ABSTRACT

This paper presents an evidence-based study intended to offer a problem-solving program for reducing patient falls in clinical settings and providing nurses with knowledge for approaching adverse events in hospitals. Customer service and patient satisfaction is increasingly becoming significant in the healthcare industry. Given enough resources and myriad of choices of improving patient care services, this paper tests the hypothesis of hourly rounding as the solution for eliminating and reducing patient falls in a clinical setting. The purpose of this study is to show that implementation of purposeful hourly rounding in a clinical setting can effectively decrease patient falls and call light usage thereby improving patient satisfaction. The results of the study showed that the implication of implementing hourly rounding program would lead to successful improvement of patient satisfaction. The study analyses a theory used to determine the effectiveness of the program hence providing a conclusive statement that tests significance and effectiveness of the hourly rounding program.

Hourly rounds-involve intentional checking on patients at regular intervals-perhaps every hour. The program requires nurses and their assistants to make often rounds on even and odd hours. While making rounds, they should engage patients by checking on the “four (4) Ps” Pain, Position, Potty, and Proximity of Personal needs. Conducting hourly rounds might also prevent adverse events such as patient falls hence enhancing patient satisfaction with nursing care. The study concludes that hourly rounding program is an autonomous intervention, which provides nurses with surveillance mechanism to purposefully keep patients safe and comfortable by proactively meeting their needs. As depicted on the study, the hourly rounding program requires an implementation plan so as to enhance positive results. Otherwise, the adoption of the program might yield limited success.

CHAPTER ONE

1.     Introduction

Hourly rounding is a healthcare term referring to the process of checking on patients every hour. It may also encompass other types of consistent visits and checkups for management purposes. However, sensitivity to individual patient situation is a vital requirement to understanding the importance of service awareness. Patients are vulnerable, seeking comfort from the hospital specifically to care for them in their time of need, therefore, their safety is paramount important. Senior Nurses and their assistants have a key role in quality and patient safety in order to achieve best patient care outcome to ensure a positive experience. When nurses conduct hourly rounds, they obtain the most exact and appropriate information, as well as controlling would be patient falls.

Patient falls are among the largest reported adverse events in healthcare centers and hospitals. With this notion, incidents of falling decrease the level of patient satisfaction. The cases of patient falls are estimated to cost the healthcare sector approximately USD 20 billion every year (Kolin, Minnier, Hale, Martin & Thompson, 2010). Therefore, the goal of decreasing patient falls and lessening the seriousness of the injuries taking place at medical institutions require the adoption of quality improvement program.

This paper explores the option of hourly rounding as an effective piloting program run by the nurses with their assistants in ensuring improved service delivery. Nurses work with their nursing assistants to ensure that different aspects of patient care are checked on hourly. These include pain assessment, patient positioning, assessing the accessibility of different possessions to the patient and also checking toileting needs. For those patients whose assessment scores have categorized them as “at risk” of falls, an hourly rounding program could perhaps help in intervening because the nurse is aware of particular risk factor. While specific interventions are significant in addressing personal factors, the hourly rounding program should assess the main fall risk factors for the patient in order to develop primary interventions, which could enhance responses for falling risk factors. Moreover, conducting frequent rounds is significant in monitoring trends, evaluating and improving quality, safety, and efficiency of patient care.

1.1.  Background of Study

There are various healthcare regulatory organizations addressing the problem of patient falls. Following the publication of the 1999 report by the Institute of Medicine (IOM), the National Quality Forum produced a survey report, revealing 27 adverse events that could be prevented through the adoption of more effective care practices. These adverse effects include the disability and the death of patients caused by patient fall while in the hospital or healthcare facility (NFQ, 2007). The Center for Medicare and Medicaid Services (CMS) adopted policies objecting compensation of facilities received from care provided to patients following a significant negative hospital incurred outcome (Sherrod, Brown, Vroom & Taylor Sullivan, 2012). The serious disability and the deaths arising from patient falls that occur among the patients under the case of healthcare institutions are among the hospital-acquired conditions that could not be compensated. Among the solutions proposed to address the problem of patient falls, through the guideline summary drafted towards its prevention was the adoption of hourly rounding (AHRQ, 2008).

1.2.  Problem Statement

In most healthcare systems, there is a lack of a systematic and thorough attention paid to potential healthcare issues, particularly in aspects of falls. Recent research indicated that most falls that have occurred in hospitals show direct results in terms of patient satisfaction. Patient falls are one of the most adverse events that are commonly reported in hospitals. The causes for patient falls include intrinsic factors such as the nature of the patient, situational causes like reaching and bending as well as extrinsic causes including environmental pressures. Organizational factors such as the unavailability of equipment to assist with mobilization or staff shortages can also impact the rate of patient falls in hospitals (Oliver, Healey & Haines, 2010). Some of the circumstances leading to patient falls include cases where patients do not call for the assistance of nurses, failure of hospital employees to set the bed-exit alarm, and cases where the patient is under the influence of high-risk medication (Oliver et al., 2010). Other conditions that could lead to patient falls include inadequate patient assessment and delays in responding to call alerts or delivery of care.

1.3.  Objectives of the Study

The goal of the study is to develop a framework demonstrating the relationship between the development of service delivery among nursing personnel and a reduction in patient falls. In a theoretical context, this study presents hourly rounding as an intervention targeting reduction of patient falls in hospitals and other healthcare centers. Moreover, the structure demonstrates an existing relationship between the improvement of service delivery among nursing personnel and a reduction in patient falls. Through broad literature review, the paper will revolve around the effectiveness of initiating an hourly rounding program on patient fall rates (Pearson & Coburn, 2011).

Hourly rounding has numerous benefits useful for future researchers and practitioners in that the hourly rounding experience provides a better understanding of the effectiveness of hourly rounding in healthcare hence becoming an eye opener for others. Also, the analysis of the statistics reported through the wide array of sources will be presented as the result of the project.

1.4.  Significance of the Study

The study will help to confirm whether the goals of the study have been achieved and to form the basis of further research. The study will also be valuable for other scholars. This is important in adding information to the already existing pool of information and for the purpose of filling in the knowledge gap. Additionally, the study is useful to healthcare centers as they can strategize and reduce patient falls through implementation of hourly rounding. Also, it is helpful in allowing nurses and their assistants to identify principal methods of reducing risks of patient falls.

1.5.  Value of Hourly Rounding as the Solution for Patient Falls

The program of hourly rounding would be initiated to improve safety of patients and to reduce the avoidable healthcare expenses. Hourly rounding is not a new concept despite the fact that it had been reviewed and redeveloped (Oldrich, Kalman & Nigolian, 2012). The program entails nurses and nursing assistants and their commitment in checking the situation of their patients every hour, documenting status of individual patients. Ordinarily, the hourly rounding program involves evaluation of the situation of patients in different areas (Studer Group, 2007). The areas that must be checked include pain assessment, toileting needs, and patients positioning on their beds and facility furniture, and assessing their access to important possessions, including call buttons (Studer Group, 2007).

During rounding, nurses talk with patients and inquire about any information needs relating to the patient’s diagnosis or condition, which might put him or her at risk of falling. Through focused and frequent interaction, a nurse determines the patient’s level of understanding and cognitive ability. Additionally, adoption of the hourly rounding program enhances checking of patients needs ensuring that optimal levels of patient safety are maintained.

Hourly rounding contributes to the lowering of risks of falls and prevents increased patient falls. Research indicated that healthcare systems can be more efficient if patient falls are eliminated as a result of hourly rounding (Ford, 2008). Healthcare facilities observing hourly rounding, experience improvements in the safety of patients and also improved quality of care as well as the enhanced effectiveness of nursing personnel in the delivery of healthcare services (Ford, 2008). Hourly rounding activities encourage increased patient satisfaction relative to caregiver efficiency.

Accordingly, the scale of hourly rounding explained on this paper would enable nurses to be more customer-centric making the hospital receive increased number of positive feedbacks. Patients are likely to recommend others to visit a particular hospital for the good care they received. Therefore, hourly rounding would be even more helpful to nurses if their patients recommend others for the good services offered during their stay in hospital.

CHAPTER TWO

2.     LITERATURE REVIEW

2.1.  Problem Identification

In today’s ever changing healthcare, nurses must be actively involved in clinical activities and problem-solving regarding patient care. With exploration and review of the literature, practices of hourly rounding can not only save money but also improve the quality of care. Therefore, nurses and caregivers should seek out, analyze, and use the best available program of hourly rounding in order to achieve their goals, as well as the needs of their patients. Furthermore, American Nurses Association (ANA) delineated that nurses should develop and maintain clinical and professional knowledge and skills in order to meet the standards of care and competence in practice. In this regards, incorporation of hourly rounding program is a requirement to meeting the standards of care and competence in nursing practice.

As mentioned earlier on this paper, cases of patient falls are estimated to cost the healthcare sector approximately USD 20 billion every year (Kolin, Minnier, Hale, Martin & Thompson, 2010). However, poorly understood and managed hourly rounding would result in disappointing results. The study further noted that an interdisciplinary rounding on some units like the intensive care unit (ICU) resulted in a reduction, in incidences of pressure ulcers. Therefore, implementation of hourly rounding program would improve the quality care to make patients safe due to reduced fall risks and other related conditions such as pressure ulcers, which might jeopardize patient safety and health (Brant, 2010).

However, today, majority hospitals utilize hourly rounding as one of the most effective instruments of improving health care services. Sophisticated and systematic research based on hourly rounding can help in understanding the concept of hourly rounding.

2.1.1.     The Implication of Patient Falls

More than 1 million patient falls occur every year in health care facilities. Among U.S. hospitals, falls rates range between 3.1 and 11.5 cases/1,000 patient-days (Quigley, Hahm, Collazo, Gibson, Janzen, Powell-Cope, Rice, Sarduy, Tyndall & White, 2009). Rates of patient falls differ, depending on a hospital unit; the highest rates of falls are reported in the medical and the neuroscience units. Fall rates in those units are 3.48 and 6.12/1000 and 6.12 and 8.83/1000 respectively (Quigley et al., 2009). About 30 percent of the total number of patient fall cases result to some form of injury; 10 percent cause the patients serious injury, including fractures or trauma of the head. Among aged patients, these falls can be extremely dangerous, as they can result to death or further illness (Oliver et al., 2010).

The statistics documenting the incidence of patient falls and their effects among older patients are critical and disturbing. Presently, patients of 75 years and older comprise about 22 percent of hospital admissions (Wier, Pluntner & Steiner, 2010). Further, significant areas of hospital costs are related to patient falls: these include liability, length-of-stay and care services. The patients that suffered serious injuries due to falls while under the care of hospitals remained under care for 6.3 to 12 days more than their counterparts and they also registered higher healthcare costs by an average of USD 13,316 (Brand & Sundarajan, 2010).

Additionally, starting in 2008, the Center for Medicaid Services revised their policies-directing that they will not compensate hospitals for the costs incurred in the treatment of these types of injuries (Inouye, Brown & Tinetti, 2009). This leads to significant conclusion that a reduction in the number of patient falls will lead to a major reduction in the costs borne by hospitals and patients.

2.1.2.     Effectiveness of Hourly Rounding Program

Despite the fact that the majority of nursing personnel are still objecting to the adoption of the program, there is a wide variety of literature reporting its effectiveness in reducing the cases of patient falls as well as improving the quality of health care. The nursing staff members opposing the adoption expresses different concerns including that it can lead to an increase in documentation, over regulation of nursing personnel activities, and reduction in the effectiveness of nursing time.

However, numerous studies have revealed that the program can increase the efficiency of nursing staffs, and it is, therefore, highly recommended for adoption (Meade, Bursell & Ketelsen, 2006). The use of a structured protocol for nursing activities like the hourly rounding can improve the quality of care and patient satisfaction as evidenced by a study done by Meade et al. The same studies have also reported that the adoption of the program would lead to a reduction in paperwork and also an increment in the safety of patients (Meade et al., 2006).

Hourly rounding needs a health care environment that supports and facilitates transformative changes. Hourly rounding requires resources, which include organizational culture that supports acceptance and change, leadership support, staff resources including doctoral prepared nurse resources, and time. Hourly rounding model provide frameworks for systematically putting complex evidence-based knowledge into operation to achieve best practices (Meade et al., 2006).

 

2.1.3.     Proposed Solution

A number of solutions have been implemented to solve the problem of patient falls such as lowering of beds among others, but their resulting results are minimal. Research reveals that the only evidence-based practice model defined to produce positive results is the hourly rounding program. While the other models proposed for solving the issue differ in context and the detailed content, all of them are relative to hourly rounding. Therefore, identification to the need of establishing an hourly rounding program would mean emergence of new knowledge related to patient fall and care.

Hourly rounding program can be implemented to address the problem of patient falls. It is expected to improve the care offered to patients through structured hourly rounds. The contents of the program were reviewed by a team of managers and staff nurses from different units. The team reviewed existing service practices to determine the best program strategies for the development of the rounding protocol.

The program will include checking four critical areas of care during the routine rounding, which include toileting needs, pain management, fall prevention, and patient positioning (Oldrich et al., 2012). Other aspects of the program will include addressing personal questions of patients, administering environmental checking for systems like IV pumps, bed alarms, and urinals; informing patients when the next routine check will be done, and then documenting the completed rounding.

The results expected from the program include reduction in the number of patient falls and reduced usage of call lights for would be notification of an occurring fall. This has competitive benefits of increased patient satisfaction levels, and reduced noise and interruption caused by unnecessary call lights (Oldrich et al., 2012).

2.2.  Solution Description

2.2.1.     Description of Hourly Rounding

The hourly rounding program is aimed at addressing the problem of patient falls. Hourly programs have been used before, as a model for the improvement of patient safety and increasing the safety of patients, but in this case, it will be focused on reducing patient fall rates. The program will proactively organize the care offered to the patients within the hospitals covered by the program, towards reducing patient falls (Oldrich et al., 2012).

The focal areas of the program will include assessing the 4 Ps of patients: pain management, potty needs, patient positioning, and the proximity of personal items like call buttons. The adjustable aspects of the program include that the toilet times can be rescheduled by the nursing staffs to suit different patients, and assistance could be arranged whenever it is needed, prior to the scheduled rounding time (Oldrich et al., 2012).

2.2.2.     Consistency with Current Research

Recent studies on clinical effectiveness of initiating an hourly rounding program of addressing the problem of patient falls concluded that the results included a reduction in the adverse effects of patient falls (Mant, Dunning & Hutchinson, 2012). For example, a study done in 27 nursing units from 14 hospitals based in U.S. demonstrated that hourly rounding not only reduced patient falls and patient’s use of call lights but also increased patient satisfaction (Brant, 2010). Hourly rounding can as well be referred to as safety rounding because it is a strategy allowing nurses to monitor for changes in the patient conditions. The adverse results that were reduced in frequency included long hospital stays, fall-related injury, and fall-related mortality. Recent literature showed that hourly rounding can be expanded to comfort and safety rounding (Meade et al., 2006).

According to a study by Mant et al., (2012), the factors contributing to the incidences of patient falls included the experiences of the previous fall, age, unsteady gait, reduced vision, musculoskeletal system weakness, acute illness and mental illness. Toilet related issues are other causes of patient falls. Studies have shown that 45.5 percent of all falls are toilet related (Tzeng, 2010). Following the inferences of the study, the authors arrived at conclusions that are in line with those made by other studies, including Oldrich, Kalman and Nigolian, (2012). The emphasis of the different studies is that many of the causes leading to patient falls could be eliminated through the initiation of an hourly rounding program, which would reduce the rates of patient falls. The conclusions of this study support the adoption of the hourly rounding program as a strategy for countering patient fall cases in hospitals.

Deitrick et al., (2012) explored the challenges related to the initiation of an hourly rounding program within the hospital environment particularly in acute care unit, and finalized their study with the conclusion that the implementation can be difficult, but it can yield positive results.  The emphasis of the study was that a number of aspects should be taken into account in order to ensure that the program bears positive results (Oldrich et al., 2012). The study reveals various areas, which need to be assessed including the careful planning of the program, among other methods of program implementation such as effective communication within the organization. A carefully monitored program implementation and the evaluation of different aspects of the program would guarantee its success (Deitrick et al., 2012). Therefore, conclusions of this study emphasize the importance of careful and a well-planned adoption of the program, so as to guarantee its success, which supports the effectiveness of hourly rounding in addressing the problem of patient falls (Oldrich et al., 2012).

Similar to the study by Deitrick et al. (2012), the study by Tucker et al. (2012) explored the challenges of implementing the hourly rounding program, and its results in reducing patient fall. The conclusions of the study included that the adoption of an hourly rounding program in healthcare setting or rather in a hospital reduced the rates of patient falls, but emphasized that the success of the program was determined by the balance between the fidelity of intervention and the personalized attention of care (Tucker et al., 2012). In general, the different evidence-based research support the adoption of hourly rounding as an effective solution to the problem of patient falls.

2.2.3.     Feasibility of Implementing Hourly Rounding

The integration of the finds of the wide range of research emphasizes that hourly rounding reduced unit noise levels and the usage of call lights; it reduces patient falls and increases patient satisfaction. The increased effectiveness of service delivery also led to the reporting of higher satisfaction levels among medical personnel; they reported that the program allowed them more control over their patients (Oldrich et al., 2012). Taking into account the costs of patient falls, hourly rounding programs should be implemented in all hospitals, and they are fully feasible. However, to increase feasibility of the program in hospitals, managerial personnel should engage hospital staffs in the planning, as well as the implementation of the program-so that the different groups can identify with the benefits of the program (Mant, Dunning & Hutchinson, 2012).

2.2.4.     Consistency with Culture and Hospital Resources

The cultures of hospital, as well as, the resources – human and financial- are continually channeled towards the improvement of the satisfaction of patients (customers). For that reason, noting that hourly rounding improves patient results and reduces the resources spent on patients, including finances and time, as well as improving health results, it is evident that the program is consistent with the culture of hospitals (Oliver, Healey & Haines, 2010).

There is an existing relationship between hourly rounding programs with organizational change programs as well as those of service delivery programs. With hourly rounding program set in place, it becomes easier for nurses to improve technical efficiency of particular service delivery such as lowering of beds if a nurse detects an occurring patient fall. The notion of lowering the bed demonstrates an act of changing organizational contingencies, which could produce the risk, injuries and even diseases in health care setting.

2.3.  Research Support

2.3.1.     Research Base for Hourly Rounding

Falls, and fall-related injuries are common in hospitals especially in the acute units. Falls not only harm the patients, but also lead to physiological and financial burdens. Organizations are also affected as a result of increased length of stay, higher level of supervision, possibility for litigation, and extra diagnostic procedures. Research reveals that hourly rounding can be used to diminish the number of falls. During the hourly rounding, the nursing staff assesses the patients, and addresses their comfort and personal needs such as

• Offering toileting assistance
• Repositioning the patient
• Checking lighting and temperature of the room
• Checking the call lights and patient belongings
• Assessing the room for environmental and hazardous concerns just to mention but a few.

2.4.  Implementation Plan

2.4.1.     Background of Problem and the Solution to be Implemented

Patient falls are among the adverse events undermining the effectiveness directly of care at acute care centers, among other healthcare institutions (Tucker et al., 2012, p. 19). Studies exploring the impact of structured hourly rounding show that it is a promising prevention practice, which can be implemented in a healthcare setup. However, translating, implementing, adapting and maintaining the rounding program in healthcare facilities is a major determinant of the success of the program. Tucker et al. found that the effective implementation of an hourly rounding program can significantly reduce the rates of patient falls (Tucker et al., 2012, p.26). However, the challenges facing the implementation of the program included nurses seeing the program as an imposed program and the required documentation as a burden. Due to the difficulties facing the implementation of hourly rounding programs, this section explore the variables that need to be addressed, towards ensuring that hourly rounding offers practical solutions to the problem of patient falls.

2.4.2.      Methods of Implementing the Proposed Solution

The processes and structures used during the implementation of hourly rounding affect the success of the program. Unlike a traditional approach used when implementing hourly rounding program, the current approach will engage the consult medical staff and patients, who will offer their feedback regarding the impact of the program and the areas to be reviewed, so as to maximize the benefits of the program (Rondinelli et al., 2012, p.326). The major indicators to be reviewed in determining the effectiveness of the program include increasing patient satisfaction-patients feeling that they are well cared – and a reduction of patient falls. More importantly, the feedback collected from patients and medical staff will be used for the review and the repositioning of the structure, processes and administration of the program, towards realizing the desired results (Rondinelli et al., 2012 p. 326). The main difference of this hourly rounding program from others will be that the routinized approach will be abandoned, and flexibility will be maintained at all stages of program implementation.

The implementation of the program will employ a person-centered approach to realizing the anticipated changes; the person-centered approach will be instrumental in changing the cultural values of the care facility, so as to ensure the effectiveness of the program. The hourly rounding program will involve the medical personnel and also the leaders of the facility and the cooperative effort of the two groups will be instrumental in evaluating the effectiveness of the implementation teams (Rondinelli et al., 2012, p. 328). During the implementation of the program, the leaders will train and develop the medical personnel in the areas that limit the effectiveness of the program. The leaders of the health center will be accountable for the progress of the program, and will be required to report progress on a weekly basis.

2.4.3.     Resources Needed for Program Implementation

The following resources will be required for the implementation of the hourly rounding program.

Staffing: The program will not require the Midland hospital to recruit new staff persons at this time; the existing staff (including two agency care partners and two agency RN’s) will incorporate the rounding program into their daily program (Rondinelli et al., 2012, p. 329).

Costs: The upfront costs to be consumed by the program include the time required for the institution’s consultant and nurses to attend the training courses and the costs of training. The program will require ongoing operational costs, including printing costs. The daily log books and pens supplied to personnel, traditionally, will be used during the program. Additional care partners will be planned into the fiscal budget for the next year. Current year agency staffing will be drawn from emergency funding. Additional monitoring equipment such as blood pressure monitors will be required as well as additional computer on wheels (COWS) to facilitate nursing documentation.

Funding Sources: Current year funds will come from set aside emergency funding. Next years budget will include the costs for equipment and increased staffing of care partners.

Tools: the tools required for the program include a nursing proficiency checklist and a 90-day implementation plan, which were developed during the consultation meetings. In addition, monitoring equipment as well as more computers on wheels for documentation is necessary.

2.4.4.     Methods of Monitoring Program Implementation

The accountability of the program will include the reporting of unit leaders. Unit leaders will review the rounding logs completed by medical personnel. The unit leader will check that rounding has been done by checking that the rounding staff signed after completing the round. After reviewing the logs, unit leaders will address compliance issues and discrepancies with the staff member in question. The information will also be recorded in a central database, which will help with the tracking of progress, and in comparing the effectiveness of the program with that implemented at other hospitals (Tonges, 2011, p. 374). Towards increasing the commitment of nursing staff among others, during the implementation of the program, the performance of rounds will be reflected in the annual performance evaluation. Entering rounding information into the computer terminal of every patient will verify that rounding programs were administered.

2.4.5.     Theory of Planned Change in Program Implementation

In the course of implementing the hourly rounding program in the hospital, the use and application of the change theory would be vital. The change theory proposed by Lewin focuses on three phases: Unfreeze Phase, Change, Phase and the Refreeze Phase (Kaminski, 2011, p.1). As argued by Kaminski (2011, p1), the Lewin’s change model aids in changing the perception of the staff in regard to working together and achieving the best results for the patients. In the event that all the stakeholders work in unison, the patients get the best service, and the same should apply for hourly rounding. The theory argues that behavior is a vigorous balance of forces that function in contrasting directions (Kaminski, 2011, p.1).

Through the unfreeze concept of the change theory, the staff will go through preparation for the change; thus, accept the need for change (Kaminski, 2011, p.1). The author argues that unfreeze concept then leads to change among the stakeholders; hence, the refreeze stage (Kaminski, 2011, p.1). The execution of the hourly rounding plan is created in a way that sees to the implementation of the change theory through improving on the aspects that enhance patient contentment and also to transform the ideals and culture of the hospital. This theory will also be functional in forecasting on delivery of care and assessing the phases involved in a series of planning, the actions involved and an assessment of results of the action by the staff (Kaminski, 2011, p.1).

2.4.6.     Feasibility of the Implementation Plan

The program will call for the recruitment of new care partners, but the schedules of the existing nurses will be incorporated into the program. The oversight nurse will work as a resource nurse for the hospital because she has supervised the implementation of the program in another hospital. For the Surgery Trauma Floor, the costs of training are estimated to be $4, 200; this amount will cover the entire nursing staffs of the floor. The hospital has divided the implementation of the program into three sections with pilot areas beginning and then training subsequent units. An hour of training is estimated at $40 for one nurse. Three additional care partners will cost $81,120 yearly. Additional COWS cost $2,400 each. Total cost of cows equals $9,600. Additional monitoring equipment cost $3,000 each. Total cost of monitoring equipment equals $12,000. Printing costs for the duration of the program are approximated to reach USD 3,500. The total costs of implementing the program will be 4,200 (training costs) + 3, 500 (printing costs), + $81, 120 (staffing costs), + $9,600 (COWS), +$12,000 (monitoring equipment).  This totaled $110, 420.

The daily logs books and pens supplied to personnel prior to the implementation of the program will be used during the program; therefore, this area will not require extra costs. Securing the nursing proficiency checklists and the 90 – day implementation plan that were developed by the implementation team will not be an extra cost, which will help in reducing the costs of implementing the program.

Taking into account that the costs of patient falls are estimated to cost the healthcare system USD 30 billion, the expenditure of $110, 420 will be highly feasible for the hospital, as well as others that acknowledge the importance of the program (“Costs of Falls Among Older Adults,” 2013).

2.5.  Evaluation plan

2.5.1.     Methods of Evaluating the Solution

The hourly rounding program can be evaluated through various methods. First, there has to be a record of the rate of patient falls before implementation of the hourly rounding program. This will be compared with the rate or number of patient falls after implementation of the hourly rounding program. Second, the solution can be evaluated by checking for notable reductions in call lights (Krepper et al., 2012). In addition, evaluation can be done by analysing the response to call lights. The hourly rounding program can be evaluated by gathering patient and staff feedback about impact of hourly rounding to gauge patient satisfaction and perhaps might also assess staff satisfaction after instituting the program. Finally, nurse satisfaction can also be measured via survey to determine if the workload is decreased with reduction of patients using the call bell.

2.5.2.     Outcome Measure

It is imperative to note that when nurses take too long in one patient’s room, they lag behind in their work, yet they are charged with the responsibility of providing surveillance to prevent errors and ensure quality care. Patient safety is enhanced when effective hourly rounding is implemented (Deitrick, Baker, Paxton, Flores, & Swavely, 2012). Therefore, appropriate outcome measure should be developed that evaluates the extent to which the project objective is achieved.

An outcome that is used to evaluate achievement of the project’s objectives involves patients and nurses. The nurses are required to provide health care to the patients in their units or rooms, through hourly rounds. During these hourly rounds, nurses are expected to offer proactive care, addressing patient needs before patients ask for assistance. This can reduce patient falls and increase patient satisfaction. In addition, nurse satisfaction can also be enhanced. Therefore, the outcome measure addresses occurrence of adverse events, patient satisfaction, nurse satisfaction, and barriers that nurses’ face as they seek to achieve the objectives of the solution.

The outcome measure register/log consists of five major rows and nine minor rows. In the major rows, results such as patient fall, call lights, response to call lights, patient satisfaction and nurse satisfaction, as well as barriers to achieving hourly rounds’ objectives are assessed. Response to call lights, patient satisfaction and nurse satisfaction results are categorised into subdivisions of highly efficient to inefficient and high to low (see Appendix).

Each column represents a day, and the last column is meant for overall remarks. The nurses are supposed to fill in all the sections of the outcome measure except the patient satisfaction part, which should be filled by patients. Leadership will make daily rounds using an IPAD to access survey monkey.  Specific questions are asked of each patient on all units.  The response is tallied by the Performance Improvement Committee and distributed to nurse managers.  A weekly meeting, involving nurses on the unit, will be held to discuss the components of the outcome measure for each nurse. Nurses are allowed to provide their recommendations on how the project can be improved, as well as note the challenges they face and the barriers they encounter as they pay hourly rounds to patients. This will evaluate the extent to which the project objective is achieved.

This outcome measure is valid and reliable because it incorporates all the subjects. Validity can correlate with other measures of safety, and also with patient satisfaction ratings using different measures.  Both nurses and patients are included in the assessment of outcome measures. Second, the outcome measure uses data from all units within the hospital, increasing internal validity and reliability of the results reported. In addition the outcome measure is sensitive to change because it allows patients and nurses to make overall remarks that could be used to make changes to the measure, when appropriate. Therefore, the outcome measure is valid, reliable, sensitive to change and appropriate for use in this project.

2.5.3.     Evaluation of Data Collection

According to Berenson, Pronovost and Krumholz (2013), process or outcome measures require that data is collected manually, and should be performed by quality improvement staff so as to enhance their ability to participate in efforts of improving care.  Therefore, appropriate methods should be used in collecting outcome measure data. Hourly recording of the time of the hourly round and the patient care activities performed, in the hourly rounding register/log, is among the methods of data collection that will be used to collect outcome measure data. Data trackers will be created that are placed outside of each room.  Nurses and care partners will place a check each time they perform hourly rounding on a patient.  During the weekly meetings, nurses and care partners are expected to provide information pertaining to the challenges and barriers they encounter during the hourly rounds. As mentioned earlier on this paper, hourly rounds will take quite much of staff time because nurses need to make notes every hour for every patient.

Collection of patient fall data should already have a process for collection.  Call lights can be monitored by unit secretaries at specific times during the implementation process.  A patient fall rate record will document the number of falls per patient and any other emergent issues, such as injuries while a call lights rate record will document the number of call lights per nurse. These methods are effective for use in collecting data for this project because they can be monitored and improved upon to meet the goals of the project effectively. The records will be used as resources for the weekly meeting, when the records will be reviewed, and discussions involving nurses can be held to discuss issues of compliance and barriers identified, as well as proposals for improvement. The meeting will be open for all staffs and managers.  The weekly meeting will include all unit staff to include leadership, staff nurses, care partners and unit secretaries.

This evaluation plan is highly feasible because it can be achieved easily. The plan incorporates nurse and patient feedback, which can be easily acquired. According to the findings of a study carried out by Rondinelli, Ecker and Crawford (2012), patient satisfaction and patient perception that they receive high quality care are imperative outcome considerations in the evaluation. Therefore, use of the IPAD and the questionnaire in Survey monkey to collect information pertaining to patient satisfaction is beneficial towards achieving the project’s objectives Patients will be expected to answer a set of structured questions pertaining to how they value services of hourly rounding The focus of concern in the questionnaires was derived from the objectives of the study and the literature review. Second, feedback from nurses pertaining to the challenges that they face can be easily obtained, increasing the feasibility of the project. Nurses are mainly challenged with issues of documentation and skill mix (Neville, Lake, & LeMunyon, 2012). When this information is obtained and discussed during the weekly meeting, it is probable that the project’s objectives can be achieved.

The two possible grant funding sources for this project are the Agency for Healthcare Research and Quality (AHRQ) and the hospital’s funding system. AHRQ will be an ideal source of funds because the proposed project is a feasible project that seeks to improve the quality. Similarly, the hospital‘s funding or finance system will fund the proposed project to enable it achieve its objectives. These two sources of funds are ideal for the proposal due to ease of their accessibility.

2.6.  Decision Making

2.6.1.     Methods of Deciding the Future of the Solution

In deciding the future of the proposed hourly rounding project, accountability and cross learning support will be used. Therefore, nurses and other officials and hospital leaders of the project will be required to comply with the requirements. Pilot units will be identified and discussions will be held to identify what has gone on well and the barriers identified. Leaders will make decisions from the findings and suggestions to ensure future success of the project. A successful outcome will ensure review of call light logs and patient satisfaction, as well as nurse satisfaction. Leaders will be required to offer feedback to nurses and other leaders and to discuss improvement proposals, as well as agree on the next courses of action to maintain and ensure success.

The successful hourly rounding project can be extended to other units and departments within the hospital. This can be done by training the existing nurses with the requirements of the new solution. New nurses will have to undergo the same training. Upon completion of the training, nurses will be provided with the necessary tools to achieve the project’s objectives.

In revising an unsuccessful solution, the responsible personnel will have to go back to the first phases of implementation. Revaluation of training will have to be carried out. New approaches will be used while retraining the nurses and this will be followed by provision of appropriate monitoring tools. Monitoring of the project should be reinforced and feedback provided on a more frequent basis.

In the event that the solution becomes unsuccessful, there has to be a right approach for terminating it. All the nurses responsible for the hourly rounding program will have to be summoned to a meeting. In this meeting, barriers and obstacles that have led to failure of the program and why it may be impossible to revise the solution will have to be explained adequately. Management will request the nurses to hand over the tools that had been distributed for proper custody till the time when the solution will be revaluated. In offering feedback and communicating the project and its results to qualified performance improvement experts outside of the facility, management is able to compare results to published reports about the achievement of the proposed solution in other hospitals. Such reports will include statistics such as the rate and number of patient falls, call lights and response rates to such calls before implementation, compared to the current number of patient falls, call lights and response rate. Also, staff and patient satisfaction levels reported after implementation of the program, will be included. These reports will then be sent to professional groups.

 

CHAPTER THREE

3.     Research Methodology

3.1.  Research Design

Meade et al. (2006) conducted a comprehensive study to look at how programmed rounds can decrease call light use and enhance patient satisfaction. The study was conducted using pseudo-investigational, non-comparable groups design and data was collected from 27 nursing acute care units. According to Meade et al. (2006), during the hourly rounds, the patient pain levels were assessed using a pain-assessment scale, and were given toileting assistance, along with necessary medications. The researchers in this study came up with a number of findings.

First, they established that regular rounding can significantly reduce patient call light use. The one-hour rounding is more efficient compared to the two-hour rounding. However, this finding should be verified using a larger sample. In addition, one hour-rounding significantly improves the patients’ and nurses’ satisfaction levels. However, the methodology used in this study was very weak, as the population was not randomly selected. In addition, the sample size was rather small and the control and the intervention groups were not equivalent. (Insert the number of controls, n=XX).

Although Meade et al. (2006) found out that one hour rounding can reduce fall rate among the patients, it appears that the nurses do not have enough time to successfully implement this intervention. Some of the data gathered by Meade et al. (2006) shows that some of the nurses expressed concerns about lack of enough time to perform the rounding and their normally scheduled tasks. The concerns raised by the nurses are confirmed by a study that was conducted by Tucker, Bieber, Attlesey-Pries, Olson & Dierkhising (2012). In this study, Tucker et al. (2012) examined the effectiveness of the structured nursing rounds interventions in reducing the risk and incidences of patient falls. The intervention in this study was applied for 12 weeks and Tucker et al. (2012) found out that during the intervention period, fall rates reduced significantly. However, during the post-intervention period, the nurses were not happy about the extra burden of making hourly rounds. In addition, one year after the intervention was started; the fall rate decrease had vanished. The study highlights the importance addressing the nurses concerns and the need of balancing intervention commitment and individualizing patient interventions.

While Meade et al. (2006) and Tucker et al. (2012) use primary sources, Guttierrez and Smith (2008) used secondary data, to show how hourly rounds can reduce falls and fall-related injuries. The study used an Evidence Based Framework, to show that hourly rounding can reduce fall rates from 4.87 per 1000 patient days to 3.59 per 1000 patient days. Guttierrez and Smith (2008) conducted a systematic review of 100 publications but later settled for 18 of them. Just like the other studies, Guttierrez and Smith (2008) insisted that it is important to obtain compliance from the nurses. This can be achieved by enrolling them in education programs on the use of fall prevention protocol. According to Guttierrez and Smith (2008), hourly rounds should also be used in conjunction with other interventions such as strong leadership and resources.

Although the above studies have established a positive effect of hourly rounds on falls prevention, some of the studies described on this paper especially the study conducted by Deitrick, Baker, Paxton, Flores & Swavely (2012) using ethnographic methods have produced mixed results. In literature review section, Deitrick et al. (2012) discusses the effect of hourly rounding on the following outcomes: the number of bells per shift, patient falls, pressure ulcers, patient satisfaction, and the satisfaction of the nursing staff. The data obtained was analyzed by qualitative tools and some themes that emerged include:

• Effectiveness of the hourly rounding
• Rounding Processes
• Staff Attitudes towards hourly rounding
• Patient Safety

Deitrick et al. (2012) found out that in some units, hourly rounds did not lead to reduction in the number of falls; he attributed this to lack of communication between leadership and the staff implementing the process.

 

CHAPTER FOUR

4.     Conclusion

In conclusion, it is palpable that patient falls is a calamity that has cost the health sector a great deal.  It is also perceptible that a lot of resources have been shifted to a reduction of patient falls. In order to trim down the implications of this adverse event, it is evident that hourly rounding needs to be adopted. From the work, hourly rounding will undeniably lead to a turn down of these falls; thus, a cutback in the costs involved in managing the falls. It is recommended that the health institutions resolve the degree to which they apply hourly rounding as a remedy to patient falls in their workplace. This correlates to the verity that, it is the duty of the hospital managers to make sure that the health institutions take on hourly rounding as a tradition of the health facilities if patient falls have to decrease.

With research authenticating the reliability of hourly rounding in decreasing patient falls drastically, it is the exclusive liability of the hospital managers, thus, to adopt the same in intervening on the concern of patient falls. Nonetheless, other aspects such as patient education are vital in a successful implementation of hourly rounding. The staffs also need to change their perception towards hourly rounding as proposed in the change theory, as change can only be adopted if the stakeholders accept the need for change. The costs incurred in dealing with patient falls, in the long run, are expected to reduce considerably.

 

 

Appendix

Hourly Rounding Information Register/Log

	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7	Overall Remarks
Number of Patient Falls
Number of Call Lights
Response to Call Lights	(Check  where appropriate and include notes about any observations in the Overall Remarks)
Highly Efficient
Satisfactory/ Average
Inefficient
Patient Satisfaction	(Check where appropriate and include notes about any observations in the Overall Remarks)
High
Remarkable
Low
Nurse Satisfaction/Barriers	(Check where appropriate and include notes about any observations in the Overall Remarks)
High
Remarkable
Low

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