Work system barriers and facilitators to family engagement in rounds in a pediatric hospital

There are increasing demands on physicians to provide safe, effective, and high-quality care that is patient and family-centered [1] . Engaging patients has been suggested as important for patient safety [2] and may be especially so for children, who experience three times the medical errors adults do [3] . During a child&s;s hospitalization, Family-Centered Rounds (FCR) represent a crucial opportunity for healthcare professionals, students, patients and families to communicate information, solicit input and make decisions about the child&s;s care. However, no evidence exists as to how family engagement in FCR can be optimized. Our study uses the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety [4] to comprehensively identify the work system barriers and facilitators to family engagement in FCR. The study was conducted in a 61-bed pediatric hospital located in the Midwest of the USA. Stimulated recall, similar to the ‘confrontation’ methods used by Falzon and colleagues [5] , was used to elicit barriers and facilitators of family engagement. A sample of 13 bedside rounds were videorecorded. Healthcare team members (N = 16:4 attending physicians, 5 medical students, 4 interns, 1 nurse, 1 nurse practitioner and 1 pharmacist) and parents (N = 5:2 mother/father pairs, 1 father and 2 mothers) who participated in those rounds watched the video of their rounding session and were asked about barriers and facilitators to family engagement experienced during the session. The interviewees were instructed to review the videotape and paused the video at any time they felt either comfortable or uncomfortable participating in the bedside round. The interview data were analyzed using the NVivo© 9 software for qualitative data analysis. Content analysis of the interview data identified a range of barriers and facilitators that covered all five aspects of the SEIPS work system model (people, tasks, tools/technologies, environment, and organization). Barriers and facilitators related to people included child/parent experience with rounds and individual characteristics of clinicians. Tasks that acted as barriers or facilitators of rounds included the inclusion of a physical exam during rounds and the need to teach during rounds. Tools and technologies that acted as a barrier or facilitator of family engagement included the use of computers during rounds and access to patient-related information via the electronic health record system. The environment included positioning of team in the patient room and the physical layout of the room. Organizational factors included the timing of rounds, role ambiguity for the healthcare team members, size of the team, and interruptions. These preliminary data show that multiple system factors need to be addressed in order to optimize family engagement in FCR and, therefore, improve communication, decision-making and ultimately patient safety. The next step of the study is to design, implement, and evaluate an intervention to enhance family engagement in FCR, based on the results of this content analysis. Ultimately, the study will examine the association between family engagement and pediatric patient safety.