Thank you, Jerome, and gosh, let me add my thanks to this morning's speakers so far. Fantastic stuff. And I'll tell you, our hope here is to allow for you all to network with each other as well as with us. We do have some roundtables coming up, and we're absolutely going to maximize the time we have to spend in that networking and discussion, and anticipate it'll flow a bit into lunch as well. As you're willing to and have interest. So my talk is to really say, you know, we all do rounds. We do a lot by habit. Can we do better? And I do not have any financial conflicts of interest with this topic in terms of improving efficiency of bedside rounds. And so we're going to talk about some of the things that have been published about optimizing rounds, some of the things I've observed over the years, talk about how you can evaluate your rounds and get feedback from others who are on your rounding team, and talk a little bit of case studies on how places have improved their rounds. And so, you know, it takes a little bit of introspection and obviously willing to challenge the status quo and awareness of when things are going well, what does it look like? How do you feel about the things that work really well? And how can you make that happen more of the time? And it's probably not going to be just an individual. It's going to be the team focusing on a similar perspective to really accomplish some change and move toward what you all as a group think would be a better scenario for your rounds. There's a fair amount of literature actually on how places have improved their rounds. And honestly, it's a very important topic in the pediatric community. So shout out to PEDS folks for their contributions. One of the earliest reports I was aware of came from Critical Care Medicine and VOTS and their group said, you know what, let's do a lean assessment on rounds and really examine and decide what are value-added activities? What's required? What's essential? You know, obviously we need a team report and assessment of the patient and discussion. The nurse has to be involved and we need a plan of care. And then obviously a mechanism to accomplish that. Let's define non-essential activities, things that happen on rounds and they have some value but perhaps aren't as important. And most importantly, what do we not need on rounds? What's non-essential and distracting? And so they really work to minimize non-essential activities. And some of this is out of our control. You know, if it's time for your patient to travel, it's time for your patient to travel. Do whatever you can to kind of manage that around rounds. Probably one of the most important things they did was to set up a resource team for the rounding period of time to deal with the things that come up, a new admission, an urgent discharge because you need a new admission, somebody to really handle all of that, perhaps run a code so that rounds can continue without interruption or less interruption. They really focused on timely completion of rounds. And so they elected to do their family updates right after rounds. And then moved a lot of their teaching beyond a single point per patient, moved teaching into an afternoon discussion. And so what they found is they were able to accomplish that without changing the amount of time per patient. But they felt that the time was more well spent. They reduced the non-essential activities, improved their timeliness and efficiency. They did a survey of staff and families and there was satisfaction with the improved process. They felt they had improved throughput. And so as you're talking about data for change, here's something that you can perhaps say, you know what, if we get our patients out faster, maybe that is a benefit to the whole group. They actually reduced their attending physician hours in the day required for patient care. And certainly that's value added in everyone's estimation. And assessed specifically around teaching and whether that was felt to be appropriate. And so they actually were, from before and to after, reduced the amount of time spent on rounds from about 157 minutes to about 120 minutes they felt was statistically significant. So process is important. Culture is similarly important. And there are factors that make a difference. And so this evaluation looked at variables that were associated independently with both psychological safety of the individuals on the team as well as the teamwork itself. And what they found is that leader inclusiveness was independently associated with a sense of psychological safety, the feeling that I can contribute on rounds and that my role is important. And an anecdote, I worked with a lot of different attendings at the bedside over the years. And posture and position in the room by the attending can be huge. If the attending and the resident or fellow are talking face to face with essentially their shoulders are back to the rest of the team, that doesn't make anyone else feel safe or included. So little things can make a big difference in that approach. But beyond that, the teamwork sense is also similarly impacted by leader inclusiveness. Does the leader stop and ask a question of the team to actively solicit input or get their assessments? Does the leader explain their rationale for key decisions? And do they make an opportunity for disagreement to occur and a discussion about that? Are dissenting or different opinions permitted or encouraged? There's a whole continuum of acceptance there. Now importantly, the negative factors for everyone as we've heard already this morning is job strain is an important component that can detract from your team. And so workload is something we can't get past and other issues that strain you, worried about the patient in the next room because they're crashing or could crash at any minute. There are a lot of distractors to be aware of. So for the improvement of team rounds, you can take a specific approach like these other groups have had with process improvement mechanisms, LEAN or PDCA, and important again to consider your whole team. Define your team. Who do you want on your team? Who do you want on rounds? And include them in the planning and assessment as well. And this group, as part of their process improvement, actually developed an improvement toolkit, specifically defining a rounding schedule. What time are we going to start? And the night shift resident said, here's the order that you should round in. Start with the sickest person and address those needs first. Because if you don't do that, you're probably going to get interrupted anyway. And do your best to stay on that schedule. And that gets the nurse involved in knowing when they need to be at the bedside because nurses are obviously taking care of multiple patients at present and may have to travel and the other things they get pulled to do. And it values their time. But if nothing else, find a point in the rounds where it's part of the script that specifically solicits the nursing input, again, part of making them an important contributor on rounds. And again, I had attendings who make an effort to do that and attendings who don't make an effort to do that. And for the rest of the team, at least, we can see that difference. And most importantly, finish with a summary of what the plan is for the day, how you communicate that. We'll talk about differences and the way that that's been done. But making sure that at the end of the discussion, the decision is made and everybody knows where you're headed. They tested it in a variety of different ICU types within their one institution and saw an improvement individually in their medical and surgical ICUs and similarly in combined data as I've presented here with the pre-intervention light gray to post-intervention in dark gray, showing an improvement in communication of the order of rounds. And that's pretty darn good at 96%. Nurse present the whole time, definitely an improvement. It's probably never going to be 100%, but you certainly strive to at least have a charge nurse or someone knowledgeable of the patient there to facilitate the rounding experience. To get the nurses to actually be there during the presentation of the patient and to have the nurse participate in the plan was probably one of their biggest improvements. And again, you can't assume somebody else knows what you want done unless you communicate it effectively. Another group, COWS group, actually mapped out their plan for rounds with timelines. And so the resident gets three minutes, the nurse gets three minutes to review the overnight events and important pieces of data that they specifically wanted to have discussed. The respiratory care specialist got two minutes, as appropriate. Not everybody's going to need that. If they're not on the vent, for example, there may be less to discuss. And then the resident synthesizes the assessment and plan, invites input from the other team members who are there, and recognizing that some of this might have to be dis-synchronous, right? So if a social worker covers multiple ICUs, as was the case where I worked, they can't always be there. They have to find a specific time to meet with that social worker to get their perspectives. Or as was done really effectively during COVID and certainly can continue, use telecommunication within the hospital to effectively make that discussion happen. And then talk about your quality improvement, and again, discuss your plan. And then finally, the most important thing, the attending invited the patient and family to ask any questions. And so an important acknowledgment that they're a really important part of your rounding team. And then ideally you get your orders entered in real-time or near real-time, and then kind of be prepared to move on to the next patient in an efficient way. Another group said, you know what, let's assess our rounds before we make any changes and see if indeed we're accomplishing what we think we are in setting a plan of care and that everybody knows where we're headed. And so they developed a tool called the REACT tool, which I'll illustrate that again was a pediatric quality improvement tool. And again, did the plan-do cycles. And so they developed this tool. And each person on rounds, and they didn't do this every day of course, but periodically they had people fill out what they thought were the important points and the important issues for the patient, and you know, just a simple checkmark, and then write down what they understood as the goals for the day. And when they started at the end of 2013, they varied a bit, averaged in the 50-60% agreement between different observers on the team. And so they assessed a baseline period for a couple of months. They moved to this tool, the REACT tool, and had people write stuff down to see if that was going to help. And then they periodically retested and honestly didn't create a lot of change until they started to consolidate, rather than on an individual piece of paper, a whiteboard to write down the plan of care. And so somebody was writing down the plan of care and survey, various tools were modified along the way. But it wasn't until they really had a structure to say, all right, as a group, we're going to write it down and we're going to read it back. And that was where they really affected some substantial change. And that was all the way to September of 2015. So they spent a lot of time with this incremental process. Now hopefully if you really wanted to get it done, you could do it faster than that based on some of their experiences. But it doesn't always have to be in academia. This is an example from a community hospital that isn't a teaching hospital. And so some of their patient populations were perhaps different from yours. But they said, you know what, it's a medical ICU and a lot of chronically ill patients come to us for a variety of reasons that the why, the social aspects of care, really become important determinants of how they got to us and where they're headed. And so they restructured the order of their rounds in a very unique, I think, way and used some of the other tools that we've talked about in daily goals checklists and quality metrics. And they called it the Lotus rounding tool. And if the patient could speak for themselves or the family was present, they started with a social worker to help them incorporate their story of what brought them to the ICU at that point. The pastoral care group helped with what's important value to this patient and where does this stay fit in the big picture of their care. And then went on to nursing, pharmacy, respiratory with the more traditional rounding and daily goals assessment, finally with the intensivist doing their impression, suggesting the goals of care and plan of care and opportunities for transfer. And then the charge nurse or the critical care nurse did the summary document. And so, you know, there are different ways to go about this. And so sometimes thinking outside the box is beneficial. And in fact, this ICU, and I am sure this happens in a variety of different ICUs led by nurse practitioners or PAs on a more routine basis, but in this case, the nurse led their pediatric ICU rounds following a script with a safety checklist and felt that it had indeed improved some of their team-ness and still were able to accomplish their goals. And so Cliff Deutschman, past president, always said, it doesn't have to be the intensivist. I know that's our model for the intensivist-led team. But for the day-to-day, perhaps it doesn't always have to be that the intensivist is leading it. Certainly, they ought to be there. But perhaps somebody else can be the organizer. I'm thrilled that finally, because of the challenges of a daily goals checklist as a separate piece of paper and another thing to be done, that electronic medical records are providing some clinical decision support and providing the data up front to say, not just the question, is GI prophylaxis or other elements of your checklist indicated, but rather say, gosh, you don't have orders and the patient's on the vent, or they were on a med at home chronically that may need to be addressed for GI prophylaxis. So it's presenting the data to us in an actionable form that is just more efficient to get our more task-oriented behaviors done. Now big challenge on rounds is always interruptions. And those will never go away based on the nature of our patients. And so this group categorized different scenarios to say, all right, what do we need to be interrupted for and what less so? And used that as a nurse training tool to try and minimize the number of interruptions to make sure that the most important things, or if the nurse was just really uncomfortable about something, that they felt empowered to interrupt, but that they would stop and make sure that it's an interruption for a purpose. And if people get interrupted a lot, it's harder to be efficient, and certainly things can get overlooked. And so if you don't have a team to admit your new patients while you're rounding, is that important? And in this particular study, they did find that new admits who came in during rounds did have a poorer outcome. Perhaps they were just more urgent. But this setting did not have a 24-hour intensivist and various other things that could be a factor. And so it may or may not be a factor if you have to stop your process to admit a new patient. That wasn't a problem when they had a 24-hour ICU teams. So just again, tools to help with triage can be important. So to summarize, what you want is you want your essential team members. You want attendance by starting at a consistent time. Do some structural improvement communication tools to minimize interruptions or to say, you know what, send me a text so that you remember it, I remember it, versus call me right over to try and triage some of those things. And plan ahead because there's always going to be variables. Determine the role you want for patients and families at the time of rounds. Obviously you want their input, but if it's an in-depth discussion, maybe come back for that so that you can really spend the time you need. And other team members who aren't involved don't get distracted and pulled away. Limit the amount of teaching done on rounds and find a way to do more in-depth teaching at a time that's conducive to everyone's schedule and their ability to pay attention. Do measure the quality of your rounds and set goals for improvement. And if you're really into improvement of your rounds, there are a variety of tools. And I'll point out the last reference in particular, Lane did a systematic review prior to 2013 on a variety of other things that had been reported in the literature. And there are resources, some training tools as well. So thank you so much and we'll talk more at the Q&A.

improving efficiency

bedside rounds

teamwork culture

reducing non-essential activities

timely completion of rounds

psychological safety