Background

Intentional rounding is an essential part of healthcare and nursing facility where the caregivers or nurses perform a direct assistive surveillance to identify any discrepancy in patient’s health or physical condition such as falling injury, agitation, breathing issues and others. Intentional rounding is also associated with care rounding every 1 hour during the day to check on the 5 Ps, meal times, needs of assistance and others. The rounding is also associated with the appropriate documentation and review of the overall condition (england.nhs.uk 2014). The rounding can be executed in daytime as well as in nighttimes or sleep time. Both of these rounding have their individual significance in healthcare service and assessments. However, in the taken scenario multiple issues are hindering the whole process and its effectiveness. In this report the cause of these dilemma has been discussed by using various strategic tools and techniques such as 5why root cause analysis, fishbone analysis. After that, the possible risks have been also analysed by utilising risk management matrix.

After accumulation of crucial factors, the requirements for changes have been discussed to formulate the PDSA (Plan Do Study Act) cycle of efficient development. Along with the formulation of PDSA (Plan Do Study Act), the report has also assessed the required leadership approach for making the changes sustainable and effective. Throughout this process, ensuring the healthcare related compliance. With this regards, the appropriate intervention of NHS regulations and code of conducts within the implementation procedure of the development planning have been discussed. Moreover, the purpose of this report is to find an appropriate development planning and implementation technique that can change the existing condition of ineffective rounding and documentation anomaly. Through this planning and development procedure, the health care organisation can uplift their entire facilities and the reputation within the consumers as well. At the same time, the caregivers would have a new opportunity to enrich their professionalism and competency.

In this current scenario, multiple issues are hindering the whole process and its effectiveness where the caregivers, nurses, nursing leaders are also involved. The issues that have been found are follows:

• In the geriatric ward, nurses and health care assistants including the shift leader completing care rounding shift without physically checking on the patients
• Only the patients that rang the bell here attended.  
• One patient was found lying on her back agitated and extremely wet during the medication round
• The shift leader appeared unworried indicating that it is not always possible to follow the care plan especially at night when patients were sleeping
• During the day shift, staff just ticked boxes without even speaking to the patients

As per the findings mentioned above the following root cause analysis has been performed to identify the origin of all these dilemmas. In the following section the root causes of this situation have been analysed with 5 Why analysis.

Root cause analysis is the procedure of learning from consequences that is usually used by the healthcare providers to gain acquaintance from near-misses, adverse events, or sentinel events in the healthcare facility (England 2017). The following questions have been made keeping the findings and major outcomes in mind.

Operational Anomalies in Intentional Care Rounding

Why are the patients not checked physically during the night shift?

The healthcare governance system of this organisation provided a shift plan for all caregivers, nurses and shift leader. However, the caregivers show a reluctant behaviour by seating in the nurse’s room. They all know about the shift timing and procedures, but they have no will to follow the rule and regulations.

Why do some patients become agitated in spite of having appropriate care plan?

During nighttimes rounding shift the patients only receive attention for the caregivers and nurses when they ring the bell. Sometime, patients do not have the ability to ring the bell properly and becomes agitated out of their helpless condition.

Why are there some argument about implementation of nigh shift routine within the staffs?

The management board of the healthcare facility warned the caregivers and nurses of nigh shift repeatedly. However, the shift leader is equally inactive as the subordinate caregivers and nurses. This problematic situation is causing the consistent argument within the healthcare system of the organisation about the rounding procedure, especially in night shift.

Why are only the patients who ring the bell taken into observation and care?

Most of the nurses and caregivers are aware of their negligence and their faults in professionalism. However, they are less likely to prioritise their duty over their relaxation. At the same time, if a patient perceives complete ignorance in a vulnerable condition even after ringing the bell all staffs of night shift will face the legal consequences in any case of lethal and non lethal outcome (Sharma and Klocke 2014).

Why are not the nursing staffs communicating adequately with the patient even in day shifts?

The lack of monitoring procedure on staff’s activities allows them to perform inadequately during their daytime shift. In spite of having set of well-structured regulations, the staffs ignore the procedure and perform only the necessary duties. The healthcare staffs always want to get rid of their daily work procedure and duties.

As per the above analysis of 5Why multiple operational anomalies have been found. The major causes behind this inefficient workforce performance are listed below:

• Lack of mentoring and control over the shift system, staffs and even leaders
• Lack of effective enforcement of strict regulations and code of conduct
• Inefficient leadership process
• Lack of professional value and ethics within all staffs and leaders
• Lack of effective administration over the execution procedure of duty planning
• Lack of respect and dignity towards the patients
• Ineffective documentation structure with inaccurate and irregular records
• Lack of patient-care giver communication

Fishbone analysis is a process of examine the interconnections between attributes that contribute to the result. The attributes are further classified by various operational fields such as staff, process and others. In this case study, four major fields of attributes are involved that cause the discrepancies within the care giving facility (Smith and Williams-Jones 2012). These fields are Patient, Staff, Process and Environment.  Here, Patient refers the care receivers of the organisation who are the main victim of the work process dilemma. Staffs represent the caregivers and nurses who are responsible to provide adequate care and assessment to the patient within their shift timings. Process represents the existing execution process of providing healthcare service to the patient. Environment emphasise the overall external situation that stimulating the situation to worse

Strategic Tools for Root Cause Analysis

Figure: Fishbone Analysis of healthcare facility

Source: (Created by author)

The fields that directly contribute to the resultant situation of inefficient rounding and poor workforce performance are the process and the employees or staffs. It has been found that reluctant behaviour of staffs, poor sense of responsibility, lack of effective monitoring process and inability to perform commitment teamwork are contributing to the staff base anomalies (Reimer and Herbener 2014). On the other hand, poor regulation enforcement, lack of proper leadership model, inefficient execution of workforce procedure are acting as major hindrances within the process field. At the same time, patients are unable to communicate which is also causing additional distress. Apart from that, consistence agitation and resultant physical and mental insecurity are causing further dilemma from patient’s side. Another essential field, which is contributing as a whole, is environment. Poor workforce culture with lack of ethical consideration and morale are causing significant declination of healthy work culture (Forde-Johnston 2014.). Along with the poor sense of respect and dignity to the patients is causing additional hindrance. Therefore, it is clear that most of these causing attributes have been generated due to the lack of administration, control and law enforcement.

The inefficient rounding process can cause several risk issues. Therefore, to eliminate the risk issues the identification of those risks is highly crucial.  Risk management is an essential tool that can help to examine the existing factors that can cause serious hazards. The risk factors have two separate parameters namely severity and likeliness. The severity emphasise the impact of the risks on the system or organisation (Olrich, Kalman and Nigolian 2012). On the other hand, the likeliness represents the probability of occurrence of the risks. A risk factor with higher possibility of occurrence has higher likeliness.  Both severity and likeliness contribute to the magnitude of the riskiness. In other words, the significance of any risk equals to the product of the severity and the likeliness (Risk=Severity x Likeliness). As per the existing situation of the healthcare organisation, the risk factors have been analysed and presented below along with their severity and likeliness.

Risk factors	Severity	Likeliness
Falling	High	High
Complaints	low	Medium
Bladder and Bowel dysfunction or urinary / fecal incontinence	medium	medium
Respiratory failure	high	low
Cardiac arrest	high	medium
Missing out treatment	Medium	low
Thirst or hunger of the patient	medium	high

To visualise and examine the risk factors of the selected attributes have been shown in the risk assessment matrix where the vertical axis represents the severity and the horizontal axis represents the likeliness of the instances.

Severity	High (3)	Respiratory failure (3)	Cardiac arrest (6)	Falling (9)
Medium (2)	Missing out treatment (2)	urinary / fecal incontinence (4)	Thirst or hunger of the patient (6)
Low (1)		Complaints (2)
	Low (1)	Medium (2)	High (3)
Likeliness

In the above risk matrix the major risk factors are Falling, Complaints, Bladder and Bowel, dysfunction or urinary / fecal incontinence, Respiratory failure, Cardiac arrest , Missing out treatment and Thirst or hunger of the patient. However the most risky factor of all of these issues is Falling which has high severity and high likeliness index. Apart from that, other essential risks are Cardiac arrest and Thirst or hunger of the patient (Klindworth and Risk Management Solutions LLC 2014). Both of these issues are equally risky. However, patient complains and missing out treatment are lower level risk factors with the coefficient of 2. Urinary / fecal incontinence is another essential factor with risk coefficient of 4 that is the third most essential risk factor. Respiratory failure is a serious issue but it has very less likeliness compared to others. The following list representing the risk factors in descending order:

1. Falling
2. Cardiac arrest
3. Thirst or hunger of the patient
4. Urinary / fecal incontinence
5. Missing out treatment
6. Complaints

Risk Management Matrix: Identifying Risk Factors

As per the above analysis, it has been found that several issues are causing the operational discrepancies in rounding system in day as well as nigh shifts. At the same time, some essential risk factors are also associated with these regulators. According to fish bone analysis reluctant behaviour of staffs, poor sense of responsibility, lack of effective monitoring process, inability to perform commitment teamwork, poor regulation enforcement, lack of proper leadership model, inefficient execution of workforce procedure, lack of ethical consideration, poor sense of respect and dignity to the patients have been found to be the major hindrances. Therefore, in further development plan of the healthcare organisation some major changes are required including:

• Persistent and effective workforce training
• Appropriate enforcement of regulations and code of conducts
• Rescheduling the resource allocation that will allow the employees to alter their shifts
• Increase surveillance and monitoring system on the staffs
• Implementing appropriate leadership model to handle the situation and the role of the caregivers perfectly
• Increasing the healthy communication between patients and caregivers to highlight the key problems
• Conducting repeated meeting to encourage the staffs about their job and responsibilities

In order to implement the changes the management of the organization should express the core problems and the potential outcomes of the existing dilemmas in the work process and execution (Card, Ward and Clarkson 2012). This process could be executed with the helpful interference of Human Resource Management System. Initially the resistance against these changes should be minimised through appropriate leadership and communication. Then the change management process including defreeze, change and freeze phase that allow the administration to introduce the new policies and process, then incorporating the change and finally to evaluate the sustainability and accuracy. The recognition and rewarding are other effective evaluation procedures that will help to increase the proficiency of the workforce (Wingate 2016).  Throughout the change management procedure the essential risk factors including Patient Falling, Cardiac arrest, Sudden Thirst or hunger of the patient, Urinary / fecal incontinence, Missing out treatment and Complaints of the patients should be chiefly considered.

The PDSA or Plan Do Study Act is a cyclic model of implementing or developing new process, system and workflow. The plan phase emphasises the designing and finding the appropriate process of execution that would help to achieve the objectives. The Do phase refers the execution process where, appropriate control and implementation plan are required. The Study phase reflects the assessment part of the executed plan that includes the examination of efficiency, tangibility, affectivity, potentiality and scope of farther improvement. The major objectives of this PDSA model are incorporating the code of conducts for the nursing staffs, increasing patient-caregiver communication and eliminating potential risks for inefficient rounding (Card and Klein 2016). The Plan, Do, Study and Act phases are aimed to achieve these objectives in time and cons efficient ways.

Figure: PDSA for implementation of effective rounding

Recommendations for Improvement: PDSA Cycle

Source: (created by author)

At the initial Plan phase of the PDSA cycle, the management and responsible personnel have to Plan effective enforcement and controlling process for the caregivers and nurses. In this section the management should be careful about all the essential risks including Patients Falling, Sudden Cardiac arrest, High Thirst or hunger level of the patient, Urinary / fecal incontinence, Missing out treatment and patient’s Complaints. The further phase of PDSA cycle depends on this Planning phase.  The next phase is the execution phase also known as Do phase. In this phase, the management and administrator of the organisation have to execute effective training and development module for new as well as for existing nursing staffs and caregivers in order to ensure that they have enough knowledge and reliability to conduct rounding process regularly (Baathe et al. 2014). Apart from that, the training method should also ensure that the nursing staffs have enough morale, value about their duties and responsibilities while having appropriate dignity towards the patients needs, culture and experiences. It will help to increase the communicational efficiency within the patient and caregivers as well.   

The Study phase requires effective monitoring and documentation system that will help analysing the loop whole within the existing implementation procedure. Both direct and indirect monitoring is effective in this situation. The direct monitoring can be executing by direct surveillance by leaders, checking documents and other supervisors (Cornell et al. 2014). On the other hand, indirect monitoring will help to collect data through collecting feedback from peers and patients. Lastly, the Act phase will help find out required changes in the existing process that can make the updated execution plan more efficient and effective. It is the foundation phase of the planning phase. In this section the outcomes of the executed procedures are analysed by aligning them with the three objectives namely incorporating the code of conducts for the nursing staffs, increasing patient-caregiver communication and eliminating potential risks for inefficient rounding.

In healthcare service providing effective leadership is an essential factors that enables the other factors to achieve the objectives of the organisation. However, in this case study the shift leader is supportive to the subordinates about their reluctance to perform the duties and responsibilities to execute effective and efficient rounding process while making appropriate interaction with the patients. In this situation, an effective leader should keep the communication and encouraging interaction with the subordinate to support the management, to prioritise the patient safety and satisfaction, to sustain the mission, vision and values within the employees (Al-Sawai 2013). The appropriate time allocation to the caregivers and other staffs can enhance the overall quality of care giving. Apart from that it is the duty of every leader to promote the nursing excellence and optional patient outcomes to the tame member while increasing the awareness of teamwork and integration within the workforce (Delmatoff and Lazarus, 2014). All of these factors will act together to decrease the patient falls and other negligence related outcomes such as  Cardiac arrest, Thirst or hunger of the patient, Urinary / fecal incontinence, Missing out treatment and others.

Healthcare Compliance and Regulation: Ensuring Sustainable Development

A leader should take care of some of the essential duties such as Valuing the service ethics while being curious about how to improve services and patient care. Apart from that the leader should behave in a way that reflects the principles and values of the NHS within the workforce. A successful leader also creates a shared purpose, where diverse individuals can do different work and the leader can inspire them to believe in shared values to enable them delivering benefits for patients, their families and the community. Another crucial factor of a leader in healthcare service is Staying true to NHS principles and values while holding to principles and values in own work process to be ideal example of a perfect caregiver (Cliff 2012.). A leader should never hesitate to take personal risks in order to stand up for the shared purpose or to encourage the team members for the benefit of the service. At the same time a Leader should understand the underlying emotions of every team members that affect their team, and care for team members as individuals by helping them to manage unsettling feelings so that they can focus on their work to deliver a competent service.

A System leadership does not enable the leader to working behind the scenes rather than leading from the front for achieving the success of the team as well as the quality of the overall healthcare system. However, as per the unprecedented challenges faced by the NHS, the system leaders need to motivate staff and managers to work differently, across service and organisational boundaries while aiming towards same purpose of serving the patients (Edmonstone 2013). The system leadership is the only way to meet the needs and expectation of the growing number of patient with complex and long-term conditions. Moreover, system leader should take care of valuing the service ethics while being curious about the improvement services and patient care through leading the team member abiding by the code of conducts, rules, regulations and guidance by NHS.

The new regulation and rounding procedure should be aligned with the regulation of Patient  Care Regulation by National Health Service of UK. Therefore for this organisation the care rounding should be executed in every 1 hour during the day as well as night in order to check on the 5 Ps – pain, position, pulse, paralysis and paraesthesia of the patients. In night shift the two hours of frequent rounding is essential event when the patients are awoke.  This procedure cannot be skipped irrespective of the alteration of risk assessments, care plans (Daly et al. 2014).

Apart from that as per the Healthcare Service Providing Checklist proposed by NHS the ward managers, as an essential part of the ward documentation audits should regularly check all of these procedures regarding shift timing, rounding and the implementation of 5p.  Apart from that, the consequences of noncompliance or irregularities should be regularly usually discussed in staff meetings. Lack of compliance and efficiency may not only devastating to patients but can result in huge costs by the NHS in terms of treatment, length of day, continuing care, death and litigation (van Rossum et al. 2016). All of these factors influence the reputation of the organisation as well as the regulatory operation of the NHS at national level as well.

As per the published report of NHS digital in 2017, Health safety thermometer, prevalence of pressure ulcers and falls resulting in  harm were approximately   4.4%  and 0.6% in 2017 respectively (england.nhs.uk 2014). It is not the situation of a particular area of the nation, rather it reflects the overall situation of healthcare facilities which are under the governance of NHS UK. There are many healthcare execution techniques proposed by NICE guidelines that can be very helpful during the planning and implementation phase.  According to NICE guideline G179 of 2014, some recommend expert assessment and regular reposition of adults for risk management and developing effective rounding plan can be helpful for the healthcare organisation to maintain the compliance more easily (England 2017).

According to the Parliamentary and Health Services Ombudsman and Department of Health  and the term “basic nursing care” – attending to patients’ emphasise the needs for support with feeding, positioning, personal hygiene and skin integrity.  Along with that, the training method should also ensure that the nursing staffs have enough morale, value about their duties and responsibilities while having appropriate dignity towards the patients needs, culture and experiences (england.nhs.uk 2014). These procedures also reflect the assessment part of the executed plan that includes the examination of efficiency, tangibility, affectivity, potentiality and scope of farther improvement.

Conclusion: 

From the above analysis and discussion, it can be said that Intentional rounding is an essential part of healthcare and nursing facility where the caregivers or nurses perform a direct assistive surveillance to identify any discrepancy in patient’s health or physical condition such as falling injury, agitation, breathing issues and others. Throughout this study, the purpose was to ensure the healthcare related compliance with regards to the appropriate intervention of NHS regulations and code of conducts within the implementation procedure of the development planning.  In the discussed scenario, multiple issues are hindering the whole process and its effectiveness where the caregivers, nurses, nursing leaders are also involved. The caregivers and shift leader show a reluctant behaviour by seating in the nurse’s room. They all know about the shift timing and procedures, but they have no will to follow the rule and regulations.

As per the above analysis it can be concluded that the major causes behind the issues are Lack of mentoring and control over the shift system, Lack of effective enforcement of strict regulations, Inefficient leadership process, Lack of professional value and ethics within all staffs, Lack of respect and dignity towards the patients. As per the risk assessment it has been found that Falling, Cardiac arrest, Thirst or hunger of the patient, Urinary / fecal incontinence, Missing out treatment, Patient Complaints are the major risks. Some changes are required to resolve these issues, such as Persistent and effective workforce training, Appropriate enforcement of regulations and code of conducts, Rescheduling the resource allocation, Increase surveillance and monitoring system, Implementing appropriate system leadership model, Increasing the healthy communication between patients and caregivers. With this regareds, the PDSA or Plan Do Study Act cyclic model will be helpful for implementing or developing new process, system and workflow. Moreover, it has been found that in healthcare service providing, effective system leadership is an essential factor that enables the other factors to achieve the objectives of the organisation.  

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