Hello, my name is Maureen Madden. I've been invited to participate in this session, The Role of Patients and Families in the Quality and Safety Mission, We Are One. A specific topic I will address is presence of families on rounds, a safety net of early alerts, and mitigated disinformation. I wanted to say a thank you to the Congress Planning Committee for inviting me to speak today. In pediatrics, family-centered care is based on the understanding that parents and family members are a child's primary source of strength and support. This approach to care incorporates patient and family input into clinical decision making for the child and their presence on rounds is a discrete source of mitigating disinformation as well as optimizing patient outcomes. I have no financial disclosures and no off-label or investigational use will be discussed during this session. Family-centered care is an umbrella term for a model of care. It includes the concepts of communication, parental needs, treatment, information, spirituality, organizational, and family resources. It addresses the psychosocial symptoms of stress, anxiety, depression, or coping that a hospitalized child or parent may experience or display. The delivery of family-centered care occurs with the belief that this model of care meets the psychosocial, emotional, and physical needs of the hospitalized patient and family. The question exists of how well we have integrated this concept into our intensive care units and specifically for family-centered rounding. The mission of the Institute for Patient and Family-Centered Care integrates the four concepts of respect, dignity, information sharing, and participation and collaboration to promote empowered relationships between patients, families, and health care professionals. There's over 30 years of reported research that the family-centered care model continues to affect positive and negative health care experiences for the parent, hospitalized individual, and health care professionals in developed and developing countries. My specific frame of reference is the pediatric intensive care unit but the concepts that I'm going to discuss apply to all types of intensive care unit admissions and patients and families. Everyone experiences short and long-term psychosocial emotional distress, individual needs vary, there's technology and interventions, and this concept of post-depensive care syndrome or PICS. So the admission of a person into a critical care unit can cause short and long-term physical as well as psychosocial emotional distress for both potentially the patient as well as their family. The individual needs of the patient and family are varied and can change across different developmental age spans, treatment regimens, prognosis, and settings. The patient is subjected to and the family witnesses ongoing monitoring, investigations, interventions, and are lifesaving treatments that can affect normal growth and development physically and psychologically. The newly developed post-intensive care syndrome framework highlights importance of baseline status, organ system maturation, psychosocial development, interdependence of family, and trajectories of health recovery. Depending upon the developmental capabilities and emotional resilience of patients and families there may be an impact that destabilizes the patient and or family and impacts functional outcomes for extended periods of time. There are several organizations that have recognized family-centered rounds. The American Academy of Pediatrics promotes family-centered rounds as a standard of practice. The ACGME recognizes patient and family-centered care-based environments as a positive not only for patients and families but also learners. And the Institute of Medicine finds family-centered care key to improving quality and safety of health care. Family-centered rounds have been identified as interdisciplinary bedside case presentations and discussion and collaboration with patients and families. Family-centered care rounds relate to patient and family-centered care principles that require the establishment of a partnership and alliance of patients and families with the health care professionals. This is a change from the traditional rounding process within a teaching hospital to create a context where the medical plan could be developed or updated in conjunction with providing medical education for training physicians. While physician teaching remains a focus, new value has been placed on providing patient and family-centered care during rounds. Pinto in 2014 surveyed 95 pediatric residents who completed questionnaires. Approximately 70 percent of the respondents participated in family-centered rounds and traditional rounds and 18 percent participated in just family-centered rounds. So irrespective of rounding experience and PGY year, the majority believe that the family-centered rounds benefit families as well as pediatric training. But specifically when you look at it, we found that there was a stronger alliance with patients and their families with a 72 percent agreeing in that. 86 percent felt better information exchange and collaboration with families occurred. Almost 55 percent found improved communication among members of the health care team and there was approximately 67 percent greater child and family satisfaction with family-centered rounds. Patient and family-centered care and in particular patient and family-centered care rounds create an environment where families are allies for quality and safety. This is created by providing constant support across settings and assisting with transitions of care and the participation in developing care plans and supporting patients in following those plans. Additionally, it provides opportunities where misinformation has been generated for the recognition and correction of that information. In order to meet the needs of families, a set of clinical practice guidelines for the support of the family were developed and published in 2007 by the American College of Critical Care Medicine Task Force of the Society of Critical Care Medicine. More than 300 studies were reviewed and 43 recommendations were presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferences to reduce family stress and improve consistency and communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, and family presence at both rounds and resuscitation. This included a recommendation that parents or guardians of children in the intensive care unit be given the opportunity to participate in rounds. There are numerous studies that have found benefits to family-centered rounds. The ideas that have come across have showed improved communication, the development and building of relationships between the individuals on the health care team and between the family, the importance of sharing information and ensuring that correct information has been shared, there's a decrease in medical errors, engaging in decision-making on all participants, there's increased efficiency, it affects timely discharges, and has a significant impact on improved staff and family satisfaction. Taking a quick review of the literature, in 2012, WHO found statistically significant that families were more likely to report consistent medical information and that the option of discussing the care plan. MIDDLE, in 2010, found that a significant perception of nurse participation in comparison to conference room rounds and that effective team communication was identified. ROSEN, in 2009, found nurses with a higher level of satisfaction with family-centered rounds with a statistically significant improved communication identified, as well as collaboration, a greater understanding of the plan of care, and a greater feeling of working on a team. Lata et al., in 2008, found that parents stated they liked being asked to participate in rounds. They found three positive teamwork elements, seeing the team working together, hearing the discussion of their child by the team, as well as being a member of the team and participating. Euclid, in 2007, found the efficiency of care was improved with the bedside nurse, provided information regarding the patient's condition and progress towards discharge goals. Both, in 2011, both fellows and nurse practitioners increased in their staff collaboration and satisfaction scores. All of these together go to optimizing patient outcomes and mitigating disinformation and miscommunication. In 2007, Cincinnati Children's Hospital published their implementation of a new process that allowed families to decide if they wanted to be a part of attending physician rounds. Findings included that family involvement seems to improve communication, shares decision making, and offers new learning for residents and students. Despite initial concerns of staff members, family-centered rounds have been widely accepted and spread. Three common concerns were regarding teaching, time, and confidentiality. In regards to teaching, although not all teaching can occur with families, residents believed that teaching is better and that they are learning in ways not possible in the classroom or conference room. In regards to time, there was concern that family-centered rounds would take more time, be difficult to carry out in a busy day. It does take a little bit more time, approximately 20 percent longer, and they were found to have no significant concerns in regard to patient confidentiality. HIPPS in 2007 addressed concerns regarding mixed views about parental participation or family-centered rounds. Concerns were expressed by health care providers about patient confidentiality, mostly in non-single patient rooms, increasing the duration of rounds and limiting teaching and patient discussions. The study addressed many of the concerns expressed and the results found that there was no significant difference between time spent on rounds in the presence or absence of family members. There was no significant difference between the time spent teaching by the attending physician and the presence or absence of family members. Overall, family members reported that the medical team spent an appropriate amount of time discussing their family member and were not upset by the discussion. Family members did not perceive that their own or that their family member's privacy was violated during rounds, and the majority of medical team members reported that the presence of family on rounds was beneficial. In 2017, this article, A Family-Centered Rounds Checklist, Family Engagement, and Patient Safety, a randomized trial was published. Order readback was associated with significantly more family engagement. Asking families for questions was associated with significantly better rating of staff's communication, openness, and safety of handoffs and transitions. Family-centered rounds are suggested to improve the quality and safety of inpatient rounds and have become standard of care despite limited evidence to support consistent high quality family-centered round delivery or evaluation of their benefit. Implementing the family-centered round checklist significantly improved the likelihood that families were asked for questions, the health care team was asked for questions, and the health care team read back orders during rounds. The performance of specific family- centered rounds elements was associated with significant changes in family engagement during the rounds and improvements in family perceptions of safety. The family's perception of staff communication openness significantly increased with the proportion of family-centered rounds in which the family was asked for questions. The family's perception of the safety of handoffs and transitions significantly increased with the proportion of family-centered rounds with an assessment of the patient's progress was given and asked if the family had any questions. This article in 2015 explored family involvement in rounds and found that it was an important component of family-centered care, a consistent and a timely way to discuss the child's or patient's care. It kept the family informed, it minimized parental anxiety or family anxiety, it builds trust between the family and the health care team, and it improves communication and team building. The implementation of patient-centered bedside rounds in the Pediatric Intensive Care Unit was published in 2015. They had performed a literature review during their study and found that two necessary interventions were required. Rounds needed to be more patient-centered approach at the bedside, and a nurse-driven rounding checklist would be helpful in facilitating this. So the development of a checklist to standardize the script of rounds involved the patient and family, established daily patient goals, and aided further process improvement was created. The specific aims of the project included improvement in patient-centeredness, to enhance patient-centeredness in rounding practices by the removal of barriers, to look at teamwork in order to improve the multidisciplinary approach to rounding, decision making, and problem solving by including bedside nurses, pharmacies, respiratory therapists, and clinical dieticians on rounds. Communication was enhanced by standardizing the resident daily presentation, and safety was also incorporated by implementing nurse-driven daily checklists. Family-centered rounds seek to incorporate principles of family-centered care. They do not necessarily ensure that the principles of family-centered care are felt. Efforts to more effectively deliver family-centered rounds needs to consider physical, organizational, and cultural factors that influence patients, families, and medical team behavior. Family-centered rounds are seen as a forum for information sharing. Teams approach families with practices to demonstrate respect. Family members have the opportunity to participate in care, and it's a starting point for collaboration. The primary advice families offered providers to improve family-centered rounds was to be more considerate and courteous, including accommodating family schedules, minimizing distractions distractions for all providers, and limiting computer viewing. Inconsistency with family-centered rounds and the principles of family- centered care is a medical jargon sometimes limited communication. Contextual factors undermine this intent of respect. It did not guarantee family involvement, and it did not guarantee that collaboration occurred. And specifically, non-English speaking families may need more support to attend and benefit from family-centered rounds. Looking at family-centered rounds as an aspect of a safety net of early alerts and mitigated disinformation. In order to do this, having daily goal-oriented discussions has been associated with improved patient outcomes. Knowledge exists that multidisciplinary rounds have been associated with improved patient outcomes. The discussion during rounds becomes more concrete and goal-oriented, and the utilization of a structured checklist during rounds has been found to increase provider satisfaction, understanding of care, communication, adherence to practice guidelines, and outcomes. But it's imperative that the family and the patient are active participants in this process, as they can correct any information that is being stated that is incorrect. They have knowledge of the plan of care, and they have knowledge of the trajectory of their care and discharge, and ideally this impacts and optimizes patient outcomes. Thank you very much for your attention. I hope you have a wonderful Congress.

family-centered care

patient outcomes

quality and safety

family involvement

interdisciplinary collaboration