Department Focus: Quality - The 24-Hour Executive

Maureen Larkin, for HealthLeaders Magazine , October 13, 2008
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Night rounds can give senior leaders insight for quality improvement in their "other hospitals."

Ramanathan Raju, MD, remembers what it was like working night and weekend shifts as a trauma surgeon. He remembers the bizarre incidents, the low staffing levels, and the absence of hospital administrators when the hospital was at its busiest. But mostly, he remembers how different the night shift is from regular daily life at the hospital.

The chief medical officer and executive vice president of medical and professional affairs for the New York City Health and Hospitals Corporation often recounts his experiences on the night shift when he's working to improve care at his system's hospitals. "Physician backgrounds are different," Raju says. "I worked more night and weekend shifts because that's the busiest time for trauma surgery. But some physicians work in areas where they do not practice at nighttime. If they become CEOs, they will not have a complete understanding of how the night works in the hospital."That disconnect, Raju says, is why nighttime rounding is particularly important for hospital executives who don't come from a medical background and are unfamiliar with the overnight hours at a hospital. "It's extremely important for a CEO to know what is going on at their hospital at all times of the day," he says.

Some hospital CEOs are coming to the same conclusion. In an article published earlier this year in the New England Journal of Medicine, David Shulkin, MD, president and CEO of Beth Israel Medical Center in New York City, discusses how he started doing nighttime rounds at his 1,106-licensed-bed hospital after hearing stories about the facility during evening and weekend hours and examining the organization's quality data. "At first, many people did not know me—a very different experience than when I walked the hospital during the day," he says. "But then people began to see me and seek me out when I was there on the units at night."

Rounding at night, Shulkin is able to hear firsthand about quality and safety concerns from those who work the overnight shift. He gains insight into the differences in care offered in the overnight hours and how these variables affect patient outcomes.

The most notable difference, Shulkin says, is the reduced staffing on night and weekend shifts. "The units are quiet, and it's not as easy to find as much help around during off hours," he says. "Doctors are even more scarce—except for those that are in training."

Since Shulkin began nighttime rounds, the organization has made several changes to make the level of care offered at night more comparable with that given during the day. "We've added full-time attending physicians in our ICUs and brought in nocturnists to our medical floors to provide on-site nighttime coverage," Shulkin says. A nursing supervisor has been added to the night shift, and Shulkin meets regularly with evening supervisors to review experiences, issues, and how improvements can be implemented. And he no longer does his night rounds alone; he's now joined by members of his administrative staff.

"Our quality staff is now more sensitive to the role of off hours in our process improvement plans, and we now address these issues between the day and the night hospital," Shulkin says. But the organization's work isn't done yet. "I believe we've just begun to learn and listen."

Getting in touch with your "other hospital" is a necessary part of any CEO's job, Shulkin says, even if night rounding isn't possible (see story below). "Some CEOs may prefer to meet during the day with their evening supervisors; some may want to do a survey or focus groups with their off-hours employees, medical staff, and patients," he says. "Some may prefer to delegate the off-hour supervision to a trusted and respected member of the senior team. But however one chooses to explore this issue, I would encourage all CEOs to take a careful look at the other 12 hours of the day—I think it will be both surprising and valuable."

Maureen Larkin is an editor with HealthLeaders magazine. She can be reached at
Listening to employees can bring quality concerns to light

Just as doing nighttime rounds can open a CEO's eyes to what's really going on at his or her hospital, taking the time to hear the concerns of employees can also shed light on quality and patient safety concerns.

At the University of Michigan Hospitals & Health Centers, executives do biweekly rounding of hospital departments, seeking comments and concerns from staff members that will help identify and remedy quality and patient safety concerns. Employees of all staffing levels are invited to sit down with executives and share the everyday challenges they face while providing care, says Maureen Thompson, RN, patient safety manager for UMHHC, a three-hospital system with 913 licensed beds.

"It's different than observing staff doing work and talking on a one-on-one basis," Thompson says. "We're talking about pulling the staff together and talking about their chief safety concerns."

Administrators are careful not to pick out just the floor's leaders to share with them what is going on in the department, she says. Encouraging employees of all levels to meet with administrators brings a more complete picture of the care offered in the particular unit.

"You could pull only certain individuals, but what you wouldn't get is that synergistic voice of eight or 10 or 12 sharing their perceptions of patient care," says Thompson.

A clinician is always present in the room to translate for executives when employees use medical jargon. "When staff speaks in shorthand, often, the clinical director will understand the shorthand, while an administrator might struggle," Thompson says. "Having both of these heads in the room hearing raw data and staff sentiment is helpful."

Even when some explaining is needed, it's still helpful for executives to hear concerns directly from employees, Thompson says. When a hospital depends on managers to relay staff concerns to executives, sometimes what's really going on can get lost in translation.

"The administrative leader can hear, unfiltered, what the staff is talking about," she says. "It's good for nurses, residents, and staff pharmacists to be able to say, 'This is a barrier to safe patient care' and to explain the barrier."

And when backed up by raw data, Thompson says, administrators can learn a lot about where the hospital can improve the care it offers.

Staff members, too, have found it valuable, she says. Since the rounds started in 2002, hundreds have taken the opportunity to meet with administrators to discuss concerns. Even members of the night shift, she says, will often stay into the morning hours to have the opportunity to share their concerns. "Administrators can hear those voices and implement them into the decisions they are making," she says.

Maureen Larkin

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