely beneficial. And we talked about rounding with hospitalists. Again, you're going to rotate your nurses in and out. If your hospitalists are geographic, and by that I mean they're assigned to a nursing unit, well, you got it made because that's the most efficient way, obviously, to use the hospitalist. And we are seeing that starting to happen more and more. Physicians, we're in a different paradigm. You know, they had their assignment of patients and then those patients could be anywhere in the hospital and they're running around all day, too. And when they're running around all day, they're surely not able to attend rounds on multiple units. So that makes it very difficult. So the fact that we're seeing more movement toward geographic units for hospitalists, I think, is great. And just as an aside, we're starting to see the same thing happening with physical therapists. Physical therapists also had the paradigm of running all over the hospital, but we're starting to see them geographically assigned as well. And what you'll hear, the reason they don't like this so much is because they lose some continuity as patients may transfer off a particular unit. But there's more pros than cons if you really sit down and work that through. But it can be difficult to get them to think this way. But if you've got your hospitalist and your physical therapist and the rest of the team all on that unit, well, how much more efficient is that? I tell you, I think it's a great thing. But even with all this good planning, you know there's going to have to be those days where things have to be flexed this way or that, and that's just understood. Okay, so I've been mentioning scripting. So let's talk now about scripting because the reason why scripting is so important is because it gives you an opportunity to delimit the information shared, keeping it to the most important and relevant pieces of information, and that also helps control the time allotted. So you should have standardized or key questions that are going to be asked among the team members. You should have a goal sheet or some other tool. If you're doing this electronically in your EMR, well, certainly somebody can scribe or enter the information. It's usually drop-down, and they can bring a laptop or some other device into the room and do this fairly quickly. That was always a barrier before we had electronic solutions. It was always a barrier. Who is going to document this is very time-consuming, so that certainly has gotten better. The team is going to stand in the hall first, and academic-type discussions, heavy-duty clinical discussions are going to happen in the hallway first. And again, those should be kept to a minimum, and if there's a deeper or longer discussion needed, well, certainly that, again, can be taken offline. So it's a quick discussion in the hall and then to the bedside, allowing 60 seconds per patient on the average. You're going to have ones that take longer and others that are quicker. Maybe the patient's asleep, for example. So it all should average out in the end. If the patient starts asking a lot of questions, okay. Tell them you'll come back after rounds and spend more time. The other thing is you don't want people running out of the room to get pain medication or tissues or water or whatever. So you want to educate your support staff to be on standby to get water or tissues, and then there should be a designated, let's say, staff nurse if pain medication is needed quickly. So I'm going to give you in the next couple of slides, three slides or so, the kinds of information that should be shared. Now, that's not to say every one of these has to be spoken out loud. You may have a tool, something printed out for folks, but most of this information should be shared. Obviously, if you're standing at the bedside, you don't have to talk about the room number and all of that, but you should say, it's day two of an expected length of stay of five days, what have you. Who are the members of the primary team? Remember we said earlier that so many times people don't know who the actual team members are, and so let's talk about who the primary team is, what the patient's code status is perhaps, any relevant family information or insurance information. So case managers, social workers, you can certainly quickly say, this patient has traditional Medicare, or this patient has a particular managed care plan, you know, whatever it is, because if it's a particular managed care plan, that's difficult to get approval for, you know, that may delay things, and the team should know about that. You can use what they call a diagnostic one-liner, including age, sex, relevant past history, all sort of in one long sentence, chief complaint or reason for hospitalization, and it should be the reason, the true reason for hospitalization. If the true reason for hospitalization was the family left the patient in the emergency department, then that's the reason, albeit inappropriate, that's the reason. And then a problem list. We're all familiar with those, pertinent past medical history, systems-based list of current problems, any invasive tubes or devices. Expected tasks to be completed. So you're waiting for that MRI to be done, and then what are you going to do with that information? The physician can talk to that. Tests to order or follow up on. You can even use, if your hospital allows, if-thens, frequent issues to be expected with a plan to resolve in if-then format. And I've seen this in a lot of hospitals. They're almost like standing orders, and they can really save time. If hypertension, and of course, they would have to give you a definition, what the blood pressure should be, please give hydralazine. That saves, again, a lot of time. I see that a lot in ICUs more than on floors. Therapeutics, so what therapeutics is the patient on? Medications, IV meds, okay, and when can they be transitioned to oral? That can be a big length-of-stay issue if that transition doesn't happen in a timely manner. Diet with maybe diet progression or weaning orders, oxygen with weaning instructions, and progressive ambulation. These therapeutics, just these five things, if you're on top of these five things, this can have the greatest impact on managing your length-of-stay. Results and other important facts can be discussed, and I know this sounds like a lot, but you'd be amazed at how quickly this can all be put out there. Labs, cultures, radiology test results or consults, case management, expected against actual length-of-stay. Again, the physician may or may not start off with that when rounds are started, but you certainly can jump in and speak to the expected length-of-stay. If you don't have one, then the team should decide what the expected length-of-stay should be. The physician should have a sense of the plan, again, the plan for the stay and how many days they anticipate that should be. That doesn't mean it's a hard and fast rule, but it's a goal to work toward if it's going to be four days or three days or five days. And again, any patient care barriers. So case management can be represented by the RN or the social worker, depending on how you have your model designed. So it could be social issues, insurance issues. It could be issues in the community. So during the rounds, determine the key goals for that particular day. Oh, I'm sorry, this is a repeat slide. I'll have to delete that. But in any case, we can... I'm just writing myself a note to take this out. Okay. Thank you. All right. Again, you want to provide feedback and reflection on the progress toward those goals every day. So let's say our goal was for the patient to ambulate 20 feet, as we saw earlier, and the patient was only able to get to the bathroom and back. Well, everybody needs to know that because that might require some different approach. Maybe physical therapy isn't as involved anymore. Maybe they have to come back. You can start to see how the patient's progress will impact on the interventions that are needed. And then the other huge advantage, as I mentioned, is engaging the patient and family in the rounding process. So you should invite them to participate. This can be a very powerful and positive tool for family members. Before you invite them or before they attend, you want to make sure they are oriented. So they should know what the focus of the rounds will be, what the routine will be, and what the expectations should be. So they can understand that it's very quick, that you will be able to ask some quick questions. This team will be there only for a couple of minutes. Whatever other information you may want to share with them. The other really great thing to do is post the day and time of rounds in the patient rooms. That can be on the whiteboard, near the whiteboard, and if you can also put it maybe somewhere else in the nursing station, I don't know, anywhere that you may be able to also put that out there. You should also discuss it with the patient during their initial admission assessment, so that they can maybe speak to their family about that. You're going to start with that brief introduction to the patient and family each time rounds happen at the bedside, because that's sort of level setting each time. The purpose, the time, and encouraging them to participate. Here I just gave you an example of what a sign might look like. So rounds to be conducted in patient rooms at 930 a.m. daily, family members are invited to attend. That's very simple, no big deal saying, and you will please note I have 930 there, because I think that's a sweet spot for rounds. So if you come in at 7 a.m. or 8 a.m., that still gives you enough time to do your homework, so that you are prepared to speak to your patient population on those rounds, and still early enough completed to allow you to do what you need to do for the rest of the morning. Okay, so in the next several slides, I'm giving you again kind of a structure here, and you'll notice the balls there, pre rounds, rounds, and post rounds. So this is your provider, so this could be your hospitalist, your community based physician, it could be a resident or an intern if you're in a teaching hospital. Actually, I have a resident one next, so erase that, this is your physician provider. They should know what happened in the last 24 hours, they should discuss the working diagnosis, or actual diagnosis if there is one, they should enter any patient orders, and review the preliminary plan for discharge meds and testing. So in other words, they're doing their due diligence before they attend rounds. Now the thing that, I know you're not going to believe this, but the Joint Commission is encouraging us to sit next to the patient, and to speak eye-to-eye with them, as opposed to kind of hovering over them at the bedside. So this is okay, it's encouraged actually, it improves the communication. Introduce the team, this should happen every time, name and discipline, interview the patient, get their story, again, very quickly, discuss the plan, what the patient should expect to happen, and answer any questions. And some of this can be on the whiteboard, saves time. After rounds, the physician might enter orders, or clarify any issues, progress notes, if consultants need to be called, or family members need to be called who were not present, they can do that then, and summarize their expectations to the team members. So again, a very formalized structure for your physicians. For you folks who are in teaching hospitals, if you have residents, I love chief residents, I worked most of my career in teaching hospitals, and I always enjoyed the chief resident, they seem to know more about the patients than anybody else. And so, pre-rounds for them, they might be presenting the case to the attending physician, or the physician who they're, you know, working with. Update the team on the patient's condition, give recommendations for the plan of care, enter any orders, including meds. And then they are, so they've done all that, and they're going to support the attending physician during that assessment of the patient, and help answer any questions. So they're really there to support that hospitalist, or community-based physician, whatever the case might be. After rounds, enter orders as needed, enter progress notes, and call consultants, and discuss medication reconciliation with the pharmacist. Yes, pharmacists can attend rounds too. The staff nurse pre-rounds, again, your staff nurse should be up to date. Now, they've already had their change of shift reports, so they've gotten that information, maybe they're gathering other information. They're going to focus on any abnormal findings, obviously, so they can bring that information forward. Any patient or family concerns that have been identified, any barriers that they may identify relative to patient discharge, that might be different from what case management might identify. And then review orders such as activity, Foley, IVs, wound vac, anything like that. During rounds, somebody, could be that staff nurse, somebody else, brings the laptop or other device to the patient room, again, to do that real-time. Documentation that I mentioned earlier, listen to the conversation with the patient, answer any questions, and note orders to be placed later. And then after rounds, verifying orders, medication issues, you know, any remaining concerns. The RN case manager, now again, folks, you do have lots of information that you should be sharing. So before rounds, you're going to look at the patient's status. Are they inpatient or observation? And you should tell the team of that. If the patient is observation, which means they are outpatient, if you have a scattered bed approach to observation, the team needs to know this is an outpatient, and we want to expedite throughput for this patient. If you weren't the one who did the admission assessment, or even if you were, you want to review it, review the initial discharge plan, the patient's insurance, the expected length of stay. So lots of data sets for you. And then you can discuss all of those on the rounds, the length of stay, the day of discharge, the discharge plan, such as it is at that point in time, any additional patient education needs, any social work triggers for referral to social work. Clarify the next steps based on the patient's goals that have been achieved. Document changes to the discharge plan. So maybe based on the conversation that took place, maybe you have to change the discharge destination, for example. For our social workers, you may be the one attending, it may be either the RN or the social worker attending the rounds. So you're going to have some similarities, each discipline. But for the social worker, you're more focused on those psychosocial needs for that patient or social determinants of health, as we've talked about in other webinars. So you want to come forward when there is such an issue and discuss that with the team, because one of those issues can really derail the process. The rounding information consistent with the RN case manager, the length of stay, expected day of discharge, discharge plan. And this is a time to discuss that with the patient and family right there at the bedside and the physician. If you are the social worker picking up that case, you can begin your psychosocial assessment with a few key questions. And then after rounds, again, all that documentation. And then you're going to go back and do the more in-depth psychosocial assessment. There's our registered pharmacist. I've worked in many hospitals that have the clinical pharmacist present on rounds. Again, they may not be able to attend all the rounds, but I see sometimes, particularly, let's say a geriatric unit or a medical unit that has older patients, and you may have polypharmaceutical issues, that's a good place to ask the pharmacist to be a member of that rounding team, because you may have issues that they need to work on with you. So they're going to look at the progress notes, look at the medication and medication reconciliation, PRN med use, and so forth. And they're going to look at all of that against laboratory information. They're going to listen on rounds. They're going to answer any questions the patient might have, and note orders to be placed later, and then do all of that follow-up after rounds. So they're a good member to have. The other member that folks don't always think about, but that I've done many times and found it really helpful, if you have a clinical documentation improvement specialist, and I like to see them also assigned by unit, if you've got enough of them to do that. That can be a whole other discussion, because I often see them assigned by payer. I think, again, you lose that continuity on a unit, but if they are assigned to a unit, they can become a member of the rounding team. And what happens there is they can hear what the physician's thoughts are, what the physician's expectations are. Just take that in and make sure that what the physician's expectations are are consistent with the documentation in the medical record, and that the medical record supports that. Otherwise, they can query the physician for additional information and documentation. Okay, so talking points. We have some just general information regarding rounds. Sure, we would love rounds to be seven days a week, but I can tell you, very few hospitals have the bandwidth to do that. So a minimum of Monday through Friday at a consistent time, and as I said, I recommend 930. All critical members are expected to attend. The physician or nurse manager will facilitate rounds, and again, one to two minutes per patient. This is, you know, standard stuff. Process. Each person participating has talking points or a script, and everybody has to stay on script. I mean, it's okay if somebody starts going off on a tangent for somebody to say to them, let's take that offline when rounds are over. That's perfectly fine. So the physician and staff nurse are bringing forward clinical information, the plan, the clinical assessment, the expected outcomes, and maybe those, again, are for the day and the stay, the expected length of stay. If that isn't forthcoming, case management should really push to get that information. If they know the discharge plan, they can contribute to the discussion of that, or if they know of any barriers to care. So the RN case manager, discharge plan and status barriers that we may have identified, any reimbursement issues or other insurance-type issues, expected length of stay. Social worker, if you are representing case management, you're going to do all of the above, but you're also maybe adding psychosocial issues or barriers to discharge. And if you have a respiratory therapist or a physical therapist or an occupational therapist or speech and swallow, or a nutritionist, you know, there are certain units where speech and swallow may be really important, along with physical therapy. They're going to talk about the interventions they're providing and their goals of care and any barriers they're coming upon that also may be barriers to discharge. So they are bringing, again, their vantage point, their point of view. Now, this is a checklist that I have used, and you could take a look at this. I think it's one, let's see, three slides. So what we have essentially is sort of these different things that should be addressed. And then I've got the person or the role responsible for reporting out on that issue, what the status is of that issue, and what the follow-up is if one is needed. And again, this can be automated. It's similar to what you might find in the EMR, but you can take something like this, and it's very quick, you know, to check off. You can have drop-downs for a lot of this stuff, so people aren't typing, typing, typing. Excuse me. So you can see I'm just looking down on the goals of care, aggressive, palliative, unknown, you know, expected discharge disposition. Was the patient out of bed in the prior 24 hours? If not, why not? Oh, gosh, I still see that a lot, where patients are not gotten out of bed. Catheters, IV, you know, all the things we discussed. Working diagnosis, if you do that, or working DRG, rather. Expected length of stay, what is the day of hospitalization, expected discharge date. All the things we've been discussing are kind of formatted here, so you can see how quickly they can be done. What is the plan for the next 24 hours? What can we expedite? What can be done as outpatient? That should take place on rounds on every patient where it's appropriate, you know, so that everybody's aware, no, we don't need to do this. While this patient's still in the hospital, they can have that care given as an outpatient. Pending results of tests and consults, medication review, barriers, real quick, real quick on each one of these. Now, I mentioned huddles earlier. So, if you have your rounds in the morning at, say, 930, like I mentioned, there will be some outstanding issues to be followed up on in the afternoon. So, in the afternoon, those three key members, I asked you to remember that one slide, and we had the case manager, we had the staff nurse, and we had the physician for our huddle. So, this is a shortened version of your care rounds that took place in the morning, and it's typically done as a follow-up, and it's typically done to address only the outstanding issues from the morning. So, it's a subset of all the patients. You're not going to go through all the patients like you did in the morning, but for those patients that had an outstanding issue, maybe they have been waiting too long, let's say for an MRI, however you define too long, somebody is going to look into that, and the designee to look into that should be decided upon during morning rounds, and then the outcome of that can be discussed in the huddle in the afternoon. Rather than waiting 24 hours until the next morning, things can get resolved same day. So, the huddle in the afternoon is important. While I say it can be scheduled or impromptu, I do recommend that it's scheduled. So, if everybody knows at 2.30 we have the huddle, we can come prepared. If you're just gathering people together randomly, they may not have been prepared at that moment. So, if I know I have to huddle at 2.30, I'll be ready at 2.30. So, again, this is what you're going to talk about, those outstanding issues. I have to tell you, this can really, in a big way, impact also on your length of stay, because just think about it, you're not waiting, as I said, you're not waiting until the next day to say, did that MRI get done, or not, or why not, or why didn't the patient go to the OR, or whatever it is. You can deal with it in a much quicker fashion, therefore, really, you know, moving things along. It's also part of your care coordination process. So, of course, we want to see that this thing that we're doing has an impact. These are some of the things the IHI has identified. So improved communication and teamwork across caregivers, reduced duplication and redundancy, reduced length of stay, improved patient flow, reduced errors, expedited discharge planning, and increased collaboration and satisfaction among all members of the team. So these are the impacts that the IHI has identified in terms of these rounds. And then you also want to look at your process measures, and this should be done at a leadership level. Number of days per week that rounds occur or don't occur. You can do it either way. If you say this is hardwired five days a week and somehow on Tuesday rounds didn't happen, you need to track that and figure out what happened there. Number of disciplines involved. You may find that there's a particular discipline who often doesn't attend. Percentage of patients with a documented daily goal in their record. Did folks adhere to scripting and talking points? If you're the leader evaluating this, you're going to have to drop in on rounds, you know, various rounds. There's no other way to know that some of these things are happening, especially with the scripting and the length of the rounds, 60 to 90 seconds per patient on the average. Outcome measures, reduction in length of stay. So the primary nurse, the hospitalist, or the case manager are discussing the team members' recommendations with the attending or consulting physician if they're not present and the recommendations are evaluated and implemented. Reduction in ICU patient days. The team members identify stable patients who can move out of the ICU by looking at all of their clinical information. And then the primary nurse or clinical coordinator, case manager, collaborates with the physician regarding patients that may be ready for possible transfer out of the ICU. Reductions in morbidity and mortality. A proactive approach to patient care through collaboration and the use of evidence-based care bundles helps care goals become realities. Again, IHI. Quick assessments. Doing rounds enables the team to have a quick sense of the patient's progress by looking at their appearance and communicating with them. You can look at that patient and get more information in that look than reading the medical record in terms of their mental status and their physical appearance and how they respond to you, if they're connected or not connected, and so forth. Really, that physical look is critical. And you can have an environmental check done. Removing unnecessary supplies and liens is reinforced to the nurses and patient care technicians, you know, as we strive to integrate this into hospital culture, so you don't want a lot of extra resources or supplies floating around in the patient room. Safety check. Side rounds provide another opportunity for rounding on patients who are at risk for falls or who have the potential to pull their life-saving devices or liens. So nursing likes the environmental check and the safety check because these are things that they need to keep track of, as well as that regulatory check. As an example, an assessment of the number of side rails used as a regulatory compliance check can be made during rounds. So these are buy-in issues for the nursing department. Patient satisfaction. Patients are glad to see members of the team, in addition to the staff involved in their care, and appreciate the incorporation of holistic care. I really do agree with that one because I've seen it and the patients love it. Staff satisfaction and education. Staff members share related information and evidence whenever necessary and participate in the promotion of a culture of safety and quality. Ventilator days. I mean, you begin to see how many different things can be impacted by this. Team members identify stable patients who can wean off the ventilator or be removed from the ventilator by reviewing their clinical picture and so forth. The staff nurse collaborates with the physicians and respiratory therapists regarding patients identified for changes in ventilator use. Number of pharmacy changes, such as discontinuing antibiotics. Did the change occur in a timely manner and when clinically appropriate? Number of discharge delays. Were they associated with communication delays or care coordination delays, perhaps? Okay, so let's just quickly look at a few hospitals that have had some success stories that they have been willing to share. So Cincinnati Children's Hospital, post-implementation, the staff, including the bedside nurses, felt more knowledgeable about the care plan. Care errors decreased from 9% to 1%. Decreased overall daily time per patient, although rounding took 20% longer. Okay, well, we would have to know what that meant. Increased patient satisfaction and increased faculty and learner satisfaction. Intermountain Healthcare in Colorado, they focused on CVA patients specifically. And these are some of the things that they reported. The social work slash case management no longer unilaterally deciding disposition for CVA patients. And that should never happen, regardless of the unit or anything else. Any discharge destination should be determined through the team and, again, not by one individual, any one individual. Increased camaraderie among members of the team. Yep, we saw that earlier. Palpable relief for the hospitalist service. Length of stay for CVAs improved. Onset day for rehab significantly improved. And a higher percentage of eligible CVA patients admitted to the specialty unit. Sure, if you're moving those patients through in a more timely manner, then rather than having your CVA patients scattered all over the place, you're going to open up those specialty beds, you know, for those patients, and that increases quality of care. Concord Hospital Cardiac Surgery Program, after implementation, decreased mortality by 50 percent, increased patient satisfaction to the 99th percentile, and improved staff satisfaction. MCG Health in Georgia. Three years after implementation, improved patient satisfaction from 10th to 95th percentile, decreased length of stay by 50 percent, decreased RN vacancy rate from 8 percent to 0 percent, increased faculty and learner satisfaction. Texas Health, Presbyterian Hospital of Dallas. They focused on critical care. They had improved patient outcomes, improved communication, greater collaboration between all members of the team. The medical intensive care unit has not had a ventilator-associated pneumonia, central line infection, or a hospital-acquired ulcer during the five months of the study. And they felt they had a healthier work environment. So you can see some hospitals focus on one thing or another, but all report really amazing results. So in terms of your practice implications to support your rounds, you want to make sure you have effective practices in terms of the structure and processes of the rounds, and we've talked a lot about those today. Electronic support, again, that could be a sticking point, but if you've got it, it will ease the cumbersomeness of the documentation. Decreases in patient transfers, reducing the number of those handoffs, and you have standardized health care teams. Specific goals. First of all, some of you may remember Dr. Deming. Dr. Deming was considered the father of quality, and he said reducing variation improves quality. I alluded to that earlier. You know, if everybody's doing it a different way, then things aren't standardized to the extent that things get missed, overlooked, dropped, you know, all that stuff. So you want to aim to understand and reduce the variation in how you do this. Highlight the handoff as the transfer of professional responsibility, detect and correct vulnerabilities in your handoff. Again, if you can standardize it, that's the best way to achieve all of that. So as we can see, walking rounds do make a difference. They make the patient the center of activity. That alone says a lot to your patient and family. Within 30 to 60 minutes or 30 to 60 patients, the team achieves a patient interaction, focused quick assessment, plan of care discussed, safety check, environmental check, and regulatory check, and staff education. That's a lot. And you'll see a cultural change in patient care with your walking rounds. Within the current demands of healthcare, this culture of safety, transparency, efficiency, collaboration, and autonomy makes a big difference in the quality of care patients receive. Okay. Well, look at that, Lindsay. We're on the dot, 1131. I'm going to turn it back to you. Perfect. Thank you so much, Dr. Sesta. Perfect timing. Sorry for all, I had to drink so much water today. Oh, you spoke for an hour and a half, so breaks are definitely needed and expected for sure. Okay. So we have, I know we advertised a session for two hours, just so that we would make sure to have time for your questions at the conclusion of the presentation. So if you are sitting on a question, go ahead and type that into the Q&A option found there at the bottom of your Zoom window, or if for some reason you don't see that as an option, you can of course type in your questions there into the chat window. And while you are doing that, let me just take just a moment to give you some closing comments as well. I'm going to put some information here for you in the chat, just as a quick reminder that you will all receive an email tomorrow morning, but just note that it will actually come from educationnoreply at zoom.us. And so, because it does come from that Zoom email, it may get caught up in your spam or your quarantine, possibly your junk folder or something of that nature. So if you don't see it in your inbox in the morning, I would encourage you to just check those additional folders. And then if it's still not there and you would like to access the recording, you can always use the same Zoom link that you use to join us for today's live presentation to also access that recording. And then just remember that the recording is available for 60 days. And then we do have an additional security measure in place of manually approving each of those recording access requests. So if you haven't joined us for a webinar before or accessed a recording of a webinar with us before, you will just need to click on that Zoom link and then you will type in your information. That will prompt an email to come to us for approval. And then as soon as we receive that request, we do grant that approval, assuming that it is a legitimate request, typically within just a few moments of receiving it. But we ask you give us one business day to approve those requests. And then again, you will have full access to the recording for 60 days from the date of each live session. That applies to each of the sessions that are in this five-part series. And then also included in that email will be a link to the slides that were presented today. But I did go ahead and provide that link there for you in the chat. So you can have that as a resource now as well. Okay. It looks like we had one question or comment here that says, I'm at a level one trauma safety net hospital and 100% academic facility. Have you had the experience with this type of facility and how hard it was to implement around all the teach rounds? Well, I don't envy this issue. Oh, the question went away on me. Oh, I'm sorry. I can put it back up for you. Oh, okay. Thanks. I want to make sure I'm addressing it correctly. Yeah, absolutely. Yeah, I mean, I have. I've worked in safety net hospitals. I worked in a hospital that was 85% Medicaid and a level one trauma center. And an academic facility such as you're describing. It wasn't as hard perhaps as you might think. I think when you're in an academic facility, folks get it. However, I think what you're probably referring to is the morphing, as I like to say, of teaching rounds with rounds. I think you have to get with your medical leadership. We're not taking anything away from them, but it's apples and oranges. And so what I typically try to get them to think about is doing the rounds at 930, and then they should have their teaching rounds after that. And if you can get them to at least try it out. When people are really pushing back on something like this, asking to do sort of a demonstration. I don't like to say pilot. I know I said pilot this morning, but demonstration always sounds less temporary to me. Pilot sounds like, well, if we don't like it, you know, we're not going to do it again. Say demonstration. So allow them to participate, you know, or ask them to participate in the rounds at 930, and then ask them if they would do the teaching rounds afterwards. I mean, you know, they have to realize that the goals for each are very different, and to not expect the rest of the team to stand there while they're teaching a resident or an intern about one clinical thing, one clinical aspect, is really not fair to the rest of the team. So I think if they understand the goals of the rounds and the goals being significantly different from teaching rounds, I hope for your sake that that will make it work. I know that person asked anonymously, but if you try that out, would you email me, whoever you are? I'd love to hear how it went. I hope you have strong medical leadership that you can get to support this. And don't neglect to mention the Joint Commission and IHI because sometimes that helps too. Perfect. Thank you so much. And you do see Dr. Sesta's contact information here on the screen. And like she said, I know she'd be happy to hear a follow-up from you. And then in that same vein, if you have additional questions that you may just not think of today or possibly after going back and listening to the recording or sharing information with your colleagues, please don't hesitate to send those questions over to education at gha.org. And we'll be happy to get those to Dr. Sesta. She is so kind in taking the time to send a thoughtful and timely response. So we certainly appreciate her doing that. I just put that email address there in the chat for you all. And I do see a question here asking about CEs. And thank you to Karen for asking that question. If you are joining us as a member of the Georgia Hospital Association, we will send an email at the conclusion of the series that will include a link to a survey that you will need to complete. And then we are providing ACHE credit for this series. But you can, of course, use the certificate of attendance that you will obtain upon completion of this series to self-report any other CEs that are applicable to you and your license. And then if you're joining us as a member of a partner state hospital association, please reach out to your contact at that hospital association to obtain any further information regarding the CEs that they may be offering for this series. As GHA is only able to provide CEs for GHA members. So I hope that helps clarify that question. Okay, Dr. Sesta, I don't see any other pending questions here in the chat or the Q&A. So I want to thank you so much for being back here with us for this series, for getting us started in part one today. We just are so thankful for the opportunity to work with you again. And thank you for sharing your time and information with us. We look forward to having you back with us and all of our attendees for part two next week. Be on lookout for additional information on how to join that session and the slides that will be presented. And again, if you have any questions between now and then, please don't hesitate to reach out to us at education at GHA.org. And we'll be happy to help in any way that we can. Thank you so much for joining us and I hope you all have a wonderful afternoon. Thank you, Dr. Sesta. Thank you. Thanks, everybody. Just lots of great comments saying that it was great. So as always, we appreciate you having a wonderful afternoon. Thank you. Bye, everybody. Thank you. Bye-bye.

interdisciplinary bedside rounds

effective communication

care coordination

healthcare

patient satisfaction

structured rounds

teamwork

standardized processes

patient engagement

geographic units

scripting

patient outcomes

teaching rounds