Elizabeth D. Cox, MD, PhD

A growing body of literature suggests that patient‐ and family‐centered care can improve patient outcomes[1, 2, 3, 4, 5] as well as patient, family, and provider satisfaction.[6, 7, 8, 9, 10] Engaging patients and families as a way to improve the quality and safety of care has been widely endorsed by leading healthcare organizations,[11, 12, 13] including the Institute of Medicine.[14] In the pediatric inpatient setting, family‐centered rounds (FCR), defined as bedside rounds in which the patient and family share in the control of the management plan as well as in the evaluation of the process itself,[15] potentially provide a consistent venue for family engagement and are recommended by the American Academy of Pediatrics as standard practice.[13]

According to a recent study by Mittal et al.,[16] FCR are the most common type of rounds practiced among pediatric hospitalists surveyed in the United States and Canada. Despite this widespread shift from rounding in a conference room to the bedside with patients and families, there exist only a few studies that provide specific recommendations on conducting FCR.[15, 17, 18] This research has been limited, primarily focusing how rounds are conducted, and further investigation is needed to identify the impact of other processes and elements within the hospital work system that may also affect family engagement during rounds.

The objectives of this study were to: 1) identify strategies to enhance family engagement during FCR drawing from the viewpoints of the various stakeholders on rounds, and 2) characterize these strategies into known elements of hospital work systems and rounding processes using a recognized human factors engineering approach, The Systems Engineering Initiative for Patient Safety (SEIPS) model.[19] According to the SEIPS model, barriers and facilitators to family engagement during FCR are likely embedded in the design of the hospital work systems and rounding process; therefore, we hypothesized that strategies that influence engagement will target all work system and process elements. This work is part of a larger study in which, after prioritization of this group of strategies based on feasibility and sustainability, a bundle of best practices for conducting FCR will be developed, implemented, and evaluated.

METHODS

RESULTS

A total of 37 interviews were conducted with 11 parents, 4 children, and 22 HCT members (8 attending physicians, 6 resident physicians, 5 medical students, and 3 nurses) in 24 videos of rounding sessions. The duration of the interviews ranged from 30 to 60 minutes.

A total of 338 separate instances related to strategies for improving family engagement on FCR were identified and sorted into 21 categories. Using the SEIPS model, these categories were organized into 2 themes: the work system and process of FCR (Figure 1). Of the 21 categories, 12 were mentioned by both families (parents and/or children) and HCT members and 9 were solely mentioned by the HCT.

Figure 1

DISCUSSION

Using recognized qualitative systems engineering methods, we identified a broad range of strategies for enhancing family engagement on FCR from the perspectives of a diverse group of stakeholders on rounds and described how these strategies target known fundamental elements in both the hospital work system and rounding process. We highlight recommendations on the content and style of communication during rounds with families, but also introduce more complex system‐wide elements that likely play a role in family engagement, such as the composition of the HCT; organization and environment of rounds; tools and technologies used; and preparation of the HCT, families, and patients beforehand.

Our research both confirms and builds upon practices previously described in the FCR literature.[17, 31, 32] In a case report by Muething et al.,[17] recommendations were developed using a series of plan‐do‐study‐act cycles to determine the components needed to conduct FCR. These components included: 1) determining family preference prior to rounds, 2) defining HCT roles, 3) introducing HCT to family and explaining the purpose of rounds, 4) describing what is shared and how it is said on rounds, 5) describing the contribution of families, nurses, and ancillary staff, and 6) providing teaching recommendations to senior physicians on rounds. All of these components are suggested by one or more of the participants in our study. In addition, our research identifies a variety of new work system‐related strategies, such as scheduling rounds, using computers appropriately on rounds, and providing training of HCT members beforehand.

Of particular interest was the discordance between strategies mentioned by families and the various members of the HCT. Although HCT members mentioned all identified strategies, families were interested in certain ones. Regarding the structure of FCR, families showed particular interest in HCT composition, timing and scheduling of rounds, location of rounds, and positioning of the HCT. In comparison, families did not mention the importance of the roles and duties of HCT members, HCT preparation for rounds, and use of computers during rounds. With respect to the FCR process, families stressed the importance of family preparation beforehand, introduction and explanation of rounds at the beginning, presentation style and communication style, customization, and management of distractions during rounds. None of the families, however, mentioned the rest of the strategies, including HCT preparation before rounds, involvement of the nurse, teaching and performing the physical exam, the role of the attending and senior resident roles during rounds, and following up with the family after rounds. These different perspectives are likely, in part, inherent to the different roles and experiences of parents and HCT members. For example, parents' knowledge of what goes on in the hospital outside of FCR, such as orientation and preparation of HCT members for rounds, is relatively limited. Future research using methods to evaluate and prioritize strategies as well as understanding reasons for contradicting strategies is warranted.

We recognize that, although family engagement is recommended as a critical component of care, strategies to improve engagement may be in direct opposition to other goals of the HCT. For example, some of our participants suggest having a smaller team may be more beneficial for family engagement on rounds. In some settings, it may be feasible to have a small team; however, in institutions that accommodate a large number of learners, excluding students from the teaching opportunity of rounds may actually compromise educational experiences. In patients with chronic and/or complex care, a larger multidisciplinary team may better facilitate information exchange among disciplines and expedite discharge planning. Moreover, one might speculate that it may not be that the size affects family engagement as much as the composition of the team, especially if tailored to the needs of the patient. For example, a large team consisting of primarily physicians and trainees may not be as engaging as the same sized team with one attending physician and a respiratory therapist, case manager, and consulting subspecialist. Finding a balance between engaging families, teaching learners, and maintaining efficiency is paramount and needs to be studied further.

This study has several limitations. Our data are from a single academic children's hospital, which may limit generalizability due to a small sampling of multiple stakeholders on different services, our specific patient population, HCT composition and roles, and teaching needs. However, we face similar barriers to engaging families during rounds as those published from both another single institution[17] and a national sampling of pediatric hospitalists.[16] Furthermore, our recommended strategies to address the FCR process are supported by prior work.[17] Because this study was voluntary, our interviewees were likely more engaged participants in general. Specifically, the viewpoints of engaged families and HCT members may not represent the viewpoints of those who are less engaged or supportive of FCR. We did not enroll nonEnglish‐speaking patients and families, which is a potential direction for future research. In our interviews, we also relied solely on the perceptions of rounding participants, rather than those of outside observers or researchers, which may only provide a partial perspective of potential strategies to improve family engagement. Last, this qualitative research approach does not provide quantitative information regarding whether certain strategies are preferred by a majority of participants, which we hope to address in future research.

This work is part of a larger study that aims to implement a bundle of these strategies after stakeholder prioritization based on impact on family engagement, feasibility, and sustainability. We plan to systematically evaluate the implementation process of these strategies and measure their impact on family engagement and, ultimately, patient safety. One or more of these strategies could be implemented in a similar manner at other hospitals depending on specific institutional needs.

In conclusion, as recently reflected by Barry et al. in The New England Journal of Medicine, Although talk about patient‐centered care is ubiquitous in modern health care, one of the greatest challenges of turning the rhetoric into reality continues to be routinely engaging patients in decision making.[33] FCR provide a crucial opportunity for family involvement in daily care decisions in the pediatric inpatient setting. This study highlights the importance of prior work defining the components of involving families in this process, while emphasizing new systems‐based strategies that further facilitate the expectation of family engagement in the care of hospitalized children.

Disclosures

This work was funded through an Agency for Healthcare Research and Quality Health Services Research Dissemination and Demonstration Grant, R18 HS018680, and also supported by the Arthur Vining Davis Foundation and the National Patient Safety Foundation through the James S. Todd Memorial Research Award. Funding organizations did not contribute to the design and conduct of study; collection, management, analysis, and interpretation of data; or preparation, review, or approval of the manuscript. The authors report no conflicts of interest.

A growing body of literature suggests that patient‐ and family‐centered care can improve patient outcomes[1, 2, 3, 4, 5] as well as patient, family, and provider satisfaction.[6, 7, 8, 9, 10] Engaging patients and families as a way to improve the quality and safety of care has been widely endorsed by leading healthcare organizations,[11, 12, 13] including the Institute of Medicine.[14] In the pediatric inpatient setting, family‐centered rounds (FCR), defined as bedside rounds in which the patient and family share in the control of the management plan as well as in the evaluation of the process itself,[15] potentially provide a consistent venue for family engagement and are recommended by the American Academy of Pediatrics as standard practice.[13]

According to a recent study by Mittal et al.,[16] FCR are the most common type of rounds practiced among pediatric hospitalists surveyed in the United States and Canada. Despite this widespread shift from rounding in a conference room to the bedside with patients and families, there exist only a few studies that provide specific recommendations on conducting FCR.[15, 17, 18] This research has been limited, primarily focusing how rounds are conducted, and further investigation is needed to identify the impact of other processes and elements within the hospital work system that may also affect family engagement during rounds.

The objectives of this study were to: 1) identify strategies to enhance family engagement during FCR drawing from the viewpoints of the various stakeholders on rounds, and 2) characterize these strategies into known elements of hospital work systems and rounding processes using a recognized human factors engineering approach, The Systems Engineering Initiative for Patient Safety (SEIPS) model.[19] According to the SEIPS model, barriers and facilitators to family engagement during FCR are likely embedded in the design of the hospital work systems and rounding process; therefore, we hypothesized that strategies that influence engagement will target all work system and process elements. This work is part of a larger study in which, after prioritization of this group of strategies based on feasibility and sustainability, a bundle of best practices for conducting FCR will be developed, implemented, and evaluated.

METHODS

RESULTS

A total of 37 interviews were conducted with 11 parents, 4 children, and 22 HCT members (8 attending physicians, 6 resident physicians, 5 medical students, and 3 nurses) in 24 videos of rounding sessions. The duration of the interviews ranged from 30 to 60 minutes.

A total of 338 separate instances related to strategies for improving family engagement on FCR were identified and sorted into 21 categories. Using the SEIPS model, these categories were organized into 2 themes: the work system and process of FCR (Figure 1). Of the 21 categories, 12 were mentioned by both families (parents and/or children) and HCT members and 9 were solely mentioned by the HCT.

Figure 1

DISCUSSION

Using recognized qualitative systems engineering methods, we identified a broad range of strategies for enhancing family engagement on FCR from the perspectives of a diverse group of stakeholders on rounds and described how these strategies target known fundamental elements in both the hospital work system and rounding process. We highlight recommendations on the content and style of communication during rounds with families, but also introduce more complex system‐wide elements that likely play a role in family engagement, such as the composition of the HCT; organization and environment of rounds; tools and technologies used; and preparation of the HCT, families, and patients beforehand.

Our research both confirms and builds upon practices previously described in the FCR literature.[17, 31, 32] In a case report by Muething et al.,[17] recommendations were developed using a series of plan‐do‐study‐act cycles to determine the components needed to conduct FCR. These components included: 1) determining family preference prior to rounds, 2) defining HCT roles, 3) introducing HCT to family and explaining the purpose of rounds, 4) describing what is shared and how it is said on rounds, 5) describing the contribution of families, nurses, and ancillary staff, and 6) providing teaching recommendations to senior physicians on rounds. All of these components are suggested by one or more of the participants in our study. In addition, our research identifies a variety of new work system‐related strategies, such as scheduling rounds, using computers appropriately on rounds, and providing training of HCT members beforehand.

Of particular interest was the discordance between strategies mentioned by families and the various members of the HCT. Although HCT members mentioned all identified strategies, families were interested in certain ones. Regarding the structure of FCR, families showed particular interest in HCT composition, timing and scheduling of rounds, location of rounds, and positioning of the HCT. In comparison, families did not mention the importance of the roles and duties of HCT members, HCT preparation for rounds, and use of computers during rounds. With respect to the FCR process, families stressed the importance of family preparation beforehand, introduction and explanation of rounds at the beginning, presentation style and communication style, customization, and management of distractions during rounds. None of the families, however, mentioned the rest of the strategies, including HCT preparation before rounds, involvement of the nurse, teaching and performing the physical exam, the role of the attending and senior resident roles during rounds, and following up with the family after rounds. These different perspectives are likely, in part, inherent to the different roles and experiences of parents and HCT members. For example, parents' knowledge of what goes on in the hospital outside of FCR, such as orientation and preparation of HCT members for rounds, is relatively limited. Future research using methods to evaluate and prioritize strategies as well as understanding reasons for contradicting strategies is warranted.

We recognize that, although family engagement is recommended as a critical component of care, strategies to improve engagement may be in direct opposition to other goals of the HCT. For example, some of our participants suggest having a smaller team may be more beneficial for family engagement on rounds. In some settings, it may be feasible to have a small team; however, in institutions that accommodate a large number of learners, excluding students from the teaching opportunity of rounds may actually compromise educational experiences. In patients with chronic and/or complex care, a larger multidisciplinary team may better facilitate information exchange among disciplines and expedite discharge planning. Moreover, one might speculate that it may not be that the size affects family engagement as much as the composition of the team, especially if tailored to the needs of the patient. For example, a large team consisting of primarily physicians and trainees may not be as engaging as the same sized team with one attending physician and a respiratory therapist, case manager, and consulting subspecialist. Finding a balance between engaging families, teaching learners, and maintaining efficiency is paramount and needs to be studied further.

This study has several limitations. Our data are from a single academic children's hospital, which may limit generalizability due to a small sampling of multiple stakeholders on different services, our specific patient population, HCT composition and roles, and teaching needs. However, we face similar barriers to engaging families during rounds as those published from both another single institution[17] and a national sampling of pediatric hospitalists.[16] Furthermore, our recommended strategies to address the FCR process are supported by prior work.[17] Because this study was voluntary, our interviewees were likely more engaged participants in general. Specifically, the viewpoints of engaged families and HCT members may not represent the viewpoints of those who are less engaged or supportive of FCR. We did not enroll nonEnglish‐speaking patients and families, which is a potential direction for future research. In our interviews, we also relied solely on the perceptions of rounding participants, rather than those of outside observers or researchers, which may only provide a partial perspective of potential strategies to improve family engagement. Last, this qualitative research approach does not provide quantitative information regarding whether certain strategies are preferred by a majority of participants, which we hope to address in future research.

This work is part of a larger study that aims to implement a bundle of these strategies after stakeholder prioritization based on impact on family engagement, feasibility, and sustainability. We plan to systematically evaluate the implementation process of these strategies and measure their impact on family engagement and, ultimately, patient safety. One or more of these strategies could be implemented in a similar manner at other hospitals depending on specific institutional needs.

In conclusion, as recently reflected by Barry et al. in The New England Journal of Medicine, Although talk about patient‐centered care is ubiquitous in modern health care, one of the greatest challenges of turning the rhetoric into reality continues to be routinely engaging patients in decision making.[33] FCR provide a crucial opportunity for family involvement in daily care decisions in the pediatric inpatient setting. This study highlights the importance of prior work defining the components of involving families in this process, while emphasizing new systems‐based strategies that further facilitate the expectation of family engagement in the care of hospitalized children.

Disclosures

This work was funded through an Agency for Healthcare Research and Quality Health Services Research Dissemination and Demonstration Grant, R18 HS018680, and also supported by the Arthur Vining Davis Foundation and the National Patient Safety Foundation through the James S. Todd Memorial Research Award. Funding organizations did not contribute to the design and conduct of study; collection, management, analysis, and interpretation of data; or preparation, review, or approval of the manuscript. The authors report no conflicts of interest.

A growing body of literature suggests that patient‐ and family‐centered care can improve patient outcomes[1, 2, 3, 4, 5] as well as patient, family, and provider satisfaction.[6, 7, 8, 9, 10] Engaging patients and families as a way to improve the quality and safety of care has been widely endorsed by leading healthcare organizations,[11, 12, 13] including the Institute of Medicine.[14] In the pediatric inpatient setting, family‐centered rounds (FCR), defined as bedside rounds in which the patient and family share in the control of the management plan as well as in the evaluation of the process itself,[15] potentially provide a consistent venue for family engagement and are recommended by the American Academy of Pediatrics as standard practice.[13]

According to a recent study by Mittal et al.,[16] FCR are the most common type of rounds practiced among pediatric hospitalists surveyed in the United States and Canada. Despite this widespread shift from rounding in a conference room to the bedside with patients and families, there exist only a few studies that provide specific recommendations on conducting FCR.[15, 17, 18] This research has been limited, primarily focusing how rounds are conducted, and further investigation is needed to identify the impact of other processes and elements within the hospital work system that may also affect family engagement during rounds.

The objectives of this study were to: 1) identify strategies to enhance family engagement during FCR drawing from the viewpoints of the various stakeholders on rounds, and 2) characterize these strategies into known elements of hospital work systems and rounding processes using a recognized human factors engineering approach, The Systems Engineering Initiative for Patient Safety (SEIPS) model.[19] According to the SEIPS model, barriers and facilitators to family engagement during FCR are likely embedded in the design of the hospital work systems and rounding process; therefore, we hypothesized that strategies that influence engagement will target all work system and process elements. This work is part of a larger study in which, after prioritization of this group of strategies based on feasibility and sustainability, a bundle of best practices for conducting FCR will be developed, implemented, and evaluated.

METHODS

RESULTS

A total of 37 interviews were conducted with 11 parents, 4 children, and 22 HCT members (8 attending physicians, 6 resident physicians, 5 medical students, and 3 nurses) in 24 videos of rounding sessions. The duration of the interviews ranged from 30 to 60 minutes.

A total of 338 separate instances related to strategies for improving family engagement on FCR were identified and sorted into 21 categories. Using the SEIPS model, these categories were organized into 2 themes: the work system and process of FCR (Figure 1). Of the 21 categories, 12 were mentioned by both families (parents and/or children) and HCT members and 9 were solely mentioned by the HCT.

Figure 1

DISCUSSION

Using recognized qualitative systems engineering methods, we identified a broad range of strategies for enhancing family engagement on FCR from the perspectives of a diverse group of stakeholders on rounds and described how these strategies target known fundamental elements in both the hospital work system and rounding process. We highlight recommendations on the content and style of communication during rounds with families, but also introduce more complex system‐wide elements that likely play a role in family engagement, such as the composition of the HCT; organization and environment of rounds; tools and technologies used; and preparation of the HCT, families, and patients beforehand.

Our research both confirms and builds upon practices previously described in the FCR literature.[17, 31, 32] In a case report by Muething et al.,[17] recommendations were developed using a series of plan‐do‐study‐act cycles to determine the components needed to conduct FCR. These components included: 1) determining family preference prior to rounds, 2) defining HCT roles, 3) introducing HCT to family and explaining the purpose of rounds, 4) describing what is shared and how it is said on rounds, 5) describing the contribution of families, nurses, and ancillary staff, and 6) providing teaching recommendations to senior physicians on rounds. All of these components are suggested by one or more of the participants in our study. In addition, our research identifies a variety of new work system‐related strategies, such as scheduling rounds, using computers appropriately on rounds, and providing training of HCT members beforehand.

Of particular interest was the discordance between strategies mentioned by families and the various members of the HCT. Although HCT members mentioned all identified strategies, families were interested in certain ones. Regarding the structure of FCR, families showed particular interest in HCT composition, timing and scheduling of rounds, location of rounds, and positioning of the HCT. In comparison, families did not mention the importance of the roles and duties of HCT members, HCT preparation for rounds, and use of computers during rounds. With respect to the FCR process, families stressed the importance of family preparation beforehand, introduction and explanation of rounds at the beginning, presentation style and communication style, customization, and management of distractions during rounds. None of the families, however, mentioned the rest of the strategies, including HCT preparation before rounds, involvement of the nurse, teaching and performing the physical exam, the role of the attending and senior resident roles during rounds, and following up with the family after rounds. These different perspectives are likely, in part, inherent to the different roles and experiences of parents and HCT members. For example, parents' knowledge of what goes on in the hospital outside of FCR, such as orientation and preparation of HCT members for rounds, is relatively limited. Future research using methods to evaluate and prioritize strategies as well as understanding reasons for contradicting strategies is warranted.

We recognize that, although family engagement is recommended as a critical component of care, strategies to improve engagement may be in direct opposition to other goals of the HCT. For example, some of our participants suggest having a smaller team may be more beneficial for family engagement on rounds. In some settings, it may be feasible to have a small team; however, in institutions that accommodate a large number of learners, excluding students from the teaching opportunity of rounds may actually compromise educational experiences. In patients with chronic and/or complex care, a larger multidisciplinary team may better facilitate information exchange among disciplines and expedite discharge planning. Moreover, one might speculate that it may not be that the size affects family engagement as much as the composition of the team, especially if tailored to the needs of the patient. For example, a large team consisting of primarily physicians and trainees may not be as engaging as the same sized team with one attending physician and a respiratory therapist, case manager, and consulting subspecialist. Finding a balance between engaging families, teaching learners, and maintaining efficiency is paramount and needs to be studied further.

This study has several limitations. Our data are from a single academic children's hospital, which may limit generalizability due to a small sampling of multiple stakeholders on different services, our specific patient population, HCT composition and roles, and teaching needs. However, we face similar barriers to engaging families during rounds as those published from both another single institution[17] and a national sampling of pediatric hospitalists.[16] Furthermore, our recommended strategies to address the FCR process are supported by prior work.[17] Because this study was voluntary, our interviewees were likely more engaged participants in general. Specifically, the viewpoints of engaged families and HCT members may not represent the viewpoints of those who are less engaged or supportive of FCR. We did not enroll nonEnglish‐speaking patients and families, which is a potential direction for future research. In our interviews, we also relied solely on the perceptions of rounding participants, rather than those of outside observers or researchers, which may only provide a partial perspective of potential strategies to improve family engagement. Last, this qualitative research approach does not provide quantitative information regarding whether certain strategies are preferred by a majority of participants, which we hope to address in future research.

This work is part of a larger study that aims to implement a bundle of these strategies after stakeholder prioritization based on impact on family engagement, feasibility, and sustainability. We plan to systematically evaluate the implementation process of these strategies and measure their impact on family engagement and, ultimately, patient safety. One or more of these strategies could be implemented in a similar manner at other hospitals depending on specific institutional needs.

In conclusion, as recently reflected by Barry et al. in The New England Journal of Medicine, Although talk about patient‐centered care is ubiquitous in modern health care, one of the greatest challenges of turning the rhetoric into reality continues to be routinely engaging patients in decision making.[33] FCR provide a crucial opportunity for family involvement in daily care decisions in the pediatric inpatient setting. This study highlights the importance of prior work defining the components of involving families in this process, while emphasizing new systems‐based strategies that further facilitate the expectation of family engagement in the care of hospitalized children.

Disclosures

This work was funded through an Agency for Healthcare Research and Quality Health Services Research Dissemination and Demonstration Grant, R18 HS018680, and also supported by the Arthur Vining Davis Foundation and the National Patient Safety Foundation through the James S. Todd Memorial Research Award. Funding organizations did not contribute to the design and conduct of study; collection, management, analysis, and interpretation of data; or preparation, review, or approval of the manuscript. The authors report no conflicts of interest.