Schwartz Center Rounds^®

If your site is interested in starting Rounds, please read all the information below. Then contact Marjorie Stanzler, Director of Programs, at 617-726-0914 for more information. Institutions can not start Rounds without permission from the Schwartz Center.

The Schwartz Center Rounds are a unique and highly effective forum for improving the relationships and increasing the understanding between patients and clinical caregivers by:

	exploring the human dimension of health care;
	increasing caregivers insight into non-clinical aspects of patient care;
	enhancing communication among caregivers;
	fostering teamwork among caregivers; and
	providing support to caregivers.

“The Rounds are cherished moments of clarity amid the hurry and disconnect of the modern medical center.”

Purpose
The constant and unrelenting stresses of our modern health care system threaten the delivery of compassionate health care. Financial pressures and bureaucratic demands mean less face-to-face time with the patient, and a focus on the illness, its diagnosis and treatment, rather than the effect of the illness on the patient’s life and family. Many caregivers today are anxious, frustrated and under pressure. They have no structured outlet in which they can express their feelings. In addition, with little or no training to handle the non-clinical aspects of patient care, many feel inadequate when responding to the difficult issues that are an inevitable part of patient care.
 
The Schwartz Center Rounds provide clinicians (physicians, nurses, social workers and others) with a regularly scheduled time during their stressful and fast-paced workday to openly and honestly discuss the difficult social and emotional issues that arise in caring for patients. In contrast to traditional clinical or ethics rounds, the focus is on the human dimension of medicine. Caregivers discuss thought-provoking topics based on actual patient cases and have an opportunity to share their experiences, thoughts and feelings. The premise is that caregivers are better able to make personal connections with patients when they have greater awareness of, and insight into, their own responses and feelings.

Schwartz Center Rounds have succeeded in diverse environments --academic medical centers, community hospitals, pediatric hospitals, community health centers, nursing homes, and outpatient practices.

“Modern medicine is good at identifying problems, at finding solutions, at making things better. But sometimes the solution is to acknowledge and validate our own feelings and the feelings of those around us, to accept things as they are, to realize it’s alright to not know the answer and that not everything needs fixing.”

History
The Schwartz Center piloted the Rounds at Massachusetts General Hospital in Boston in 1997. As the Schwartz Center’s fastest growing and most far reaching initiative, the Rounds have quickly expanded to hospitals across the country. See list of “Schwartz Center Rounds Sites.”

Audience
A broad range of professionals from diverse disciplines participate in the Rounds, including physicians, nurses, social workers, psychologists, allied health professionals and clergy. Depending on the size of the institution, 30-200 caregivers attend each session. There are always “regulars” who return each month as well as newcomers.

Topics
Rounds discussions are based on a patient case that raised a specific issue(s) for the caregivers. The case-based format is designed to stimulate discussion. A planning group at the Rounds site selects the topics and cases.  For examples of topics addressed in Rounds refer to the "Sample Topics."

“The Schwartz Center Rounds tap into the desire of health care professionals to talk about what it is really like to do the jobs we do. There is just not enough time, or an avenue, for us to do that otherwise.”

Format
The format and structure of the Rounds are basically the same at every site. Although each site may put its own stamp on the Rounds, the session begins with a brief presentation (10-15 minutes) by the panelists-- two to three clinicians from different disciplines (e.g., doctor, nurse, social worker) who were involved in the care of the patient. One of the panelists, typically the physician, presents a very brief clinical history of the patient. Each panelist describes his or her experience with the patient in the context of the psychosocial issue that is the focus of the discussion. During the rest of the hour, panelists and caregivers in the audience ask questions and exchange experiences, thoughts and feelings in relation to the topic.

Panelists disguise patient names to protect confidentiality at all times.  Caregivers in the room are also asked to maintain the confidentiality of what other caregivers say.

A professional facilitator leads and focuses the discussion and summarizes the salient points at the end of the hour.

Some sites base Rounds in their cancer center and focus on oncology patients. At most sites, Rounds are institution-wide and different specialties take turns presenting cases.

Patients and family members do not attend because it can inhibit caregivers. However, once Rounds are well established at a site, patients or family members should be invited on occasion to present their story directly to the audience and then caregivers can comment and ask questions. These are always powerful Rounds.

Rounds are held monthly or bi-monthly. They usually take place in the early morning or at noon and the site serves a healthy meal. This provides not only an incentive for busy, over-scheduled caregivers to attend but also is a way to nurture them.

Scheduling a convenient time is always a challenge but some sites take over a weekly conference once a month for Rounds.

“The Rounds give you the inner strength to go on to the next case with an open heart and the ability to relate compassionately to new patients and families."

Benefits
The Schwartz Center commissioned Goodman Research Group, an independent evaluation, research and consulting firm, to conduct a formal, comprehensive, qualitative and quantitative multi-method evaluation of the Rounds.  The final results, released in February 2008, show that the Rounds have a unique and profound impact on caregivers and on the host institutions. 

To summarize, the evaluation found:

• Increased insight into the non-clinical aspects of patient care.  Caregivers who participated in Rounds feel more adequate in responding to patients’ social and emotional issues, and more compassionate toward patients and their families.  The Rounds remind caregivers why they entered their profession and strengthen the caregiver-patient relationship.
• Improved teamwork.  Rounds give caregivers a better appreciation for the roles and contributions of colleagues from different disciplines.  Participants also reported better communication with their co-workers and more openness to giving and receiving support from each other.
• More support.  Caregivers felt that Rounds decrease their feelings of stress and isolation.
• Specific changes in hospital practices or policies.  Rounds were found to have a positive impact on the culture of teamwork at the department and hospital levels.  Also, there were many reports of specific changes in practices or policies resulting from Rounds discussions that benefited both patients and caregivers.

In addition, the study found that:

• the more Rounds caregivers attended, the greater the benefits they experienced.
  
• caregivers who attend Rounds with co-workers have higher degrees of increased insight into the non-clinical aspects of patient care and greater improvement in teamwork.

For a glimpse of moving and powerful Rounds discussions that took place at the Massachusetts General Hospital Cancer Center in Boston and at Emerson Hospital in Concord, MA, please view the Schwartz Center’s ten-minute video “Schwartz Center Rounds: Voices of Caregivers.”
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Staff Needed
Top administration and medical and nursing leadership must support the Rounds in order for them to succeed. In addition, physicians and nurse managers must be willing to let staff leave their jobs to attend the Rounds.

Schwartz Center program staff respond to initial inquiries about the Rounds and work closely with new sites. After reviewing the written and visual materials (see video above), the site must designate the following staff before starting Rounds:

	Physician leader —Each site must identify a well-respected physician leader who is committed to the purpose of the Rounds and interested in spearheading them—this person is deemed the “Rounds Physician Leader.” Sometimes two physicians share this role. Physician leadership and active participation by the medical staff are key to making the Rounds multidisciplinary and successful.
	Planning group —Each site then creates a Rounds planning group of multidisciplinary caregivers. This group typically includes eight to ten caregivers, including the physician leader, nurses, social workers, case managers and sometimes a support staff person. The group publicizes the Rounds before they start, creates awareness, and then meets regularly on an ongoing basis to evaluate the most recent Rounds and plan for the next. Members of this group decide on topics for Rounds and invite caregivers to present each month.
	Facilitator — The site, often with help from the Schwartz Center, must identify a facilitator to lead and focus the Rounds discussion and summarize the salient points at the end of the hour. The facilitator is typically a social worker or a professional from outside the site who has experience working with groups. (Occasionally, the facilitator works at the site.) New facilitators are given guidelines and encouraged to talk to an experienced Rounds facilitator. See "Facilitator Guide."
	Support staff —An organized support staff person is essential to handle all the logistics. This involves securing the space, arranging for microphones, e-mailing attendees with the date and topic, ordering the food, setting up the room on the day of Rounds, greeting attendees at the door, collecting evaluation forms and summarizing the data for the Schwartz Center.

“The Schwartz Center Rounds act as a reminder of how to practice good, compassionate medicine – it is rare that people are able to speak so openly.”

Initial Steps

	The Schwartz Center asks the physician leader(s) and representatives from the site to attend Rounds at a Boston-area hospital to observe Rounds firsthand. The visitors then meet with Schwartz Center program staff and key staff involved in that site’s Rounds to talk about the forum. This amounts to approximately a two-hour visit.
	Once the planning group is in place, Schwartz Center staff hold a telephone conference with the group to explain the purpose and benefits of the Rounds, walk through all the logistics and answer questions. The program staff is available to assist with all aspects of start-up.
	The Center views its relationship with Rounds sites as a partnership.  The Center asks the physician leader to sign a contract in order to ensure the quality and integrity of the Rounds. The contract details the criteria the site must meet as well as the ways in which the Center adds value to the partnership. The Center mails a contract to the physician leader for signature before Rounds start. See "Sample Contract."

Ongoing Support from the Schwartz Center

	The program staff provides ongoing support and consultation for sites and evaluation oversight. The staff is available at any time to answer questions, troubleshoot, make suggestions and give advice.
	A Schwartz Center representative visits each Rounds site to observe, offer feedback and ensure that the Rounds are meeting the standards set forth in the contract.
	The Center organizes yearly group meetings in Boston for Rounds physician leaders and facilitators  to exchange ideas and suggestions about the Rounds. The Center has also set up a site on Yahoo where Rounds leaders, facilitators and attendees can communicate with each other: http://health.groups.yahoo.com/group/SchwartzCenterRounds.

For tips on implementing Rounds, click here.

“Rounds are a place where people who don’t usually talk about the heart of the work are willing to share… their vulnerability, to question themselves. Rounds are an opportunity for dialogue that doesn’t happen anywhere else in the hospital.”

Budget
For new sites, the Schwartz Center pays for the direct costs of Rounds, which are the food and outside facilitator, for the first 12 Rounds or 24 months, whichever comes first.  After that time, the Schwartz Center pays for 60% of the direct costs and the site is responsible for the remaining 40%. Each site determines how it allocates these funds (ie, for food or for a combination of food and facilitator). The maximum reimbursement for food and drinks from the Center is $8 per person. The maximum for the outside facilitator is $100 per Rounds session.

The Schwartz Center will work with sites that are having difficulty securing funds for their share of the direct costs. This will include specific suggestions on how to approach senior management to obtain funding and other ideas regarding soliciting local food vendors or donors. The Center will have a financial aid fund for sites that have tried every avenue but absolutely cannot obtain the 40% funding. These sites will pay only 10% of the direct costs.

The Schwartz Center will continue to absorb 100% of its indirect costs in managing the Rounds sites, including the time of the program staff involved in ongoing consultation, evaluation oversight and site visits.

Resident and fellow attendance at Rounds can help satisfy the Accreditation Council for Graduate Medical Education (ACGME) core competencies requirements on communication.

“This is such hard work… Rounds are a place to come together and share support and validation for one another. It meets a deep need that we wouldn’t have even known to ask for. It fulfills a hole in the clinical community.”