A Framework for Providers and Nurses: Standardizing Interdisciplinary Patient Rounds Further Improving Collaborative Communication

Background: When it comes to patient rounds, there continues to be a lack of team communication between medical providers and Registered Nurses. Nationally, only 30% of patient rounds take place with both medical providers and Registered Nurses present. This lack of interdisciplinary communication is linked to sentinel events, medical mishaps, and poor patient satisfaction. Unclear expectations of how and when medical providers and Registered Nurses should communicate about their patients has been identified as a contributing factor to insufficient collaborative communication. Methods: A quality improvement project was developed to help set clear expectations of how and when inpatient medical-surgical teams should communicate. Objective data on 2 team communication was gathered utilizing surveys. Staff perceptions and attitudes on collaborative communication was assessed using questionnaires. An educational presentation and framework was created and presented to medical providers and Registered Nurses. The educational presentation and framework detailed the benefits of collaborative communication and also explained how to conduct collaborative communication moving forward. Post-education and post-framework implementation benefits were evaluated by objective communication surveys as well as staff questionnaires. Results: There were 500 staff surveys collected in the evaluation of IPRs. These surveys indicated that face-to-face medical team communication decreased by 0.8% after the intervention. Despite face-to-face communication decreasing, overall collaborative communication increased by 4.8%. In addition to the staff surveys, there were 48 pre-intervention questionnaires and 36 post-intervention questionnaires utilized to evaluate staff perceptions surrounding IPRs. In these questionnaires, medical providers and Registered Nurses indicated significant improvements in understanding their role in collaborative communication- 23/48 participants pre-intervention to 31/36 participants post-intervention (p= 0.000006). Both medical providers and Registered Nurses also reported an increased preference for informal, non-face-to-face, collaborative communication- 19/48 participants pre-intervention to 22/36 post-intervention (p= 0.004). 3 Conclusion: The results indicate that the educational presentation and framework contributed to improving overall interdisciplinary communication. Continued research on methods to improve communication between medical providers and Registered nurses is needed to determine if similar results would be reproducible in other medical-surgical units.

A Framework for Providers and Nurses: Standardizing Interdisciplinary Patient Rounds Further Improving Collaborative Communication Alexia R. Searle College of Nursing, University of Utah April 6, 2020 1 Abstract Background: When it comes to patient rounds, there continues to be a lack of team communication between medical providers and Registered Nurses. Nationally, only 30% of patient rounds take place with both medical providers and Registered Nurses present. This lack of interdisciplinary communication is linked to sentinel events, medical mishaps, and poor patient satisfaction. Unclear expectations of how and when medical providers and Registered Nurses should communicate about their patients has been identified as a contributing factor to insufficient collaborative communication. Methods: A quality improvement project was developed to help set clear expectations of how and when inpatient medical-surgical teams should communicate. Objective data on 2 team communication was gathered utilizing surveys. Staff perceptions and attitudes on collaborative communication was assessed using questionnaires. An educational presentation and framework was created and presented to medical providers and Registered Nurses. The educational presentation and framework detailed the benefits of collaborative communication and also explained how to conduct collaborative communication moving forward. Post-education and post-framework implementation benefits were evaluated by objective communication surveys as well as staff questionnaires. Results: There were 500 staff surveys collected in the evaluation of IPRs. These surveys indicated that face-to-face medical team communication decreased by 0.8% after the intervention. Despite face-to-face communication decreasing, overall collaborative communication increased by 4.8%. In addition to the staff surveys, there were 48 preintervention questionnaires and 36 post-intervention questionnaires utilized to evaluate staff perceptions surrounding IPRs. In these questionnaires, medical providers and Registered Nurses indicated significant improvements in understanding their role in collaborative communication- 23/48 participants pre-intervention to 31/36 participants post-intervention (p= 0.000006). Both medical providers and Registered Nurses also reported an increased preference for informal, non-face-to-face, collaborative communication- 19/48 participants pre-intervention to 22/36 post-intervention (p= 0.004). 3 Conclusion: The results indicate that the educational presentation and framework contributed to improving overall interdisciplinary communication. Continued research on methods to improve communication between medical providers and Registered nurses is needed to determine if similar results would be reproducible in other medical-surgical units. 4 A Framework for Providers and Nurses: Standardizing Interdisciplinary Patient Rounds Further Improving Collaborative Communication Research has shown that breakdown in hospital interdisciplinary communication is a direct catalyst to increased sentinel events, poor job satisfaction, higher staff turnover rates, disgruntled patients, and hostile work environments. The Joint Commission has linked poor communication to 60% of sentinel events and 70% of medical mishaps (Gausvik, Lautar, Miller, Pallerla, & Schlaudecker, 2015). Improved collaborative communication and subsequent staff and patient outcomes have been achieved with implementation of interprofessional patient rounds (IPRs) (Sang et al., 2019). IPRs are defined as face-to-face communication between a medical provider and a registered nurse (RN) in regards to their patient's plan-of-care. Despite proven benefits of formal IPRs, patient rounds are not consistently approached in an interdisciplinary manner, as nurses are involved in less than 30% (Sang et al., 2019). Unfortunately, at the studied hospital only 17% of IPRs were completed face-to-face with a medical provider 5 and RN. The negative outcomes related to the dysregulation of IPRs and breakdown of communication, lead to a genuinely failed delivery of patient care and dysfunctional healthcare system. To improve collaborative communication and subsequent patient outcomes, quality improvement measures need to be taken to structure interdisciplinary communication through formal IPRs. Available Knowledge & Problem Background Healthcare professionals work together in that providers fromulate orders and plans which are then carried out by an RN. The RN assesses the patient regularly, evaluating their vitals, response to treatments, dietary intake, etc. Sharing this information during IPRs allows for clarification and collaboration. As IPRs are often the only time nurses and providers discuss their patients together, the lack of interdisciplinary rounding creates a breakdown in collaborative communication. The lack of standardized IPRs leads to poor employee and patient satisfaction rates, increased medical errors and sentinel events. Higher RN turnover rate has been correlated to low job satisfaction caused by poor interdisciplinary communication, as reported by RNs (Tang, Chan, Zhou, & Liaw, 2013; Gausvik et al., 2015). Medical 6 providers, including medical doctors (MDs) and advanced practice clinicians (APCs), also report job frustration due to poor communication as it can delay the implementation of their orders by RNs and lead to poor collaborative patient care. This impact on patient care was evident in low patient satisfaction scores and increased mortality rates (Tang et al., 2013; Mccaffrey et al., 2010). Despite supportive evidence, indicating the benefits of collaborative communication, the absence of IPRs on medical-surgical units are common on a local and national level (Sang, et al., 2019). Investigative studies have found the cause for absent IPRs to be multifactorial: differing staff perception of IPR benefit, workday time constraints, needing to attend to emergencies and pages, answering call lights, and navigating differing workflows. The various externalities make it difficult to obtain full team support and have IPRs occur at a time that is convenient for all parties (Rosenstein, 2002; Basic, Huynh, Gonzales, & Shanley, 2018; Hendricks, Lamothe, Kara, & Miller, 2017). Analyzing and synthesizing the specific barriers preventing a medical team from standardizing IPRs can assist in creating the quality improvements necessary to overcome these barriers. When IPRS are successfully implemented it leads to an increase in quality of patient care and staff satisfaction. Research showed that standardized IPRs led to increased patient satisfaction, improved patient safety, decreased patient length of stay and decreased unnecessary paging of medical providers (Basic et al., 2018; Shirreff, 7 Husslein, Lefebvre, & Shore, 2018). Rationale The low rate of conducted standardized IPRs on the medical-surgical unit at the studied hospital is a safety concern. The proposed intervention to implement a standardized IPRs to improve interdisciplinary communication at the studied hospital was constructed based on previously established and successful IPR frameworks. The IPR standard that the intervention was modeled after was created and conducted by Cleveland Clinic. Cleveland Clinic's formal IPRs focused on three primary principles. First, each interprofessional involved in the rounds had a set role and responsibility during the rounds. Second, an outline on how the patient information would be presented was established. Third, a safety checklist was integrated into the collaborative discussion (Chowdhury et al., 2018). The IPRs were implemented on various units and adapted as needed. For example, on a Cardiovascular unit, telephone based rounding was used to facilitate communication between physician and RN as they met with each patient (Cleveland Clinic, 2020). Cleveland Clinic's IPRs were successful in improving interprofessional satisfaction and increasing IPR participation (Chowdhury et al., 2018). Their IPRs also led to marked improvements in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. After implementing the IPRs they had a 7.3% increase in 8 physician communication and an 8.7% increase in nurse communication (Cleveland Clinic, 2020). Additionally, RNs gave anecdotal reports that they felt an improved culture of mutual respect between RNs and providers with the practice of consistent IPRs- noting that they no longer felt nervous about interjecting their own thoughts and opinions during rounds (Cleveland Clinic, 2020). The selected IPR model was adapted and created for this improvement project using the Business Process Reengineering (BPR) theory. The BPR theory was created to help businesses improve productivity and the quality of their service. The BPR has four primary stages (see Figure 1). First, is to identify the current intervention or process. Second, is to analyze and identify key elements of the current practice, this step allows the project lead to identify inefficient elements that need to be eliminated. Third, is to formulate an alternative design through collaborative team discussion that will overcome potential barriers and achieve desired outcomes. The last step is to test and implement the new intervention (Braun, Chaczko, Neilson, & Aslanzadeh, 2012). The theory's process was used to identify the lack of consistent IPRs, to analyze the barriers attributing to a deficiency in IPRs, to formulate a framework to help address those barriers, and to lastly, implement the newly designed framework into daily practice. The theory focuses on group efforts, it was not specifically targeted towards individual RNs or providers, but instead to the whole interdisciplinary team. 9 Specific Aims The success of standardized IPRs in improving interprofessional communication is the reason it was selected as an intervention for the medical-surgical population at the studied hospital. The aim of this project was to improve collaborative communication by addressing current barriers and establishing a standardized IPR. A secondary purpose was to improve perceived job efficiency with collaborative care through consistent unit IPRs, as they have been shown to have a positive correlation. Following the BPR theory, the first objective in implementing the quality improvement project was to assess IPRs and how often both the medical provider and RN were physically present for rounds. This established an understanding of how preimplementation IPRs were conducted and frequency at which they took place on the unit. Once the current framework was evaluated, barriers and inefficient elements were identified by the medical staff. Discussion of the downfalls of the current process also aided in the objective of analyzing the overall attitudes and perceptions of medical providers and RNs in regards to IPRs. This objective was crucial in guiding the necessary changes needed to establish a culture of consistent, standardized IPRs. After collaborative input and research, a new clinical IPR framework was developed that aimed at mitigating the identified barriers. This objective was fundamental in setting clear expectations for staff members regarding how the medical 10 unit would conduct IPRs. The next step and objective was to implement the standardized IPR. This included educating staff members on the new IPR format and introducing them to unit leads. Unit leads were charge nurses who would provide guidance and assistance to staff during the implementation process. Following implementation of the new IPR, the success of the quality improvement project in reaching its specific goals would be evaluated. This would be completed by analyzing the frequency of IPRs conducted and assessing staff perceptions and attitudes regarding IPRs post-implementation. The final objective would also include evaluating the feasibility and usability of the established IPR framework for continued practice. Context The improvement project was conducted at a 425-bed hospital in Salt Lake City, Utah. The hospital is a level-one trauma-center and the Mountain Wests' only academic healthcare center. The hospital services both the local community and patients from bordering states. The project was implemented on the 36 bed medical-surgical unit that cares for an average of 30.9 patients a day. There are three distinctive nurses' stations on the unit that separate rooms 1-12, 13-22, and 23-36 respectfully. The patients within the unit include individuals of all socioeconomic, racial, and cultural backgrounds. Care for the medical-surgical patients is provided by thirty-eight RNs and thirty- 11 three medical providers. Twenty-three of the medical providers are MDs and ten are APCs, other medical professionals include respiratory, physical, and speech therapists, etc. Though medical professionals work as a team, nurse managers and physicians take leadership roles. Prior to this project, the medical-surgical unit had an informal expectation that providers and RNs conducted IPRs for each patient on the unit at their bedside. These IPRs were expected to take place from 0900 to 1200 daily. The medical teams participating in IPRs ranged from small teams with only a primary provider and an RN, to large medical teams that involved the attending, residents, interns, medical students, pharmacist, and an RN. Despite an expectation that IPRs would be conducted for each patient on this unit, there was no written material or policy to that effect. With no formalization of IPRs there was confusion on each professional's roles during rounds and what information needed to be presented. Since the medical unit opened seven years ago, staff members have voiced concerns in regards to the infrequency of IPRs and the failure to involve RNs in the IPRs. Throughout the history of the unit, no unit wide initiatives have taken place to evaluate or formalize IPRs that could potentially compete with this quality improvement project. Interventions The intervention of establishing a standardized IPR on the medical-surgical unit at the studied hospital was brought forth after the evaluation of current IPR practices and 12 the frequency in which they were performed. As mentioned above, there were no current unit set guidelines for formal IPRs. The frequency of the informal IPRs being conducted was evaluated by a four-question, self-survey that was administered prior to implementation to the new IPR model (see Figure 2). Each shift, for a total of 500 patient rounds, the self-survey asked participating RNs to document information. This information included how many of their patients had IPRs completed at the bedside as well as to how many informal rounds were completed over the phone. To evaluate the current informal IPRs effectiveness and needs of the interdisciplinary team, the medical staff, including providers and RNs, were administered a pre-implementation questionnaire. The questionnaire gathered information from the medical staff on their perceptions and attitudes regarding IPRs (see Figure 3). Information gathered from the pre-questionnaire plus the Cleveland Clinic's model for a formal IPR was used to create the new IPR model. The new IPR model included clear instructions on interprofessional roles during rounds, what medical professionals needed to be present, what patient information needed to be presented and when IPRs were to be conducted (see Figure 4). Prior to the new IPR being rolled out onto the medical-surgical unit, the RNs and medical providers were provided education on the benefits of standardized IPRs and the new IPR guidelines for the unit. The education was presented during staff meetings by the author and unit management including staff educator Jana Frampton, RN. Four educational presentations were conducted on the unit and presentations lasted 13 approximately 30 minutes. The educational presentations were attended by both RNs and medical providers. The education was provided via group presentation and focused on educating staff on performing proper IPRs and obtaining staff acceptance of the new protocol. The steps of the new IPRs were shown on PowerPoint and staff was provided a handout on the new guidelines (see Figure 4). The staff was also guided through IPR scenarios to help facilitate understanding. Staff acceptance of the new protocol was achieved by discussing the datasupported benefits of consistent IPRs as well as highlighting the previously expressed staff frustrations and its correlation to the lack of proper IPRs. The need for the new IPR framework was also emphasized by showing the pre-implementation data that showed the lack of consistent IPRs completed on the unit. Beyond the staff educational meetings, charge nurses, who volunteered to become unit leads, were provided additional training. As unit leads, they were provided additional instruction on how to support staff members with implementing the IPR framework during their workflow. Charge nurses provided medical staff a constant resource for questions and guidance as well as provided oversight to insure IPR compliance. The IPR framework was implemented after the staff education was provided. The rounds were initiated by the attending MD or APC by calling the patient's assigned nurse as listed on the outside of the patient's door. Once notified, the RN would join the rest of the interdisciplinary team outside the patient's room. Prior to entering the room the RN would update the team on significant overnight events, patient's current pain level and 14 control, last bowel movement, dietary intake, status of wounds and drains, intravenous fluids or medications that were being administered and patient concerns. This allowed the team to discuss any necessary changes to the plan-of-care prior to presenting to the patient. Following the RN's report to the medical team, the team would enter the patient's room. The second part of the IPR was conducted by the APC or attending MD. The medical provider would first introduce the entire team to the patient and then provide the patient with the current plan-of-care and schedule. The patient was then encouraged to ask any questions or provide any additional information as needed. Following Cleveland Clinics model in adapting the IPR as needed to address any unforeseen barriers, a follow-up plan was created. If an IPR was unable to be completed with the bedside nurse, the attending MD or APC would assign a member of the medical team to call or meet with the RN separately to review the information provided during the IPR. After implementing the IPR framework, the analysis of IPRs was conducted daily until 500 patient rounds had been reviewed. During this time, RNs were given a selfsurvey to gather information on the frequency of IPRs (see Figure 2). This postimplementation survey was the same as the pre-implementation survey. The postimplementation period also included reevaluating the medical staff's perceptions and attitudes surrounding IPRs via a questionnaire (see Figure 3). Study of Intervention To evaluate if the quality improvement project achieved its primary specific aim 15 of improving collaborative communication through consistent standardized IPR, the frequency of conducted IPRs was measured before and after implementation. The frequency of IPRs completed on the unit was measured using 500 RN-surveys on the unit pre-implementation and 500 RN-surveys completed post-implementation. The RNsurveys were completed by the 38 RNs who worked on the medical-surgical unit and who participated in the quality improvement project. The RN-survey collected quantitative data by asking four primary questions. The first question was "how many patients did you have from the start of your shift until noon?" The staff was instructed to only include patients that were consistently on the unit during the time period between 0700-1200. This avoided calculating rounds for patients where the opportunity to complete an IPR was not feasible due to the patients absence. The survey then inquired how many rounds the RN was asked to participate in during that set time period. The third question asked how many IPRs was the RN physically present for. This question helped quantify data in regards to what IPRs were performed face-to-face vs follow-up patient rounds where the RN was contacted and given patient updates at a later time. Further detail on follow-up IPRs was gathered from the last question on the RN-survey that asked participating RNs if the medical providers contacted them to complete a follow-up IPR, where the IPR could not be done face-toface. The secondary specific aim of the intervention, to improve perceived job efficiency through collaborative care through consistent unit IPRs, was achieved by assessing staff attitudes and perceptions of standard IPRs. This was evaluated by 16 administering a pre- and post-implementation questionnaire. The participants who were provided the questionnaire included the 23 MDs, 10 APCs, and 38 RNs who worked on the unit. The questionnaire consisted primarily of close-ended questions. The questionnaire gathered qualitative data on the participant's attitudes and perceptions regarding IPR related to job function, their understanding of their roles during IPRs and current perceived barriers to completing IPRs. The survey also asked if participants felt that unit efforts were effective in implementing IPR (see Figure 3). Post-implementation data was collected following the completion of the RNsurveys and questionnaires. The post-implementation data was compared to the preimplementation data to evaluate if the primary aim was achieved. Measures The two primary sources of data retrieval, as previously discussed, included the RN-surveys and staff questionnaires that were completed pre- and post-implementation. The quantitative data from the RN-surveys that were analyzed included four questions that yielded numerical statistics on formal face-to-face IPRs and follow-up patient rounds (see Figure 2). The surveys completed pre- and post-implementation were identical and were compared using a one-tailed Z test. The qualitative data from the questionnaires was gathered through nine questions (see Figure 3). Seven of the nine questions required a yes or no response, such as "Do you personally find interdisciplinary patient rounds to be beneficial to completing your job effectively?" The yes and no responses to this question were kept in an ordinal scale and compared pre- and post-implementation. The other two questions had greater 17 response alternatives. The first question was "what is your role on AIMA?" The answer options included MD, APC or RN. As the survey was anonymous this question allowed individual disciplines to be identified. Specific questions instructed staff to identify perceived IPR barriers, an example of this is "Nation-wide, registered nurses are only included in 30% of interdisciplinary rounds. Please indicate below any and all barriers that you perceive to be keeping nurses from interdisciplinary rounds on your unit." The five alternative response options included "morning workflows being too busy to attend, gathering all disciplines at patient bedside is too time consuming, nurses do not currently have an active role during rounds, and there is no clear identified individual responsible for notifying nurses that rounds were taking place". Beyond these four preformulated responses the participant could also select "other" and write out the barrier. The responses to the questionnaire were evaluated by categorizing the answers into common themes to provide a descriptive summary. The RN-surveys and questionnaires were sent to two separate content expert panels prior to implementation. The first content expert included Keisa Lynch, DNP, APRN, FNP. Lynch has extensive DNP research experience and was able to review constructed surveys and questionnaires for errors, misleading or confusing questions. The second expert panel who provided evaluation included Frampton, RN the medicalsurgical unit staff educator and Dr. Devin Horton, MD who is a clinical instructor with the Division of General Internal Medicine. Both Frampton and Horton assisted in reviewing the project's specific aims, interventions, and methods to ensure they were 18 applicable to both RNs and MDs. Accuracy of the data collected was secured through having identical pre- and post-data questionnaires and surveys for each staff participant. Participants were given two weeks to complete the questionnaire to allow time for the forms to be completed in its entirety. By keeping all data questionnaires and surveys anonymous, staff members were able to answer questions honestly and without fear of retribution. Data entries and values were reviewed and verified by a peer to eliminate any possible errors. The implementation of an IPR framework is feasible as it is cost and time effective. The primary resources necessary to implement an IPR framework is the unit educator, charge nurses and the facility space for education. No additional cost was incurred for training staff as education was provided during pre-established staff meetings and charge nurses volunteered to be unit leads. Decreased financial cost was achieved by maximizing resources and supplies. Education was provided via powerpoint and hard-copies of new guidelines provided. This cost could be further decreased by sending guidelines out via emails. The low financial cost and limited required resources makes the IPR quality improvement project feasible in other similar clinical settings and ensures the longevity of its practice. To promote continued use of the formal IPRs, the IPR framework was incorporated into the new staff orientation process. Analysis Descriptive statistics were used to summarize the findings of this project. As 19 mentioned above, quantitative data was collected from the pre- and post-implementation RN-surveys and qualitative data was collected from the pre- and post-implementation questionnaires. One-tailed z-tests were calculated to determine significance changes between pre-implementation data and post-implementation data. Content analysis was used to reveal patterns in words utilized by staff members in the free-response section of the questionnaires. The answers were then categorized into common themes to provide a descriptive summary and quantified according to the frequency of their use. All data was verified by a third-party individual not personally involved in this quality improvement project for accuracy. Ethical Considerations The study was determined to be non-human subjects research by the University of Utah Institutional Review Board. A potential conflict of interest includes the author being employed as an RN on the medical-surgical unit the project was conducted on; although, no data was collected from the author. Results The results of this quality improvement project were collected pre and postimplementation. Pre-implementation data was collected between October 1st, 2019 and December 1st, 2019. Post-implementation data was collected between February 1st 2020 and February 23rd 2020. The results were reviewed and verified by a third party to ensure 20 accuracy. Objective IPR Data Five-hundred patient rounds were analyzed pre- and post-implementation. Of the 500 patient rounds assessed pre-implementation, 100% (n=500) were directed by a medical provider, 21% (n=105) began only after an RN was notified they were starting, and 17% (n=85) were conducted with an RN and provider physically present. Although IPRs are defined as a medical provider and an RN meeting face-to-face to discuss a patient's plan-of-care, the author evaluated the frequency of informal patient rounds. Informal patient rounds pertain to a patient's plan-of-care being discussed between the medical provider and RN in passing or over-the-phone. Of the 500 patient rounds analyzed pre-implementation, 29% (n=145) had a provider and RN participate in informal rounds. Between formal IPRs and informal patient rounds, a provider and an RN discussed their patients together 46% (n=230) of the time. The post-implementation impact of the project's interventions on objective data was analyzed utilizing a one-tailed z-test with a p-value significant at <0.05. The author observed significant differences between pre- and post-implementation objective data under the following categories: ⦁ IPRs initiated only after an RN was notified they were beginning (p= 0.002) ⦁ Informal rounds conducted in the place of IPRs (p=0.038) The frequency of IPRs was not statistically impacted (p's >0.05) and the rate at which IPRs were conducted on the unit decreased. Subjective IPR Data 21 There were a total of 71 medical-staff participants in this quality improvement project. These participants included both medical providers and RNs. Before and after implementing the IPR framework and conducting educational seminars, these participants were asked to complete a questionnaire which included questions on their perceptions and beliefs associated with IPRs. The pre-implementation questionnaire was completed by 67.6% (n=48) of participants. The post-implementation was completed by 50.7% (n=36) of participants. The author chose to analyze the survey data utilizing a onetailed z-test with a p-value significant at <0.05 due to an overall sample size greater than 30. The post-implementation questionnaire only received 36 responses and therefore the pre-implementation sample size was reduced to 36 while attempting to maintain the original mean of the data. Significant differences between pre- and post- implementation perceptions and beliefs were noted for the following questions: ⦁ Do you feel that your role, or what you should be doing during IPRs, has been clearly defined for you? (p= 0.000006) ⦁ Would you prefer that RNs and providers discuss patients informally (e.g. over the phone or at the nurses' station)? (p= 0.004) ⦁ At this time, do you feel like the efforts on the unit to improve IPRs are effective? (p=2.2E-10) The questions pertaining to the participants attitudes and beliefs surrounding IPRs that did not result in significant statistical changes (p = >0.05) included: ⦁ Do you personally find interdisciplinary patient rounds to be beneficial to completing your job effectively? (p= 0.236) 22 ⦁ Do you find interdisciplinary patient rounds to be helpful for the patient? (p= 0.159) ⦁ Do you find that interdisciplinary patient rounds can be disruptive to your daily workflow? (p=0.334) ⦁ Do you find the involvement of an RN in interdisciplinary rounds essential? (p= 0.059) The previous four questions maintained a majority affirmative response both pre- and post-implementation. Summary The quality improvement results demonstrate that the utilization of a framework to standardize IPRs does achieve the primary aim of increasing staff communication. However, it did not increase formal face-to-face IPRs. Despite surveyed staff reporting that quality improvement efforts to improve IPRs were effective, IPRs actually decreased by 0.8 %. However, although IPRs decreased, overall collaborative communication increased by 4.8%. The secondary purpose was to improve perceived job efficiency with collaborative care through consistent unit IPRs. Unfortunately, data did not indicate significant change in staff perceived job efficiency. Interpretation The findings that informal collaborative communication increased and formal 23 IPRs decreased suggest that future efforts may be best served focusing on promoting overall collaborative communication and not necessarily formal face-to-face IPRs. The other benefit of the study was that more RNs were notified of interdisciplinary rounds and provided updates by the medical provider. One cause for this could be that staff reported a greater understanding of their roles and responsibilities related to patient care and report, a finding that was seen in other studies (Chowdhury et al., 2018). The study did not achieve its secondary aim of increasing perceived job efficiency. This was surprising, as previous studies showed that staff perceived an improvement in job efficiency as medical providers reported a decrease in number of pages from RNs ( Shirreff et al., 2019). Another interventional study reported that staff did not feel that rounds changed in length of time with formal IPRs despite the rounds increasing 86 seconds per patient (Chowdhury et al., 2018). One likely cause that perceived job efficiency did not improve with the intervention could be that postimplementation data was collected immediately after intervention and captured the natural learning cure of establishing new practices and organizing work-flow. If data was collected later once IPRs had time to integrate into the culture of the unit this specific aim may have been achieved. Limitations There were multiple limitations that impacted the universalism of this study. One such limitation was the complex layout of the medical unit which the study was 24 implemented on. The unit was a culmination of three smaller units which, over several years, had been combined to create one large unit. As a result, there were three different primary nurses' stations, three main hallways, and several main entrances and exits. This layout could have contributed to the poor IPR compliance both pre- and postimplementation as staff members had difficulty gathering in one location. An additional limitation was the introduction of smartphones for RNs to use while on shift. Although these phones were strictly meant to enhance RN-to-RN communication and did not impact provider-to-RN communication, this project had to be halted until the full effect of these smartphones on communication was understood. This scenario ultimately delayed data collection. These limitations were unique to the environment of this study and may not be applicable to similar quality improvement efforts. Limitations were mitigated through various interventions. For example, the utilization of signs outside of each patient's door which listed the nurses' phone numbers allowed the provider to easily contact the RN without having to navigate the complex unit layout. Additionally, during the delay in data collection, staff remained engaged by participating in continued staff education on IPRs. The efforts to alleviate the aforementioned limitations ensured our beliefs that this project could be recreated on other inpatient medical units. Conclusion The results indicate that the educational presentation and framework contributed to improving overall interdisciplinary communication. Continued research on methods needed to improve communication between medical providers and Registered nurses is 25 needed to determine if similar results would be reproducible on other medical-surgical units. 26 References Basic, D., Huynh, E., Gonzales, R., & Shanley, C. (2018). Structured interdisciplinary bedside rounds, in-hospital deaths and new nursing home placements among older inpatients. Clinical Interventions in Aging, 13, 2289-2294. doi: 10.2147/cia.s171508 Braun, R., Chaczko, Z., Neilson, M., & Aslanzadeh, A. (2012). A practical approach for redesigning system engineering processes. 2012 International Conference on Information Technology Based Higher Education and Training (ITHET). https://www.researchgate.net/publication/260339167 _A_Practical_Approach_to_Redesign_System_Engineering_Processes Chowdhury, A., Lehr, C. 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Introduction of physician-nurse bedside rounding and ward task list to improve quality of care in gynaecology: Prospective, single-blinded, pre- and post-intervention study. 28 Journal of Obstetrics and Gynaecology Canada, 41(8), 1108-1114. https://doi.org/10.1016/j.jogc.2018.11.004 Tang, C., Chan, S., Zhou, W., & Liaw, S. (2013). Collaboration between hospital physicians and nurses: An integrated literature review. International Nursing Review, 60(3), 291-302. doi: 10.1111/inr.12034 Appendix Figure 1 Business Process Reengineering (BPR) Theory Cycle 29 Figure 2 Pre- and Post-Implementation Survey 30 Figure 3 31 Pre- and Post-Implementation Questionnaire 32 Figure 4 Interdisciplinary Patient Rounding Framework 33