Use of Compliance Tool to Capture and Measure Leader Rounding Data

A healthcare organization performed leader rounding on patients without capturing data. The process lacked standardization, measurability, and accountability. The organization needed an electronic database to collect responses and information to develop actionable items to drive performance improvement related to patient experience and outcomes in real-time.

The Joint Commission Resources (JCR) Tracer application allowed the creation of an electronic database measuring patient experience. The questionnaire measures patients’ experience as positive or negative; it comprises 10 yes or no and one free-text response, exploring four organizational goals and six domains: communication, responsiveness, medications, discharge, pain, and listening.

The JCR Tracer tool provides simple reports of compliance executed at the unit or organizational level, downloadable as a dashboard, to compare across departments. Weekly reports provide accountability, reported at Safety Huddle. Monthly reports express the percentage of compliance related to the domains and goals, directing underperforming units to improve.

Olathe piloted the program at their smaller hospital before launching systemwide in December 2021. The pilot corrected the questionnaire structure. The pilot proved data entries take less than one minute to complete. Development of a training module and live session supported leader adoption and efficacy. PDSA provides continuous improvement strategies.

The tool generates over three hundred responses weekly. Unit-level results identify opportunities and top performance. For example, a systemwide opportunity is improving new medication communication by nurses. Year-to-date data shows process compliance at 57%. The tool allows for process improvement before patient experience surveys return.

Quality and Outcomes Coordinator - Accreditation Lead
Quality and Outcomes Coordinator - Accreditation Lead – Olathe Medical Center

Speaker Type: HQ Best Practice Tools On-Demand

  • Performance and Process Improvement IconPerformance and Process Improvement
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