PRACTICE IMPROVEMENT

INCORPORATING HOURLY ROUNDING TO INCREASE

EMERGENCY DEPARTMENT PATIENT SATISFACTION:
A QUALITY IMPROVEMENT APPROACH
Authors: Carmen Brosinski, MSN, RN, SANE-A, and Autumn Riddell, MSN, RN, CEN, ACCNS-AG, Portsmouth, VA

meet patient expectations, a process improvement initiative

Contribution to Emergency Nursing Practice involving hourly rounding was implemented to improve low pa-

The current literature on emergency department patient tient satisfaction scores.
care indicates that hourly nurse rounding may improve Methods: This project took place over 23 months and
patient satisfaction. consisted of 4 phases (baseline, intervention I, break, and inter-

This article contributes to the literature by demon- vention II). During the intervention phases, self-reported hourly
strating that incorporating purposeful hourly rounding rounding was tracked on a daily basis. Compliance with rounding
as part of a practice improvement project had a positive and patient satisfaction results were provided to staff during unit
influence on patient satisfaction. meetings and were displayed on a visual tracker board. Weekly

Key implications for emergency nursing practice found 5-minute customer service training was provided to all staff. Dur-
in this article are that hourly rounding is important to ing the baseline and break phases, hourly rounding was not
incorporate in the daily routine because it will help to tracked. However, patient satisfaction data were still collected
keep patients informed and may result in improved through the Interactive Customer Evaluation system. Three vari-
satisfaction. ables were measured using a 5-point Likert scale: overall patient
satisfaction, patient perception of staff attitude, and whether the
health care team answered all patient questions/concerns.
Abstract
Results: Hourly rounding compliance was 39% during inter-
Problem: Patient satisfaction is an important factor that influ- vention I and 51% during intervention II. Approximately 0.01%
ences the perceived quality of care delivered. In an effort to of patients submitted satisfaction data. From baseline to conclu-
sion of intervention II, overall patient satisfaction increased from
Carmen Brosinski is Commander, USN, and Associate Director for Nursing
52% to 73%; perception of staff attitude increased from 70% to
Services, Naval Medical Center Portsmouth, Portsmouth, VA. 84%; and whether the health care team answered all patient
Autumn Riddell is Lieutenant Commander, USN, and Emergency questions/concerns increased from 63% to 81%.
Department Clinical Nurse Specialist, Naval Medical Center Portsmouth,
Portsmouth, VA.
Discussion: There is a positive relationship between hourly
The views expressed in this article are those of the authors and do not
rounding and patient satisfaction scores. Despite low compli-
necessarily reflect the official policy or position of the Department of the ance with hourly rounding, patient satisfaction increased for
Navy, Department of Defense, or the United States Government. all 3 variables measured. To achieve a change in culture with
We are military service members. This work was prepared as part of our official hourly rounding compliance, nurse managers must consistently
duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title monitor staff compliance with hourly rounding.
is not available for any work of the United States Government.” Title
17 U.S.C. 101 defines a United States Government work as a work prepared
by a military service member or employee of the United States Government Key words: Hourly rounding; Patient satisfaction; Performance
as part of that person’s official duties. improvement; Emergency nursing
For correspondence, write: Carmen Brosinski, MSN, RN, SANE-A, Naval
Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth,
Virginia 23708; E-mail: [email protected].
J Emerg Nurs 2019;46:511-7.
Introduction
Available online 24 March 2020
0099-1767 In today’s competitive health care market, positive con-
Published by Elsevier Inc. on behalf of Emergency Nurses Association. sumer experience ratings are an integral component, depict-
https://doi.org/10.1016/j.jen.2019.08.004 ing the community’s perception of a medical institution’s

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PRACTICE IMPROVEMENT/Brosinski and Riddell

success. Although positive patient satisfaction scores are not clinical tasks instead of rounding, staffing shortages,
necessarily indicative of quality medical care, the patients’ departmental renovations, and staff buy-in. As a means to
perception of medical services has an impact on a facility’s enhance project success, the team focused on obtaining staff
rating. The Hospital Consumer Assessment of Healthcare buy-in while ensuring project initiatives did not increase cur-
Providers and Systems survey allows the Centers for Medi- rent workload. The project was structured to incorporate pur-
care and Medicaid Services to compile and report on the poseful rounding components into the already existing hourly
quality of hospital care provided from the patient’s perspec- rounding policy through scripting, which has been associated
tive.1 According to a systematic review of literature, the top with positive outcomes when used in the ED setting.11
3 priorities identified for improving patient satisfaction are
communication, wait times, and staff empathy.2
The dynamics associated with emergency department INTERVENTION
care are complex and have the potential to impede the ability
The goal of this patient-centered care process improvement
to meet the patients’ perspective of quality care.3 A descrip-
project was to increase patient satisfaction within a 6-month
tive cross-sectional study on the relationship between pa-
period from a baseline of 52% to 80% by increasing staff
tient and nurse perspective of care identified that a
and patient interactions. A team of 9 staff members was
positive nurse-patient relationship is important to the expe-
assembled with nurse manager oversight to champion the
rience of care.4 Furthermore, nurses recognized they may
project. Of the 9 members, 1 was selected to supervise proj-
not always be able to provide compassionate care.4 Although
ect progression and collect data, whereas the remaining
patient satisfaction is multifactorial, elements that nega-
members were divided into nurse and technician team
tively affect ED visits include perceived unfair patient
leaders, who were responsible for implementation within
flow, unexplained wait times, and a lack of information
their respective teams. Department leadership and project
sharing between staff and patients.5 To meet patient expec-
staff focused on changing the behavior of nurses and techni-
tations, process improvement initiatives involving variations
cians by involving patients in their medical care through the
of purposeful rounding have been implemented to alleviate
use of scripted communication to facilitate status updates
low patient satisfaction ratings.6–9
and address patient needs in a timely manner (Figure 1).

Methods MEASURES

SETTING Our health care system relies on the ICE tool, which allows
customers to submit either electronic or paper comment
This process improvement initiative took place in a 49-bed cards, providing managers with service quality data. Options
emergency department located in a mid-Atlantic military ac- for electronic comment submissions consist of online entries
ademic hospital with a monthly census of 5,800 patients. The through the hospital website, an ICE kiosk in patient wait-
patient population consists of active duty military personnel, ing areas, and a mobile telephone application. The
their dependents, military retirees, and civilians of all ages. comment cards focus on satisfaction questions and provide
Out of 35 institutions that provide emergency services within a free-text section for comments (Figure 2). All patient sub-
our health care system and use the Interactive Customer Eval- missions are electronically mailed to the departmental
uation (ICE) program, our hospital ranked number 17 in leadership to review and take action, as required.
patient satisfaction scores.10 Based on the submission of 91 This process improvement project took place over a 23-
comment cards from the 6 months before project implemen- month period, broken down into 4 phases: baseline, inter-
tation, the overall patient satisfaction rate was 52%. To vention I, break, and intervention II. Measures evaluated
enhance the patient experience, a process improvement consisted of self-reported staff rounding compliance, overall
initiative involving hourly rounding was implemented to in- patient satisfaction, perception of staff attitude, and pa-
crease patient satisfaction scores. This quality improvement tients’ response to whether the health care team answered
project received a waiver of Internal Review Board review all patient questions/concerns. The baseline phase consisted
requirement, since as a quality improvement project it was of data collection to obtain initial figures from the 6 months
deemed exempt from IRB review. before implementing the intervention. During intervention
During the project development, we identified multiple I, data were tracked and collected on a daily basis. Feedback
potential barriers to project success. Barriers consisted of was provided to the staff during unit meetings, and a visual
competing institutional initiatives, time spent performing tracker board was developed and prominently displayed

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1. Status of care. 2. Current plan of care. 3. Any needs at this me.

We are making every effort to expedite Your current plan of care is… (Next Is there anything I can do for you at this
your care. At the moment, we are steps, melines). me? If your symptoms change or you
waing on your (lab, x-rays, U/S, CT, have any quesons or concerns before I
consulng services…). come back, please use your call bell.

Staff Name: Date:

Place check in box if update provided
Paent Scker
0600
1800
0700
1900
0800
2000
0900
2100
1000
2200
1100
2300
1200
0000
1300
0100
1400
0200
1500
0300
1600
0400
1700
0500
FIGURE 1
Staff accountability sheets with scripted communication.

outside of the unit conference room. Throughout the break monitored daily via accountability sheets. Results were
phase, the staff were no longer required to self-report their displayed on the score board and included compliance
compliance with hourly rounding. In addition, no feedback with hourly rounding per team and overall patient satisfac-
was provided, although data were still being analyzed tion for the emergency department. Data were updated on
through the ICE tool. The intervention II phase of the proj- a weekly basis to provide real-time feedback.
ect began with a staff questionnaire designed to identify any The goal of the break phase was to determine if a cul-
perceived barriers the staff thought may have been impeding ture change occurred subsequent to the implementation
their ability to perform hourly rounding. The ICE tool was of the process improvement project. During the break
also modified to include specific questions about communi- phase, which lasted 6 months, the staff was not required
cation provided from the health care team. to self-report completion of hourly rounding, and the score
Throughout the intervention I phase, training was pro- board was removed. Leadership continued to monitor pa-
vided to all nurses and technicians regarding the importance tient satisfaction rates, but the unit’s patient satisfaction rat-
of taking a patient-centered care approach in the delivery of ing was not reported to the staff during team huddles.
health care. Weekly 5-minute customer service training ses- During the last 2 weeks of the break phase, staff members
sions were conducted, and the staff was updated on current were issued a 5-question survey designed to elicit perceived
goals and measures. The second step was to implement a barriers to hourly patient rounding.
change in culture by initiating nurse/technician hourly Intervention II was initiated following a meeting, dur-
rounding on patients throughout the emergency depart- ing which the results of the staff survey were discussed, and
ment. To facilitate staff and patient interactions, a script the unit’s current patient satisfaction rating was revealed.
was included within the staff self-reporting tool (Figure 1). Because patient satisfaction scores declined during the break
Updates included current treatment status, planned inter- phase, the process improvement project was reimplemented
ventions, pending results, and addressing patient comfort. with the same format used during the intervention I phase of
The third step was to capture patient responses by having the initial project. Following staff retraining, a new score
the team leaders provide ICE forms to a minimum of 2 pa- board was developed, and data were collected for an addi-
tients during the shift. Compliance for each objective was tional 5 months.

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EMERGENCY MEDICINE DEPARTMENT CUSTOMER SURVEY

Your parcipaon is voluntary and can be anonymous. The purpose is to obtain your opinion on how
well the Emergency Medicine Team provides care to you, our valued customer. We are connually
striving to improve the quality of service we provide, and request your honest opinion. Posive
comments are appreciated as well. Please take a few minutes to let us know if the services provided
were readily available, helpful, and sufficient. Thank you for your cooperaon.

1. Were you sasfied with your overall

Yes No N/A
experience ⃝ ⃝ ⃝
2. The emergency room hospital staff introduced
Always Usually Somemes Never N/A
themselves and told me their role when I first
⃝ ⃝ ⃝ ⃝ ⃝
met them:
3. The emergency room hospital staff updated
Always Usually Somemes Never N/A
me on my plan of care during my visit:
⃝ ⃝ ⃝ ⃝ ⃝
4. The emergency room hospital staff explained
Always Usually Somemes Never N/A
the care they provided to me in a way that I
⃝ ⃝ ⃝ ⃝ ⃝
could understand:
5. Did you observe your provider engage in hand
Yes No N/A
hygiene pracce (soap/water or gel/foam)?
⃝ ⃝ ⃝
6. Were new prescribed medicaons reviewed
Yes No N/A
with you during your visit
⃝ ⃝ ⃝
7. Did the Healthcare team answer all of your
Yes No N/A
quesons/concerns ⃝ ⃝ ⃝

Excellent Good OK Poor Awful N/A

Facility Appearance ⃝ ⃝ ⃝ ⃝ ⃝ ⃝
Employee/Staff Atude ⃝ ⃝ ⃝ ⃝ ⃝ ⃝
Timeliness of Service ⃝ ⃝ ⃝ ⃝ ⃝ ⃝
Hours of Service ⃝ ⃝ ⃝ ⃝ ⃝ ⃝

Comments & Recommendaons for Improvement (connue on the back for addional space):

If you would like a response, please enter your contact informaon below.

Name:___________________ Phone:_______________________ Email:_________________________

FIGURE 2
Interactive Customer Service survey.

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FIGURE 3
Summary of Interactive Customer Evaluation comment variables.

DATA ANALYSIS which was scored using a Likert scale (1 ¼ excellent, 2 ¼ good,
3 ¼ OK, 4 ¼ poor, 5 ¼ awful, and 6 ¼ N/A).
Descriptive statistics were used to summarize the data
collected. The variables evaluated entailed self-reported staff Results
rounding compliance, overall patient satisfaction, perception
of staff attitude, and the patient’s response to whether the The number of ICE submissions during the baseline phase
health care team answered all patient questions/concerns. was 91 out of 35,053 patient encounters (<0.01%). Overall
Questions were answered as yes, no, or not applicable (N/A) patient satisfaction was 52%, perception of employee staff
except for the question evaluating perception of staff attitude, attitude was 70%, and 63% responded that staff answered

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TABLE
Patient census, ICE submissions, accountability sheet completion, and compliance
Encounters, Ice Accountability sheets Accountability sheets Completed Compliance with
n comments, distributed returned (%) correctly, % hourly rounding
n
Baseline 35,053 91 N/A N/A N/A N/A
Intervention I 31,297 383 3,561 3,047 (85) 37% 39%
Break 39,326 269 N/A N/A N/A N/A
Intervention II 24,510 303 3,096 1,318 (25) 42% 51%

ICE, Interactive Customer Evaluation; N/A, not applicable.

all questions. During the intervention I phase, 383 ICE monitored patient rounding in an effort to address patient
comments were submitted out of 31,297 patient encounters dissatisfies. Despite there being poor participation and mul-
(<0.01%). The increase in comment card submissions may tiple limitations, hourly rounding still improved patient
have been attributed to the staff’s focus on capturing patient satisfaction metrics.
responses. Overall patient satisfaction was 75%, perception
of employee staff attitude was 84%, and staff answered all
questions 82% of the time. A summary of the response to LIMITATIONS
the 3 ICE comment variables is provided in Figure 3. Out The authors experienced several limitations throughout the
of 3,561 accountability sheets distributed to the staff, process improvement project. Both clinical and managerial
3,047 (85%) were returned to the shift team leaders. Of staff changed throughout the 4 phases of the project. The
those, 37% were completed correctly, and hourly rounding change in management may have contributed to decreased
was conducted 39% of the time. A summary of account- oversight during the intervention II phase, during which
ability sheets collected is provided in the Table. overall project compliance greatly decreased. Staffing was
During the break phase, 269 ICE comments were submit- further affected by the loss of one third of the active duty
ted out of 39,326 patient encounters (<0.01%). Overall pa- staff to an unforeseen hospital ship deployment.
tient satisfaction was 73%, perception of employee staff During a 16-month time span, the department under-
attitude was 85%, and staff answered all questions 80% of went a massive reconstruction initiative, which encom-
the time.Duringthe intervention IIphase, 303 ICEcomments passed one fifth of the treatment rooms and half of the
were collected out of 24,510 patient encounters (<0.01%). nurses’ station. Staff worked in cramped quarters with
Overall patient satisfaction was 73%, perception of employee limited access to resources such as the nurse call bell system
staff attitude was 84%, and staff answered all questions 81% and computer stations for charting. Although alternate
of the time. Out of 3,096 accountability sheets distributed to routes were developed to traverse through the department,
the staff, 1,318 (25%) were returned to the shift team leaders. physical layout added to process delays. An additional limi-
Of those, 42% were completed correctly, and hourly rounding tation may have been associated with past process improve-
was conducted 51% of the time.12 Staff identified multiple ob- ment projects not being completed, potentially leading to
stacles to accurately completing the accountability sheets. The poor staff buy-in. Although staff continued to receive pa-
most commonly reported barriers included increased patient tient satisfaction training during intervention phases I and
acuity, lack of ancillary support to assist with tasks such as pa- II, some perceived the process improvement initiative as
tient transport, performing moderate sedations, and altered “just another task.”
nursing assignments for lunch coverage. Limitations to gathering ICE responses were multifac-
torial. Although all patient rooms had bins installed to
Discussion hold paper ICE forms, the bins were not always stocked.
Even when patients were provided ICE forms, some left
SUMMARY
without completing them. Despite having an ICE kiosk in
Patient satisfaction is multifactorial, and may be related to the waiting room, it was frequently out of service, which
things such as being kept informed of the progress of care, limited submission options. In addition, posters with a
length of stay, and staff attitude. We implemented and quick response (QR) code were placed in every room,

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