What are the basic principles?
What are the key components for improving our systems?
We are using the mascot of the University of Florida the alligator and have named our multidisciplinary rounds Gatorounds, and we view this system as the equivalent of Gatorade for medical rounds. By linking our rounding system to each caregiver’s past experiences with team sports, each team member can quickly learn how to more efficiently and safely provide patient care.
Just as we have used the University of Florida mascot other medical centers can use a team mascot to name their rounding system. For example Yale University and University of Georgia could use the name Bulldog Rounds, Harvard University could use Crimson Rounds or perhaps Patriot Rounds after the New England Patriots, and the University of Miami could create Hurricane Rounds. The name can be whatever the medical team desires. The key is to follow these three principles of high performing athletic and manufacturing teams:
- Create a carefully designed playbook: Defines the roles of each member of the team, and creates a series of plays that describe how the team members will coordinate their roles to create a successful team.
- Know who is passing and who is catching: Establish stable, well defined, highly efficient customer supplier relationships. Just as the passer and receiver need to practice over and over again to consistently complete their passes, primary care teams and consultants must establish highly efficient relationships that provide the most up-to-date care. Physicians need to understand the nurses are their customers when it comes to writing clear treatment orders. The attending needs to understand that the residents and students are his or her customers when it comes to supplying teaching and supervision. Another key customer-supplier relationship is the hand off. Hand offs must be stable and direct, no fumbles: Sign-off to other team members must be accurate and efficient. Primary care physicians must be notified by the ward team when their patients are admitted. Discharge dictations must be timely and routed to the appropriate physicians. Finally we must never forget our most important customers our patients and their families. Remember they are the owners of our team and it is critical that we look through their eyes and empathize with their suffering and pain. To provide truly patient-centered care we must always ask, “What would best for our patient?”. When ordering a test or a treatment we should ask, “Is this of value to our patient?”
- Game films need to be constantly reviewed: Healthcare systems need to create a culture of constant innovation and improvement. Everyone must understand that to err is human. Just as players learn from missed blocks, fumbles, and dropped passes, healthcare providers can learn from errors in diagnosis and treatment. Mechanisms for constant constructive feedback need to be established. At the end of every daily rounding session we need to ask, “What went well today and what could be improved?”
- Just as coaches stand on the sidelines observing, advising, problem solving, and cheering on their players, attending physicians and administrators must be constantly present on the front lines (wards and clinics) performing these same roles.
- Just as team members respect and trust their fellow players to perform their roles during a game, physicians and nurses must respect and trust each other’s ability to care for the patient.
- Just as team members gather in a circular huddle to communicate. Members of the rounding team must practice horizontal communication, share ideas, and as a group, create management plans for each of their patients. In almost every situation the plans created by the group prove superior to the plans created by a lone individual, no matter how experienced.
- Just as teams learn by practicing their plays over and over, health care teams learn to work together and to apply efficient systems by doing. Lecturing and encouragement can start the ball rolling, but only by actually following coordinated systems, such as Gatorounds, can physicians, nurses and other healthcare providers truly understand the principles and power of a systematic approach to rounds.
- Just as in all team sports, no one player wins the game. The ball is shared and all the players contribute to victory in a carefully coordinated fashion. Similarly the work of caring for each patient must be shared between the primary care team and the consultants, between the nurses, pharmacists, patient care managers, social workers, and physicians.
- The Trap Play is one of the most complex and effective running plays in football (X = defensive player, O = Offensive player). During the University of Florida National Championship Game against the University of Oklahoma this play resulted in runs by Percy Harvin of 60 and 70 yards. For this play to work a number of conditions must be met:
- No ambiguity: Every player knows his exact role
- Exact timing: Each part of the play is described in complete detail
- Stable relationships: Hand off has to be perfect and players know how to work together
- Learn and improve by doing
- Constant Feedback from the coaches
- Continuous change and improvement
These same conditions are required for effective multidisciplinary rounds.