© 2024 IJNRD | Volume 9, Issue 11 November 2024 | ISSN: 2456-4184 | IJNRD.

ORG

INITIATION AND ADHERENCE TO NURSING/MIDWIFERY

PROACTIVE PATIENT ROUND AT INPATIENT UNITS OF ST. PAUL’S
HOSPITAL MILLENNIUM MEDICAL COLLEGE, ETHIOPIA, A
QUALITY IMPROVEMENT PROJECT FROM ETHIOPIA, 2022.
1Birhie Alemu Yeshaneh1, Sintayehu Abate,2 Alemu Tesfaye2, Feyisa Lemma2, Yadessa Biressa2
1
Lecturer of Nursing, Department of Nursing, Institute of St. Paul’s Hospital
Millennium Medical College, Ethiopia
2
Nursing/Midwifery Quality Improvement and Clinical Audit Team, St. Paul’s
Hospital Millennium Medical College, Addis Ababa, Ethiopia

ABSTRACT
Background: Proactive patient round is contributing to purposeful and timely rounding for best practice
intervention to routinely meet patient care needs, ensure patient safety, to decrease the occurrence of patient
preventable events, and proactively address problems before they occur, collaboration between clients, family
and nurses.
Local problem: Based on our clinical placement experience and baseline data finding, nurses/midwiferies
didn’t attend proactive patient round, which leads to communication breakdown and insufficient information
being exchanged between the clients, family and nurses & can have adverse effects on the quality of care
provided at all inpatient service area.
Methods: The study was conducted at St. Paul’s Hospital Millennium Medical College in all inpatient units
from December 1, 2021, to May, 2022. We prioritize the identified gaps by key drivers and implemented
several low-cost interventions using Plan-Do-Study-Act cycles.
Interventions: Since there was no proactive patient round formats, we have prepared proactive patient (2/3
hours) round formats and awareness creation for working staffs about the contribution of proactive patient
(2/3 hours) round was mad. We also preparing one formats for daily activity, shift hand over and procedure
note to reduce redundant documentation.
Results: Overall, in St. Paul’s hospital ten inpatient unites nursing proactive patient round activity was
increased to 93%. On average by the end of six months of initiating the project from the baseline zero percent
to this result. As a result, there was a decreased frequent patients coming to the nurses/midwifery station to
get nurses/midwives. And patient satisfaction also improved.

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Conclusions: Proactive patient round is very crucial to improve quality of health care and patient/attendant
satisfaction by health care. It is a minimum requirement to follow patients, which means every hospitalized
patient are followed by their nurses/midwifery at least every 2 hours in the day time and every 3 hours at night
time.
Key terms: Quality Improvement Project, PDSA, Proactive patient round, SPHMMC

1. INTRODUCTION

Nurses are involved in many activities in a hospital from patient admission through discharge. They provide
continuous 24-h patient care, which is divided into several shifts(1). Patient care includes performing
assessments, stating nursing diagnoses, developing intervention plans, implementing care, and making
evaluations to modify or terminate care. Examples of nursing interventions include discharge planning and
education, the provision of emotional support, self-hygiene and oral care, monitoring fluid intake and output,
ambulation, the provision of meals, and surveillance of a patient’s general condition(2). The delivery of
nursing care should involve the patient. A nurse respectfully communicates, coordinates, and integrates
nursing care, provides education and information, and considers the comprehensive and continuous physical
and emotional comfort of the patient(3).

Proactive patient round is contributing to purposeful and timely rounding for best practice intervention to
routinely meet patient care needs, ensure patient safety, to decrease the occurrence of patient preventable
events, and proactively address problems before they occur, collaboration between clients, family and nurses
(4).
In our institution, SPHMMC nurse / midwife perform direct services are in an excellent position to identify
the need for change in service delivery processes. Based on this premise, the staff nurse / midwife--who is at
the heart of the system--is the best person to assess the status of health care services and to work toward
improving the processes by which these services are provided to clients in our health care institution.
Through our data collection by chart review, client interview & clinical observation, we had identified major
& basic nursing / midwifery care service gaps which is contributing positive health outcome of our clients.
Among those identified gaps proactive patient round was selected & prioritized by priority matrix & focusing
matrix. Based on our baseline assessment, nursing proactive patient round was not conducted before.

2. NEED OF THE STUDY

Proactive patient round was not conducted for all patients which leads a difficulty to meet the intended patient
care needs, to ensure patient safety, to decrease the occurrence of patient preventable events, and proactively
to address problems before they occur, and collaboration between clients, family and nurses. Therefore we, St.
Paul’s Hospital Millennium Medical College Nursing/ Midwife quality improvement & clinical auditing
team, aim to improve nursing proactive patient (two hours individual) round 50 % from 0% by May, 28 /2022
at St. Paul’s Hospital Millennium Medical College all inpatient service area

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3. Methods
Study setting
St. Paul’s Hospital Millennium Medical College is located in Gulele sub city Addis Ababa, Ethiopia. The
hospital has 62 unites with more than 700 beds. Among those 10 are inpatient units. Total number of nurses
and midwifes are 909, 114 respectively. In inpatient units’ nurse/midwife to patient ratio is 1 to 6. Before
the implementation of this project, there was no nursing proactive patient round. This quality improvement
project was conducted at all inpatient units of St. Paul’s Hospital Millennium Medical College.
Among those proactive patient rounds were performed in 10 inpatient unites which include both maternity A
and B, gynecological ward, female and male medical ward, both adult and Pedi surgical wards, transplant
ward, maxillofacial and pediatric ward. The project was conducted from December 1, 2021 to May, 28/2022.
Study design and method
This study was conducted with continuous, detailed meetings and discussions to prepare proactive patient (2/3
hours) round in the hospital. During baseline assessment nurses/midwifery didn’t attend proactive patient
round, which leads to communication breakdown and insufficient information being exchanged between the
clients, family and nurses & can have adverse effects on the quality of care provided at all inpatient service
area. Following these, PDSA model for quality improvement was implemented to test intervention
ideas/strategies and followed for an improvement in the processes or outcomes in the project with specific
measures.
Data collection and analysis
As baseline assessment as well as follow-up in-hospital nurses/midwifery didn’t attend proactive patient
round. This finding was collected from patient interview and medical charts. Data was presented with simple
descriptive statistics such as frequency distributions were done as appropriate and the result was presented in
tables, graphs and run chart.
Strategy and implementation
The Nursing/Midwifery quality improvement team studies why nurses and midwiferies didn’t attend proactive
patient round and doing root cause analysis, plot possible intervention packages with subsequent
implementation sequentially and follow-up of the project.

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Root cause analysis/Fishbone diagram

Work Provider
Environment

 Lack of awareness.
 Repeated & unscheduled
 Considering it is not
round by co-working staff.
important.
 Work over load.
 Poor documentation
 Too much & redundant habit.
documentation.

There is no proactive
patient round at all
 Lack of documentation
inpatient service area
 Patient condition & of SPHMMC
format
 Poor concern level dependency.
 Lack of M & E  Existence of attendant
 Non-functional bed
allocation for working
staff.
Patient
Management

Fig 1. Fish Bone Diagram illustrating root causes of Absence of Nursing / Midwifery Proactive Patient Round at Inpatient units of St.
Paul’s Hospital Millennium Medical College

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Driver diagram

Depending on the root causes identified (figure 1); three primary drivers, eight secondary drivers and nine change/intervention ideas
were schemed to achieve proactive (2/3 hours) round increases to 50% from zero in inpatient units of St. Paul’s Hospital Millennium
Medical College (figure 2). Change Ideas
Secondary Driver
 Create awareness & give orientation to
Primary Driver working staff to start the activity per standard
 Lack of awareness. for all admitted patients at the inpatient
Aim Provider  Considering it is not important. service area.
 Enhance / increase activities documentation
 Poor documentation habit.
habit by mobilization of working staff &
auditing technic.

To Improve Nursing /  Schedule clear time frame for all types of round
 Repeated & unscheduled round by for working staff.
Midwifery proactive
co-working staff.  Avoid unnecessary & repeated documentation.
patient round 50 % from  Work over load and too much &  Incorporate all documentation within single
0% by May28/2022 at redundant documentation. format paper.
Work Environment
SPHMMC all inpatient  Maintain nurse to patient ratio.

service area.
 Design proactive patient nursing round format,
 Lack of documentation format test & distribute
 Poor concern and lack of M& E.  Monitor & evaluate number of round conducted
Management  Delegate functional bed allocation for at regular basis.
working staff.  Allocate proper & functional bed allocation for
working staff.

Fig 2. Driver diagram showing the aim, primary and secondary drivers, and intervention/change ideas to improve nursing / midwifery
proactive patient round 2021/22

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Measures
Process measures
Percentage of expected proactive patient round performed in the selected patient charts among
admitted patients every two weeks.
Outcome measures
Expected proactive patient round performed

Patient satisfaction

Frequency of patients coming to the nurses station to get nurses

PDSA implementation
Based on the driver diagram in figure 2, we select three change ideas that have higher score using
priority matrix to implement and test using a PDSA cycle. Each change ideas were implemented starting
from December 1, 2021 consecutively every two week in each unit. We record and track all admitted
charts and lasts two hours every two weeks bases. Depending on the findings, we made an iterative
assessment of each PDSA cycle to sustain strengths and devise solution for drawbacks to achieve better
outcome.

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Table: 1 PDSA-Plan Do Study Act; Nursing/Midwifery quality improvement & clinical audit Team; nursing/midwifery proactive
patient round.

PDSA Cycle Plan Do Study Act

PDSA Cycle-1: Awareness We scheduled to We were prepare All case teams were We trying to initiate the unit leaders to
creation present for all presentation and award and have good tolled the working staffs about the purposes
inpatient unit leaders present for all understanding about of nursing proactive patient round.
to create awareness inpatient unit and function of proactive
about the function of additional one staff patient round.
proactive patient for each units.
Working staffs were
round.
seen as additional works

PDSA Cycle-2: Design We wanted to design We design proactive We found that, the nurse Awareness was created every week in each
proactive patient round proactive nursing nursing patient and midwifery starts to unit about the function of proactive patient
nursing format patient round format round formats and perform proactive round by Nursing/Midwifery quality and
by adopting from distribute to all ten (every 2 hours during clinical audit team.
ministry of health inpatient units. day time and every 3
through the effort of hours during night time)
Nursing/Midwifery round.
quality and clinical
Acceptance from the
audit team.
staff was difficult due to
luck of awareness.

PDSA Cycle-3: Reduce We planned to avoid After discussion The working staffs were We distribute and follow single format
Work over load and too unnecessary & with concerned happy about the paper in order to avoid redundant
bodies, the prepared formats to documentation and proactive

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much & redundant repeated mechanism of reduce the redundant nurse/midwifery proactive patient round is
documentation. documentation. incorporate all documentation and started.
documentations with starting proactive
in single format nurse/midwifery
paper in order to proactive patient round.
avoid redundant
documentation by
nurse / midwife
quality improvement
& clinical auditing
team.

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RESULT

Overall, in ten inpatient units of SPHMMC, average nursing proactive patient round increased to 93% from
zero present.

See the following table and graphs about the result when each PDSA cycle is implemented.

Table 1: Proactive patient round performance in the last 6 month at St Paul’s hospital millennium
medical college at inpatient unit Addis Ababa Ethiopia, 2021/22.

No Unit(ward) December January February March April May Average

1 Maxillofacial Ward 86.60% 95% 96.20% 96% 99% 100% 95.47%

2 maternity A ward 82.60% 97.50% 97% 98% 99% 97% 95.18%

3 maternity B Ward 48% 73.20% 68% 99% 100% 99% 81.20%

4 Gynecology Ward 66.30% 86% 99% 100% 100% 100% 91.88%

5 Pediatrics Ward 79% 85.60% 95.30% 99.80% 99% 98% 92.78%

Pediatrics surgery
6 97.80% 99.50% 100% 100% 100% 100% 99.55%
Ward

7 Male Medical Ward 83.32% 89.50% 90% 99% 100% 100% 93.64%

Female Medical
8 75% 70.50% 92% 99% 94% 97% 87.92%
Ward

Kidney Transplant
9 100% 100% 98% 100% 100% 100% 99.67%
ward

10 Adult surgical ward 92.86% 93.73% 93.73% 99% 93% 97% 94.89%

Average Monthly result 81% 89% 93% 99% 98% 99%

Average 6 Month Hospital proactive round performance result 93%

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Nursing Proactive patient round result on

month of December
120%
97.80% 100%
100% 92.86%
86.60%
79% 82.60% 83.32%
80% 75%
63% 66.30%
60%

40%

20%

0%

Figure: 3 Nursing/Midwifery proactive patient round results on month of December at

inpatient unit of St. Paul’s hospital, 2021

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Proactive patient round result on

month of January
transplant ward 100%

Pedi surgery 99.50%

maternity A ward, 97.50%

Maxillofacial 95%

Adult surgical ward 93.73%

male medical 89.50%

Gyn 86%

Pedi ward 85.60%

maternity B 73.20%

female medical 70.50%

0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 120.00%

Figure: 4 Nursing/Midwifery proactive patient round results on month of January at inpatient

unit of St. Paul’s hospital, 2022.

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Results for month of February

120%

96.20% 97% 98% 99% 100%

100% 92% 93.73% 95.30%
90%

80%
68%

60%

40%

20%

0%

Figure: 5 Nursing/Midwifery proactive patient round results on month of February at

inpatient unit of St. Paul’s hospital, 2022.

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101% 99.80% 100% 100% 100%

100% 99% 99% 99% 99%
99% 98%
98%
97% 96%
96%
95%
94%

Figure: 6 Nursing/Midwifery proactive patient round results on month of March at inpatient

unit of St. Paul’s hospital, 2022.

102%
100% 100% 100% 100% 100%
100% 99% 99% 99%

98%
96%
94%
94% 93%

92%

90%
88%

Figure: 7 Nursing/Midwifery proactive patient round results on month of April at inpatient

unit of St. Paul’s hospital, 2022.

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101% 100% 100% 100% 100% 100%

100%
100% 99% 99%
99%
99% 98%
98%
98% 97% 97% 97%
97%
97%
96%
96%

Figure: 8 Nursing/Midwifery proactive patient round results on month of May at inpatient

unit of St. Paul’s hospital, 2022.

120%

100% 93% 99% 99%

98%
89% 93%
80% 81%

60%

40%

20%

0%
December January February March April May Average

Figure: 9 Nursing/Midwifery proactive patient round results of six consecutive months at

inpatient unit of St. Paul’s hospital, 2022.

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Patient satisfaction comparation

120%
97%
100%
80% 70%
60%
40%
20%
0%
Patient satisfaction befor proactive patient Patient satisfaction after proactive patient
round conducted round conducted

Figure: 10 Patient satisfaction comparison towards Nursing/Midwifery care before and after starting proactive
nursing round results at inpatient unit of St. Paul’s hospital, 2022.

Strengths and Limitation

Strengths

Proactive patient round formants were prepared well

Awareness was created for staff nurse and midwife about the important of proactive patient round and
the health professionals were accepted
The nursing/ Midwifery quality team are closely follow the activities based on the required and staffs
recorded there intervention in the chart accordingly.
Proactive patient round is very important to improve quality of care, increase patient nurse/mid wife
relationship, patients able to get there nurses/ midwives as they want
Generally patient and family satisfaction on health care were increased
Proactive patient round is start in SPHMMC, so at national level this is used as base line for other
health institution
There is managerial round weekly to confirm whether proactive patient round is addressed on patient
or not
Limitation

In the first time since it is new change idea there was a challenge in side nurses and midwifes to accept
positively
Even if it is very important to improve quality of care, to increase patient nurse/mid wife relationship,
patients able to get there nurse or midwife, it increases work load of staffs
We cannot write discussion by compared with other study due to lack of similar study
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Conclusion

The theoretical principle of 2/3 hourly patient rounds is developed in ministry level so every hospital must
apply it. Proactive patient round is very crucial to improve quality of health care and patient/attendant
satisfaction by health care. Proactive patient round is a minimum requirement to follow patients, which means
every hospitalized patient are followed by their nurses/midwifery at least every 2 hour in the day time and
every 3 hour at night time. Proactive patient round is contributing to purposeful and timely rounding for best
practice intervention to routinely meet patient care needs, ensure patient safety, to decrease the occurrence of
patient preventable events, and proactively address problems before they occur, collaboration between clients,
family and nurses.

In SPHMMC the expectation of proactive patient round was 50% but in month of December we were achieved
81%, January 89%, February 93%, March 99%, April 98%, and May 99%. This implies there is over
achievement and a good attitude and practice by health professional towards 2/3 hour patient round.

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