Family-centered rounds (FCRs) are multidisciplinary rounds that involve medical teams partnering with patients and families in daily medical decision-making. Multiple FCR benefits have been identified including improving patient satisfaction, communication, discharge planning, medical education, and patient safety. Main barriers to FCRs are variability in attending rounding, duration of rounds, physical constrains of large teams and small rooms, specific and sensitive patient conditions, and lack of training of residents, students, and faculty on how to conduct effective and effecient FCRs. In the last decade, many programs have incorporated FCRs into daily practice due to their multiple perceived benefits. Future FCRs should focus on better operationalizing of FCRs and reporting on objective outcomes measures such as improved communication, coordination, and patient satisfaction that are crucial for healthcare.
Key points
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Family-centered rounds (FCRs) are multidisciplinary rounds that involve complete case discussion and presentation in front of the patient and family so as to involve them in the decision-making.
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FCR benefits include improved perception of parental satisfaction, communication, coordination of care, discharge planning, teamwork, quality improvement and improved trainee education.
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Key FCR barriers include lack of attending and trainees training on FCR, variability in conducting FCRs, duration, patient confidentiality, and physical constraints of large team and small room.
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As FCRs are adopted, research in needed to objectively measure outcomes such as parental satisfaction, safety, and quality improvement, and communication. These can then further improve FCR implementation.
In the last decade, in an effort to improve family-centered care, pediatric hospitalists have incorporated family-centered bedside rounds in the inpatient setting. By involving patients and families in decision making during rounds, hospitalists have given a new twist to the old concept of bedside rounds, and have called it family-centered rounds (FCRs).
Bedside rounds and FCR s
Forty years ago, bedside rounds were conducted in many academic centers. Physicians rounded in teams with residents and students, and 75% of teaching occurred during rounds. Teaching during ward rounds was focused on acquiring mastery in history taking and acquiring clinical skills. Sir William Osler, father of modern medicine, liked to say, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” His best-known saying was “Listen to your patient; he is telling you the diagnosis,” which emphasizes the importance of taking a good history. Bedside rounds were the norm for physician-led teaching rounds. Over the years, the proportion of teaching that occurs at the bedside decreased to 16% in 1978, and to even lower estimates in the 1990s as rounds moved away from the bedside.
The 2001, the Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century , emphasized the need to ensure the involvement of patients and families in their own health care decisions, to better inform patients of treatment options, and to improve patients’ and families’ access to information. As a result, the focus of practice shifted from physician-centered care toward providing patient-and family-centered care. Family-centered care in pediatrics is based on the understanding that family is the primary source of strength and support and that the child’s and family’s perspectives and information are important in clinical decision making. The American Academy of Pediatrics (AAP) recommended that in the inpatient setting, complete case discussion and presentation should occur in the presence of patients and family to involve them in the decision making. As a result, FCRs have gained substantial momentum, and bedside rounds have returned to the inpatient setting, this time with focus on family-centered care. In a recent Pediatric Research in the Inpatient Network (PRIS) survey, over half the pediatric hospitalists reported conducting FCRs, and academic centers were more likely to conduct them.
Bedside rounds and FCR s
Forty years ago, bedside rounds were conducted in many academic centers. Physicians rounded in teams with residents and students, and 75% of teaching occurred during rounds. Teaching during ward rounds was focused on acquiring mastery in history taking and acquiring clinical skills. Sir William Osler, father of modern medicine, liked to say, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” His best-known saying was “Listen to your patient; he is telling you the diagnosis,” which emphasizes the importance of taking a good history. Bedside rounds were the norm for physician-led teaching rounds. Over the years, the proportion of teaching that occurs at the bedside decreased to 16% in 1978, and to even lower estimates in the 1990s as rounds moved away from the bedside.
The 2001, the Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century , emphasized the need to ensure the involvement of patients and families in their own health care decisions, to better inform patients of treatment options, and to improve patients’ and families’ access to information. As a result, the focus of practice shifted from physician-centered care toward providing patient-and family-centered care. Family-centered care in pediatrics is based on the understanding that family is the primary source of strength and support and that the child’s and family’s perspectives and information are important in clinical decision making. The American Academy of Pediatrics (AAP) recommended that in the inpatient setting, complete case discussion and presentation should occur in the presence of patients and family to involve them in the decision making. As a result, FCRs have gained substantial momentum, and bedside rounds have returned to the inpatient setting, this time with focus on family-centered care. In a recent Pediatric Research in the Inpatient Network (PRIS) survey, over half the pediatric hospitalists reported conducting FCRs, and academic centers were more likely to conduct them.
FCR s , sit down rounds, hallway rounds, and conference room rounds
FCRs are defined as a multidisciplinary rounding model that involves planned, purposeful interaction that requires the permission of patients and families and the cooperation of physicians, nurses, and ancillary staff. FCRs are multidisciplinary rounds and involve nurses, care coordinators, social workers, pharmacists, attending physicians, students, and residents. Many different types of rounds are described and practiced in the hospital setting; therefore it is important to understand how they differ from FCRs. “Sit down rounds” and “conference room” style rounds occur away from patients and families and are traditionally physician-centered rounds that involve the attending physician and students and residents rounding in a conference room to discuss a patient’s plan of care. These may or may not be attended by other staff. “Hallway rounds” involve rounds in the corridors or hallway outside patient rooms. The medical team (the attending physician and students and residents) discusses a patient’s case in the hallway without patient or family involvement. Traditionally, a team member (often a resident or attending physician) then updates or discusses the patient’s plan of care with his or her family. FCRs, unlike the other rounds, are multidisciplinary rounds and involve complete case presentation and discussion in front of family members and their involvement in the medical decision making.
Benefits of FCR s
Benefits of involving families during FCRs have been studied in the last decade. The value of FCRs in improving parental satisfaction, discharge timeliness, nursing satisfaction, communication, and resident and student education has been reported.
Muething and colleagues developed the first FCR model for improvement and described the role of FCRs in improving family-centered care, trainee education, and reducing time to discharge. They found FCRs to be efficient, and efficiency was further improved by the presence of nurses and other key ancillary staff who contributed valuable information regarding the patient’s condition and progress made toward meeting discharge goals. Family involvement and engagement were high in decision making. Rosen and colleagues, in their quasi-experimental design, studied the impact of FCRs on parental and team satisfaction when compared with conventional rounds. They did not find any difference in parental satisfaction; however, they noted that staff satisfaction was higher on FCRs. They concluded that FCRs foster team work and empower hospital staff; additionally, the family members are engaged and are the focus point of FCRs. Rappaport and colleagues identified benefits of and barriers to FCRs for individuals who attend FCRs, including trainees, nurses, patients, and families. They reported that both patients and families were satisfied with FCRs, and FCRs were beneficial for trainee education.
Parents and families are central to a child’s environment, and involving them in care plan is crucial. FCRs bring everyone involved in a patient’s care together in the same room at the same time, creating an environment of direct communication and providing a venue for immediate clarification of any miscommunication. Effective communication is crucial for parental understanding of a medical condition, plan of care, and discharge planning; therefore it is not surprising that FCRs are perceived to improve parental satisfaction and communication. Both English-speaking and limited English proficient families perceive FCRs to improve communication and parental satisfaction.
In teaching institutions with trainees (residents and students), several FCR-related benefits have been identified ( Box 1 ). FCRs provide a venue for trainees to see patients in real time. They get to directly observe the attending physicians communicate with patients and families and with members of the multidisciplinary team. FCRs also allow attending physicians to directly observe trainees and provide real-time feedback. A recent study from Johns Hopkins Medical Center reported that interns lack training on bedside etiquettes such as compassion and communication. Many crucial elements of patient care and the Accreditation Council of Graduate Medical Education (ACGME) requirements such as compassion, respect, professionalism, dignity and cultural competencies, and communication with patients and families cannot be taught in a lecture room format, and FCRs might be an excellent venue to teach and directly observe trainees. In a recent study on pediatric resident perspectives about FCRs, residents reported improved nondidactic teaching and patient satisfaction, and reduced need for clarification on patient care plans. In a focus group study at 2 large children’s hospitals, residents perceived FCRs to improve their communication skills, especially the use of lay language. Residents noted that discharge planning during rounds helped them understand reasons for admissions, criteria for discharge, and systems-based practice required to coordinate discharge. Role modeling by the attending physician was also reported to be beneficial for resident education concerning skills such as communication, compassion, and respect and dignity when communicating with patients and family.
