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PurposeThe use of a proactive hourly

rounding strategy to improvepatient satisfaction is described.Inspired by the work of Meade,Bursell, and Ketelsen (2006), staffat Baltimore Washington MedicalCenter (BWMC) piloted hourlyrounding on several units.Although results from this studyare not yet available, a brief casestudy can demonstrate how resultsat BWMC may compare to thenational study. The study’s pur-pose was to determine if patientsatisfaction increases significantlyas the new strategy is implement-ed.

Background Baltimore Washington Medical

Center, a 311-bed facility that ispart of the University of MarylandMedical System, is located on thebusy Baltimore and Washington,DC, corridor. BWMC’s 2,600employees cared for more than200,000 patients in 2009. BWMCwas named the only Solucient® Top100 Hospital in Maryland or theDistrict of Columbia in 2006(Lanham, 2007). The award, whichis now known as ThompsonReuters, benchmarks hospital per-formance across the nation in spe-cific areas, including quality ofcare, patient perception of care,finance, and efficiency (ThompsonReuters, 2010).

BWMC recently completed amajor expansion project to broad-en emergency and critical careservices, and added women’s careservices in response to the needsof the surrounding community. As

Hourly Rounding: A Strategy to Improve PatientSatisfaction Scores

(2005) supported these findings ina study based on the aims andrules in previous IOM reports.They noted, “If we are truly toachieve a health care system thatis patient-centered, we must con-tinue to search for creative ways toelicit, and heed the voice of thepatient” (p. 555).

Safety weighs heavily in patientsatisfaction. The Joint Commissionprovides its accredited health careorganizations with a list of NationalPatient Safety Goals and mandatesthe requirements necessary toimprove patient safety (The JointCommission, 2008). Problematicareas of health care are identifiedwith evidence-based and expert-based solutions designed to protectpatients (The Joint Commission,2009). Examples of safety goalsinclude reducing risk of patientharm related to falls, preventingpressure ulcers, and enhancingmedication administration. Nursesdirectly impact all these areas withroutine nursing care delivery.

Satisfaction is the perceptionof the patient. Because nursingservices play a major role inpatient satisfaction, quality of care,and safety, organizations continu-ally must seek new ways toimprove these critical services.One strategy called hourly round-ing is a suggested method toaddress these issues (StuderGroup, 2007). Hourly rounding is anew, proactive approach to organ-izing nursing care that has gar-nered positive results; its focus onpatient-centered care has led tonotably improved patient satisfac-tion scores.

Patient satisfaction is an impor-tant phenomenon in the health

care industry. Health care organiza-tions continually seek innovativeapproaches to boost patient satisfac-tion scores. Several studies uncov-ered nursing behaviors essential topatient satisfaction. Patients valuethe nurse-patient relationship, as wellas time spent with them, continuity ofcare, trust, compassion, respect, safe-ty, understandable instructions, andservice quality. They also appreciatereliability, responsiveness, and effec-tive communication (Andaleeb,Siddiqui, & Khandakar, 2007; Cheng,Yang, & Chiang, 2003; Davis, 2005;Fan, Burman, McDonell, & Fihn,2005). Satisfaction surveys are usedto identify, measure, and track keydeterminants of satisfaction (PearsonAssessments, 2007).

The Committee on QualityHealth Care in America has workedwith the Institute of Medicine(IOM) on the nation’s quality ofcare since 1996, developing a newparadigm for health care deliverybased on logic and evidence ofpatient needs. The IOM (2001) pur-ported successful care will servethe needs of the patient, keep thepatient fully informed, allow thepatient to retain control throughmore active participation, and bemindful of patient values and pref-erences. Sofaer and Firminger

Beverly M. Ford, MSN, RN, BC, CMSRN,is a Medical-Surgical Charge Nurse,Baltimore Washington Medical Center,Glen Burnie, MD.

Beverly M. Ford

MEDSURG Nursing—May/June 2010—Vol. 19/No. 3 189

a result, nursing services continueto expand. Leaders determined it iscrucial to maintain and/or exceedthe high standard of care as expan-sion occurs.

Patient satisfaction at BWMC ismonitored currently by the JacksonHealthstream Organization anduses the new Hospital ConsumerAssessment of Healthcare Pro vidersand Systems survey. This is a toolco-developed by the Centers forMedicare & Medicaid Services andthe Agency for Healthcare Researchand Quality (AHRQ). It provides anationally standardized and pub-licly reported benchmark ofpatients’ perception of their care(AHRQ, 2008).

What Is Hourly Rounding?Developed by the Studer Group,

hourly rounding is another way oforganizing existing work. Its pur-pose is to anticipate and meetpatient needs routinely, and ensurepatient safety (Shaner-McRae,2007). Rounding allows informationto be gathered in a structured way,addressing problems before theyoccur (Studer Group, 2005). Hourlyrounding addresses patient needsproactively.

How Is Hourly RoundingPerformed?

Specific scripts and tactics forhourly rounding provide consisten-cy and continuity of patient care,leading to better outcomes andgreater satisfaction (Leighty,2006a). In the Studer study (Meadeet al., 2006), staff explained topatients they would be checking onthem hourly to enhance their safe-ty and address personal needs.Staff members were taught to enterthe patient room, identify them-selves, and tell patients they werepresent to do their rounds (Wood,2005). Scheduled tasks, such asdressing changes or medicationadministration, were performed.Before leaving the room, nursesaddressed the four Ps: pain, per-sonal needs, positioning, andplacement (Studer Group, 2007) asthe most frequent reasons patientsuse the call light. Immediatelybefore leaving the room, staff askedthe patient if anything else wasneeded, emphasizing they had thetime to address any needs. When

everything was completed, thepatient was informed a health carestaff member would return withinan hour to round again (Leighty,2006a). Knowing someone willreturn in an hour allowed patientsto cluster requests and alleviatesanxiety, contributing to their safetyand well-being (Wood, 2005). Thesebehaviors contributed to increasedpatient satisfaction scores.

A Closer Look at the Four PsA specific set of actions are

addressed during each roundingsession. These actions, generallyclustered into four areas, aredesigned to meet patient needsand foster a relationship with eachpatient (Meade et al., 2006). Theseareas are described below.

Pain. The provider asks thepatient, “How is your pain?” Afteridentifying patient pain intensity,the provider offers appropriatemeasures as needed, includingposition changes, guided imagery,deep breathing exercises, diver-sion activities, and medication. As-needed medications are offeredwhen a dose is due. Other comfortmeasures such as mouth care areimplemented, and fluids areoffered.

Personal needs. The providerasks the patient, “Do you need touse the bathroom?” Toileting timesare scheduled with the patient,with assistance offered as needed.The provider remains with thepatient who requires assistance tothe bathroom or bedside com-mode and then assists the patientback to the chair or bed.

Positioning. The provider checkspatient positioning and inquires,“How can I make you more comfort-able?” Risks of skin breakdown areidentified when the provider turnsthe patient, performs hygiene, pro-vides skin care, fluffs pillows, andstraightens linens. Turning sched-ules are observed, with all patientswho cannot turn independentlyassisted with repositioning at leastevery 2 hours. This includes keepingheels up to help reduce heel pres-sure.

Placement. The provider veri-fies accessibility of possessionsand asks, “Do you need us to movethe call light, phone, water pitcher,trash can, over-bed table, or any

other possessions within reach?”Items used most frequently mustremain within easy reach of thepatient.

Hourly Rounding at BWMCFollowing the same format as

the research by Meade and col-leagues (2006), the study unit main-tained call light logs on patients fora 2-week period prior to rounding.The researcher received approvalto test hourly rounding out on herassigned patients for a 3-week peri-od. Quantitative call light data werecollected during this time, alongwith data from rounding logs anddischarge phone calls made tothose patients within 48 hours ofdischarge. To serve as controls, arandom sample of patients who didnot receive hourly rounds alsowere tracked for call light use andresults of the follow up dischargephone survey. Results were ana-lyzed and compared to the nationaldata.

Findings During the 3-week period, the

researcher rounded on up to ninepatients per day (maximum of sixpatients at any given time). The 51-patient sample included 29 females(57%) and 22 males (43%). Patientsranged in age from 21 to 90, withthe mean age 58. All patients werealert, oriented, and able to commu-nicate their needs to nursing staff,and received hourly rounding byone nurse.

Call light logs from the casestudy showed a 52% decline in calllight use after initiating hourlyrounding (see Figures 1 and 2 fordescription of call light use). Thisdecrease in call light use reflectedresults of the national study(Meade et al., 2006), and has sub-stantial implications for nursing.With less interruption by call lights,units are quieter and nurses havemore time to concentrate onpatient care and charting.

No falls were reported duringthe study period, possibly due tothe higher frequency of patientcontact. However, no additionaldata were collected because of thebrevity of this study. When thestudy is completed, results areexpected to be similar to thenational findings.

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Discharge phone calls topatients who received hourlyrounding reflected their satisfactionwith their overall care. Their com-ments on specific areas of nursingcare reflected the perception ofreceiving superior care by nursingstaff, including pain management,comfort, and safety. Other respons-es included patients’ satisfactionwhen staff members took the timeto listen to them.

Clinical ImplicationsCall light use. With call lights

ringing less, the nurse spends moretime on patient care instead ofgoing from room to room dealingwith issues as they arise. Duringnursing rounds, the nurse gets agood grasp on the patient’s needsand uses the opportunity to planwith the patient. The patient knowsnursing staff members will returnas promised, and uses the call lightless frequently.

Patient falls. Hospitals thatincorporate hourly rounding notepositive improvements in patientsafety; patient falls occur less fre-quently (Meade et al., 2006). Whenstaff members round on patientsevery hour and address basicneeds, such as toileting and place-ment of personal items, risks forfalls decrease. Patients are less like-ly to get out of bed when personalneeds are met.

Pressure ulcers. Turning andrepositioning are considered basicnursing care. When nursing staffmembers maintain regular turningand positioning schedules withtheir patients, pressure ulcer rateson inpatient cases can decrease byup to 56% (Studer Group, 2007). Inpatients with existing wounds, reg-ular turn schedules contribute tothe healing process.

Patient satisfaction. Accordingto Christine Meade, chief researcherin the nationwide Studer studies onhourly rounding, increased nursingpresence leads to better quality ofcare which in turn has a positiveeffect on patient satisfaction scores(Leighty, 2006a). Using specificscripts and eliciting key informationfrom the patient about personalneeds allows the nurse and patientto develop a plan of care that is opti-mal for both players. Satisfactionwas 92%-98% in Meade’s nationalstudies (Leighty, 2006a; Meade at al.,2006; Studer, 2007).

Nursing satisfaction. Nursingcare is more efficient and lessstressful when hourly rounding isperformed. Hourly rounding freesmore nursing time and decreasesfrustration by optimizing shift timeutilization (Leighty, 2006a). Couldthis strategy help to keep morenurses at the bedside in the midstof the current nursing shortage(Meade et al., 2006)?

ConclusionHourly rounding is “about

engaging the patients – going inand finding out their needs andaccomplishing tasks” (Leighty,2006b). Mary Shepherd, RN, nurs-ing project and Magnet® programdirector, The Methodist Hospital,Houston, TX, noted, “...rounding isa common sense approach topatient care, but it is not alwayscommon practice” (Sigma Theta

Pain19%

Other58%

Error8%

Personal Needs14%

Positioning1%

Placement0

Figure 1.Results by Category for Call Light Usage Before Initiation

of Hourly Rounding

Pain17%

Other57%

Error7%

Personal Needs12%

Positioning5%

Placement2%

Figure 2.Results by Category for Call Light Usage after Initiation

of Hourly Rounding

MEDSURG Nursing—May/June 2010—Vol. 19/No. 3 191

Tau International, 2006). Nurses,proactive with rounding, “are find-ing their shifts less stressful, theirtime more productive, and patientsafety and satisfaction scores hit-ting all-time highs” (Leighty,2006b). The positive results ofrounding exceed expectations inmost facilities where the strategyhas been used. Consistent hourlyrounding is a key for improvingsafety and quality of care; itresults in fewer call light interrup-tions, allowing nurses to organizetheir time better and reducestress. Additionally, patients areless anxious. Hourly rounding con-tributes in several key areas toachievement of high levels ofpatient satisfaction, includingquality of care and patient safety(Meade et al., 2006).

ReferencesAgency for Healthcare Research and Quality

(AHRQ). (2008). The CAHPS hospitalsurvey (H-CAHPS). (2008). Retrievedfrom https://www.cahps.ahrq.gov/con-tent/products/HOSP/PROD_HOSP_Intro.asp

Andaleeb, S.S., Siddiqui, N., & Khandakar, S.(2007). Patient satisfaction with healthservices in Bangladesh. Health Policyand Planning, 22(4), 263-273.

Cheng, S.H., Yang, M.C., & Chiang, T.L.(2003). Patient satisfaction with and rec-ommendation of a hospital: Effects ofinterpersonal and technical aspects ofhospital care. International Journal forQuality in Health Care, 15(4), 345-355.

Davis, L. (2005). A phenomenological study ofpatient expectations concerning nursingcare. Holistic Nursing Practice, 19(3),126-133.

Fan, V., Burman, M., McDonell, M., & Fihn, S.(2005). Continuity of care and otherdeterminants of patient satisfaction withprimary care. Journal of GeneralInternal Medicine, 20(3), 226-233.

Institute of Medicine (IOM). (2001). Crossingthe quality chasm: A new health systemfor the 21st century. Washington, DC:National Academy Press.

Lanham, M. (2007). Baltimore WashingtonMedical Center (BWMC) named one ofthe nation’s 100 top hospitals. Retrievedfrom http:/data.bwmc.umms.org/news/detail.cfm?ID=1687

Leighty, J. (2006a). Let there be less light.Retrieved from http://www.studergroup.com/dotCMS/knowledgeAssetDetail?inode=323218

Leighty, J. (2006b). Nursing Spectrum -Career Fitness Online. Retrieved fromhttp://community.nursingspectrum.com/MagazineArticles/article.cfm?/AID=25038

Meade, C.M., Bursell, A.L., & Ketelsen, L.(2006). Effects of nursing rounds: Onpatients’ call light use, satisfaction, andsafety. American Journal of Nursing,106(9), 58-70.

Pearson Assessments. (2007). Patient satis-faction surveys. Retrieved fromhttp://survey.pearsonassessments.com/audience/patient.htm

Shaner-McRae, H. (2007). Notes on nursing.Retrieved from http://www.fahc.org/Nursing/nursing_contribution/NON_2007/02-07_NON.pdf

Sigma Theta Tau International. (2006).RNews capsules. Retrieved fromhttp://www2.nursingsociety.org/RNL/4Q_2006/columns/rnews_capsules.html

Sofaer, S., & Firminger, K. (2005). Patient per-ceptions of the quality of health services.Annual Review of Public Health, 26,513-559.

Studer Group. (2005). The magic of rounding:Quint Studer brings a leadership tech-nique from medicine into the world ofbusiness. Retrieved from http://www.studergroup.com/dotCMS/knowledgeAssetDetail?inode=111088

Studer Group. (2007). Hourly rounding supple-ment. Retrieved from http://www.mc. van-derbilt.edu/root/pdfs/nursing/hourly_rounding_supplement-studer_group.pdf

The Joint Commission. (2008). 2008 NationalPatient Safety Goals: Hospital program.

Retrieved from http://www. jointcommis-sion.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm

The Joint Commission. (2009). NationalPatient Safety Goals: Evaluating safetyand quality using the national patientsafety goals. Retrieved from http://www.jointcommission.org/GeneralPublic/NPSG/gp_npsg.htm?print=yes

Thompson Reuters. (2010). New 2009 100top hospitals: National benchmarksstudy. Retrieved from http://www.100tophospitals.com/top-national-hospitals/

Wood, D. (2005). Rounding cuts call-light use.Retrieved from http://w3.rn.com/news_news.asp?articleID=14521&page=RN%5FNews&Profile=RN%5FNews&Headline=Rounding+Cuts+Call%2DLight+Use

Additional ReadingStuder Group. (2006). Improve clinical out-

comes with hourly roundingsm.Retrieved from http:/studergroup.com/newsletter/Vol1_Issue7/fall2006_sec1.htm

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