Arpana R. Vidyarthi, MD

DISCUSSION

KEY TEACHING POINTS

DISCUSSION

KEY TEACHING POINTS

DISCUSSION

KEY TEACHING POINTS

I hear and I forget, I see and I remember, I do and I understand.

Confucius

Hospital medicine, first described in 1996,[1] is the fastest growing specialty in United States medical history, now with approximately 40,000 practitioners.[2] Although hospitalists undoubtedly learned many of their key clinical skills during residency training, there is no hospitalist‐specific residency training pathway and a limited number of largely research‐oriented fellowships.[3] Furthermore, hospitalists are often asked to care for surgical patients, those with acute neurologic disorders, and patients in intensive care units, while also contributing to quality improvement and patient safety initiatives.[4] This suggests that the vast majority of hospitalists have not had specific training in many key competencies for the field.[5]

Continuing medical education (CME) has traditionally been the mechanism to maintain, develop, or increase the knowledge, skills, and professional performance of physicians.[6] Most CME activities, including those for hospitalists, are staged as live events in hotel conference rooms or as local events in a similarly passive learning environment (eg, grand rounds and medical staff meetings). Online programs, audiotapes, and expanding electronic media provide increasing and alternate methods for hospitalists to obtain their required CME. All of these activities passively deliver content to a group of diverse and experienced learners. They fail to take advantage of adult learning principles and may have little direct impact on professional practice.[7, 8] Traditional CME is often derided as a barrier to innovative educational methods for these reasons, as adults learn best through active participation, when the information is relevant and practically applied.[9, 10]

To provide practicing hospitalists with necessary continuing education, we designed the University of California, San Francisco (UCSF) Hospitalist Mini‐College (UHMC). This 3‐day course brings adult learners to the bedside for small‐group and active learning focused on content areas relevant to today's hospitalists. We describe the development, content, outcomes, and lessons learned from UHMC's first 5 years.

METHODS

Program Description

Figure 1 is a representative calendar view of the 3‐day UHMC course. The curricular topics were selected based on the findings from our needs assessment, our ability to deliver that curriculum using our small‐group active learning framework, and to minimize overlap with content of the larger course. Course curriculum was refined annually based on participant feedback and course director observations.

Figure 1

The program was built on a structure of 4 clinical domains and 2 clinical skills labs. The clinical domains included: (1) Hospital‐Based Neurology, (2) Critical Care Medicine in the Intensive Care Unit, (3) Surgical Comanagement and Medical Consultation, and (4) Hospital‐Based Dermatology. Participants were divided into 3 groups of 10 participants each and rotated through each domain in the afternoons. The clinical skills labs included: (1) Interpretation of Radiographic Studies and (2) Use of Ultrasound and Enhancing Confidence in Performing Bedside Procedures. We also developed specific sessions to teach about patient safety and to allow course attendees to participate in traditional academic learning vehicles (eg, a Morning Report and Morbidity and Mortality case conference). Below, we describe each session's format and content.

RESULTS

DISCUSSION

We developed an innovative CME program that brought participants to an academic health center for a participatory, hands‐on, and small‐group experience. They learned about topics relevant to today's hospitalists, rated the experience very highly, and reported a nearly unanimous likelihood to change their practice. Reflecting on our program's first 5 years, there were several lessons learned that may guide others committed to providing a similar CME experience.

First, hospital medicine is a dynamic field. Conducting a needs assessment to match clinical topics to what attendees required in their own practice was critical. Iterative changes from year to year reflected formal participant feedback as well as informal conversations with the teaching faculty. For instance, attendees were not only interested in the clinical topics but often wanted to see examples of clinical pathways, order sets, and other systems in place to improve care for patients with common conditions. Our participant presurvey also helped identify and reinforce the curricular topics that teaching faculty focused on each year. Being responsive to the changing needs of hospitalists and the environment is a crucial part of providing a relevant CME experience.

We also used an innovative approach to teaching, founded in adult and effective CME learning principles. CME activities are geared toward adult physicians, and studies of their effectiveness recommend that sessions should be interactive and utilize multiple modalities of learning.[12] When attendees actively participate and are provided an opportunity to practice skills, it may have a positive effect on patient outcomes.[13] All UHMC faculty were required to couple presentations of the latest evidence for clinical topics with small‐group and hands‐on learning modalities. This also required that we utilize a teaching faculty known for both their clinical expertise and teaching recognition. Together, the learning modalities and the teaching faculty likely accounted for the highly rated course experience and likelihood to change practice.

Finally, our course brought participants to an academic medical center and into the mix of clinical care as opposed to the more traditional hotel venue. This was necessary to deliver the curriculum as described, but also had the unexpected benefit of energizing the participants. Many had not been in a teaching setting since their residency training, and bringing them back into this milieu motivated them to learn and share their inspiration. As there are no published studies of CME experiences in the clinical environment, this observation is noteworthy and deserves to be explored and evaluated further.

What are the limitations of our approach to bringing CME to the bedside? First, the economics of an intensive 3‐day course with a maximum of 33 attendees are far different than those of a large hotel‐based offering. There are no exhibitors or outside contributions. The cost of the course to participants is $2500 (discounted if attending the larger course as well), which is 2 to 3 times higher than most traditional CME courses of the same length. Although the cost is high, the course has sold out each year with a waiting list. Part of the cost is also faculty time. The time, preparation, and need to teach on the fly to meet the differing participant educational needs is fundamentally different than delivering a single lecture in a hotel conference room. Not surprisingly, our faculty enjoy this teaching opportunity and find it equally unique and valuable; no faculty have dropped out of teaching the course, and many describe it as 1 of the teaching highlights of the year. Scalability of the UHMC is challenging for these reasons, but our model could be replicated in other teaching institutions, even as a local offering for their own providers.

In summary, we developed a hospital‐based, highly interactive, small‐group CME course that emphasizes case‐based teaching. The course has sold out each year, and evaluations suggest that it is highly valued and is meeting curricular goals better than more traditional CME courses. We hope our course description and success may motivate others to consider moving beyond the traditional CME for hospitalists and explore further innovations. With the field growing and changing at a rapid pace, innovative CME experiences will be necessary to assure that hospitalists continue to provide exemplary and safe care to their patients.

I hear and I forget, I see and I remember, I do and I understand.

Confucius

Hospital medicine, first described in 1996,[1] is the fastest growing specialty in United States medical history, now with approximately 40,000 practitioners.[2] Although hospitalists undoubtedly learned many of their key clinical skills during residency training, there is no hospitalist‐specific residency training pathway and a limited number of largely research‐oriented fellowships.[3] Furthermore, hospitalists are often asked to care for surgical patients, those with acute neurologic disorders, and patients in intensive care units, while also contributing to quality improvement and patient safety initiatives.[4] This suggests that the vast majority of hospitalists have not had specific training in many key competencies for the field.[5]

Continuing medical education (CME) has traditionally been the mechanism to maintain, develop, or increase the knowledge, skills, and professional performance of physicians.[6] Most CME activities, including those for hospitalists, are staged as live events in hotel conference rooms or as local events in a similarly passive learning environment (eg, grand rounds and medical staff meetings). Online programs, audiotapes, and expanding electronic media provide increasing and alternate methods for hospitalists to obtain their required CME. All of these activities passively deliver content to a group of diverse and experienced learners. They fail to take advantage of adult learning principles and may have little direct impact on professional practice.[7, 8] Traditional CME is often derided as a barrier to innovative educational methods for these reasons, as adults learn best through active participation, when the information is relevant and practically applied.[9, 10]

To provide practicing hospitalists with necessary continuing education, we designed the University of California, San Francisco (UCSF) Hospitalist Mini‐College (UHMC). This 3‐day course brings adult learners to the bedside for small‐group and active learning focused on content areas relevant to today's hospitalists. We describe the development, content, outcomes, and lessons learned from UHMC's first 5 years.

METHODS

Program Description

Figure 1 is a representative calendar view of the 3‐day UHMC course. The curricular topics were selected based on the findings from our needs assessment, our ability to deliver that curriculum using our small‐group active learning framework, and to minimize overlap with content of the larger course. Course curriculum was refined annually based on participant feedback and course director observations.

Figure 1

The program was built on a structure of 4 clinical domains and 2 clinical skills labs. The clinical domains included: (1) Hospital‐Based Neurology, (2) Critical Care Medicine in the Intensive Care Unit, (3) Surgical Comanagement and Medical Consultation, and (4) Hospital‐Based Dermatology. Participants were divided into 3 groups of 10 participants each and rotated through each domain in the afternoons. The clinical skills labs included: (1) Interpretation of Radiographic Studies and (2) Use of Ultrasound and Enhancing Confidence in Performing Bedside Procedures. We also developed specific sessions to teach about patient safety and to allow course attendees to participate in traditional academic learning vehicles (eg, a Morning Report and Morbidity and Mortality case conference). Below, we describe each session's format and content.

RESULTS

DISCUSSION

We developed an innovative CME program that brought participants to an academic health center for a participatory, hands‐on, and small‐group experience. They learned about topics relevant to today's hospitalists, rated the experience very highly, and reported a nearly unanimous likelihood to change their practice. Reflecting on our program's first 5 years, there were several lessons learned that may guide others committed to providing a similar CME experience.

First, hospital medicine is a dynamic field. Conducting a needs assessment to match clinical topics to what attendees required in their own practice was critical. Iterative changes from year to year reflected formal participant feedback as well as informal conversations with the teaching faculty. For instance, attendees were not only interested in the clinical topics but often wanted to see examples of clinical pathways, order sets, and other systems in place to improve care for patients with common conditions. Our participant presurvey also helped identify and reinforce the curricular topics that teaching faculty focused on each year. Being responsive to the changing needs of hospitalists and the environment is a crucial part of providing a relevant CME experience.

We also used an innovative approach to teaching, founded in adult and effective CME learning principles. CME activities are geared toward adult physicians, and studies of their effectiveness recommend that sessions should be interactive and utilize multiple modalities of learning.[12] When attendees actively participate and are provided an opportunity to practice skills, it may have a positive effect on patient outcomes.[13] All UHMC faculty were required to couple presentations of the latest evidence for clinical topics with small‐group and hands‐on learning modalities. This also required that we utilize a teaching faculty known for both their clinical expertise and teaching recognition. Together, the learning modalities and the teaching faculty likely accounted for the highly rated course experience and likelihood to change practice.

Finally, our course brought participants to an academic medical center and into the mix of clinical care as opposed to the more traditional hotel venue. This was necessary to deliver the curriculum as described, but also had the unexpected benefit of energizing the participants. Many had not been in a teaching setting since their residency training, and bringing them back into this milieu motivated them to learn and share their inspiration. As there are no published studies of CME experiences in the clinical environment, this observation is noteworthy and deserves to be explored and evaluated further.

What are the limitations of our approach to bringing CME to the bedside? First, the economics of an intensive 3‐day course with a maximum of 33 attendees are far different than those of a large hotel‐based offering. There are no exhibitors or outside contributions. The cost of the course to participants is $2500 (discounted if attending the larger course as well), which is 2 to 3 times higher than most traditional CME courses of the same length. Although the cost is high, the course has sold out each year with a waiting list. Part of the cost is also faculty time. The time, preparation, and need to teach on the fly to meet the differing participant educational needs is fundamentally different than delivering a single lecture in a hotel conference room. Not surprisingly, our faculty enjoy this teaching opportunity and find it equally unique and valuable; no faculty have dropped out of teaching the course, and many describe it as 1 of the teaching highlights of the year. Scalability of the UHMC is challenging for these reasons, but our model could be replicated in other teaching institutions, even as a local offering for their own providers.

In summary, we developed a hospital‐based, highly interactive, small‐group CME course that emphasizes case‐based teaching. The course has sold out each year, and evaluations suggest that it is highly valued and is meeting curricular goals better than more traditional CME courses. We hope our course description and success may motivate others to consider moving beyond the traditional CME for hospitalists and explore further innovations. With the field growing and changing at a rapid pace, innovative CME experiences will be necessary to assure that hospitalists continue to provide exemplary and safe care to their patients.

I hear and I forget, I see and I remember, I do and I understand.

Confucius

Hospital medicine, first described in 1996,[1] is the fastest growing specialty in United States medical history, now with approximately 40,000 practitioners.[2] Although hospitalists undoubtedly learned many of their key clinical skills during residency training, there is no hospitalist‐specific residency training pathway and a limited number of largely research‐oriented fellowships.[3] Furthermore, hospitalists are often asked to care for surgical patients, those with acute neurologic disorders, and patients in intensive care units, while also contributing to quality improvement and patient safety initiatives.[4] This suggests that the vast majority of hospitalists have not had specific training in many key competencies for the field.[5]

Continuing medical education (CME) has traditionally been the mechanism to maintain, develop, or increase the knowledge, skills, and professional performance of physicians.[6] Most CME activities, including those for hospitalists, are staged as live events in hotel conference rooms or as local events in a similarly passive learning environment (eg, grand rounds and medical staff meetings). Online programs, audiotapes, and expanding electronic media provide increasing and alternate methods for hospitalists to obtain their required CME. All of these activities passively deliver content to a group of diverse and experienced learners. They fail to take advantage of adult learning principles and may have little direct impact on professional practice.[7, 8] Traditional CME is often derided as a barrier to innovative educational methods for these reasons, as adults learn best through active participation, when the information is relevant and practically applied.[9, 10]

To provide practicing hospitalists with necessary continuing education, we designed the University of California, San Francisco (UCSF) Hospitalist Mini‐College (UHMC). This 3‐day course brings adult learners to the bedside for small‐group and active learning focused on content areas relevant to today's hospitalists. We describe the development, content, outcomes, and lessons learned from UHMC's first 5 years.

METHODS

Program Description

Figure 1 is a representative calendar view of the 3‐day UHMC course. The curricular topics were selected based on the findings from our needs assessment, our ability to deliver that curriculum using our small‐group active learning framework, and to minimize overlap with content of the larger course. Course curriculum was refined annually based on participant feedback and course director observations.

Figure 1

The program was built on a structure of 4 clinical domains and 2 clinical skills labs. The clinical domains included: (1) Hospital‐Based Neurology, (2) Critical Care Medicine in the Intensive Care Unit, (3) Surgical Comanagement and Medical Consultation, and (4) Hospital‐Based Dermatology. Participants were divided into 3 groups of 10 participants each and rotated through each domain in the afternoons. The clinical skills labs included: (1) Interpretation of Radiographic Studies and (2) Use of Ultrasound and Enhancing Confidence in Performing Bedside Procedures. We also developed specific sessions to teach about patient safety and to allow course attendees to participate in traditional academic learning vehicles (eg, a Morning Report and Morbidity and Mortality case conference). Below, we describe each session's format and content.

RESULTS

DISCUSSION

We developed an innovative CME program that brought participants to an academic health center for a participatory, hands‐on, and small‐group experience. They learned about topics relevant to today's hospitalists, rated the experience very highly, and reported a nearly unanimous likelihood to change their practice. Reflecting on our program's first 5 years, there were several lessons learned that may guide others committed to providing a similar CME experience.

First, hospital medicine is a dynamic field. Conducting a needs assessment to match clinical topics to what attendees required in their own practice was critical. Iterative changes from year to year reflected formal participant feedback as well as informal conversations with the teaching faculty. For instance, attendees were not only interested in the clinical topics but often wanted to see examples of clinical pathways, order sets, and other systems in place to improve care for patients with common conditions. Our participant presurvey also helped identify and reinforce the curricular topics that teaching faculty focused on each year. Being responsive to the changing needs of hospitalists and the environment is a crucial part of providing a relevant CME experience.

We also used an innovative approach to teaching, founded in adult and effective CME learning principles. CME activities are geared toward adult physicians, and studies of their effectiveness recommend that sessions should be interactive and utilize multiple modalities of learning.[12] When attendees actively participate and are provided an opportunity to practice skills, it may have a positive effect on patient outcomes.[13] All UHMC faculty were required to couple presentations of the latest evidence for clinical topics with small‐group and hands‐on learning modalities. This also required that we utilize a teaching faculty known for both their clinical expertise and teaching recognition. Together, the learning modalities and the teaching faculty likely accounted for the highly rated course experience and likelihood to change practice.

Finally, our course brought participants to an academic medical center and into the mix of clinical care as opposed to the more traditional hotel venue. This was necessary to deliver the curriculum as described, but also had the unexpected benefit of energizing the participants. Many had not been in a teaching setting since their residency training, and bringing them back into this milieu motivated them to learn and share their inspiration. As there are no published studies of CME experiences in the clinical environment, this observation is noteworthy and deserves to be explored and evaluated further.

What are the limitations of our approach to bringing CME to the bedside? First, the economics of an intensive 3‐day course with a maximum of 33 attendees are far different than those of a large hotel‐based offering. There are no exhibitors or outside contributions. The cost of the course to participants is $2500 (discounted if attending the larger course as well), which is 2 to 3 times higher than most traditional CME courses of the same length. Although the cost is high, the course has sold out each year with a waiting list. Part of the cost is also faculty time. The time, preparation, and need to teach on the fly to meet the differing participant educational needs is fundamentally different than delivering a single lecture in a hotel conference room. Not surprisingly, our faculty enjoy this teaching opportunity and find it equally unique and valuable; no faculty have dropped out of teaching the course, and many describe it as 1 of the teaching highlights of the year. Scalability of the UHMC is challenging for these reasons, but our model could be replicated in other teaching institutions, even as a local offering for their own providers.

In summary, we developed a hospital‐based, highly interactive, small‐group CME course that emphasizes case‐based teaching. The course has sold out each year, and evaluations suggest that it is highly valued and is meeting curricular goals better than more traditional CME courses. We hope our course description and success may motivate others to consider moving beyond the traditional CME for hospitalists and explore further innovations. With the field growing and changing at a rapid pace, innovative CME experiences will be necessary to assure that hospitalists continue to provide exemplary and safe care to their patients.

Communication and teamwork failures are the most frequently cited cause of adverse events.1, 2 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.36 For instance, many institutions have adopted SBAR (Situation‐Background‐Assessment‐Recommendation) as a method for providers to deliver critical clinical information in a structured format.7 SBAR focuses on the immediate and urgent event at hand and can occur between any 2 providers. The situation is a brief description of the event (eg, Hi Dr. Smith, this is Paul from 14‐Long, I'm calling about Mrs. Jones in 1427 who is in acute respiratory distress). The background describes details relevant to the situation (eg, She was admitted with a COPD exacerbation yesterday night, and, for the past couple hours, she appears in more distress. Her vital signs are). The assessment (eg, Her breath sounds are diminished and she's moving less air) and recommendation (eg, I'd like to call respiratory therapy and would like you to come assess her now) drive toward having an action defined at the end. Given the professional silos that exist in healthcare, the advent of a shared set of communication tools helps bridge existing gaps in training, experience, and teamwork between different providers.

Regulatory agencies have been heavily invested in attempts to standardize communication in healthcare settings. In 2003, the Joint Commission elevated the concerns for wrong‐site surgery by making its prevention a National Patient Safety Goal, and the following year required compliance with a Universal Protocol (UP).8 In addition to adequate preoperative identification of the patient and marking of their surgical site, the UP called for a time out (TO) just prior to the surgery or procedure. The UP states that a TO requires active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a fail‐safe mode, so that the planned procedure is not started if a member of the team has concerns.8 Simply, the TO provides an opportunity to clarify plans for care and discuss events anticipated during the procedure among all members of the team (eg, surgeons, anesthesiologists, nurses, technicians). This all‐important pause point ensures that each team member is on the same page.

Whereas a TO involves many high‐risk procedural settings, a significant proportion of hospital care occurs outside of procedures. Patients are often evaluated in an emergency department, admitted to a medical/surgical ward, treated without the need for a procedure, and ultimately discharged home or transferred to another healthcare facility (eg, skilled nursing or acute rehabilitation). In this paper, we introduce the concept of Critical Conversations, a form of nonprocedural time out, as a tool, intervention, and policy that promotes communication and teamwork at the most vulnerable junctures in a patient's hospitalization.

Rationale for Critical Conversations: a Case Scenario

An 82‐year‐old man with hypertension and chronic obstructive pulmonary disease (COPD) is admitted to the hospital with community‐acquired pneumonia and an exacerbation of his COPD. The admitting physician evaluates the patient in the emergency department and completes admission orders. The patient arrives on the medical/surgical unit and the unit clerk processes the orders, stimulating a cascade of downstream events for different providers.

Description of a Critical Conversation

In the hours that follow an admission, providers (and often the patients or their family as well) invariably exchange any number of inefficient calls or pages to clarify care plans, discuss a suspected diagnosis, anticipate concerns in the first night, and/or highlight which orders should be prioritized, such as medications or diagnostic studies. A Critical Conversation at time of admission does in this circumstance exactly what a TO attempts to provide before a procedure foster communication and teamwork as a patient is about to be placed at risk for adverse events. The exchange involves discussion of the following:

• Admitting diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any admitting orders

• Guidelines for physician notification when a change in patient condition occurs.

At the other end of a hospitalization, with the known complications arising from a patient's discharge,11, 12 the same process is needed. Rather than having each discipline focus on an individual role or task in getting a patient safely discharged, Critical Conversations allow the entire team, including the patient,13 to ensure that concerns have been addressed. This might help clarify simple measures around follow‐up appointments, whom to call with questions after discharge, or symptoms to watch for that may warrant a repeat evaluation. Nurses anecdotally lament that they first learn about a planned discharge only when the discharge order is written in the chart or if a patient informs them. Both scenarios reflect poorly on the teamwork required to assure patients we're working together, and that key providers are on the same page with respect to discharge planning. The exchange at discharge involves discussion of these elements:

• Discharge diagnosis

• Follow‐up plans

• Need for education/training prior to discharge

• Necessary paperwork completed

• Anticipated time of discharge.

Finally, where many patients are admitted to a hospital, improve, and then return home, others develop acute changes during their hospitalization. For example, the patient in our case scenario could develop respiratory failure and require transfer to the intensive care unit (ICU). Or a different patient might have an acute change in mental status, a new fever, a new abnormal vital sign (eg, tachycardia or hypoxia), or an acute change re existing abdominal painall of which may require a battery of diagnostic tests. These circumstances define the third time for a Critical Conversation: a change in clinical condition. Such situations often require a change in the care plan, a change in priorities for delivering care at that time (for the patient in need and for other patients being cared for by the same nurse and physician), a need for additional resources (eg, respiratory therapist, phlebotomist, pharmacist), and, ultimately, a well‐orchestrated team effort to make it all happen. The specific item prompting the Critical Conversation may impact the nature of the exchange, which involves discussion of these components:

• Suspected diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any new orders

• Guidelines for physician notification when a change in patient condition occurs.

In addition to the above checklist for each Critical Conversation, each exchange should also address two open‐ended questions: 1) what do you anticipate happening in the next 24 hours, and 2) what questions might the patient/family have?

One may ask, and we did, why not have a direct communication daily between a physician and a bedside nurse on each patient? Most physicians and nurses know the importance of direct communication, but there are also times when each is prioritizing work in competing fashions. Adopting Critical Conversations isn't meant to deter from communications that are vital to patient care; rather, it is intended to codify distinct times when a direct communication is required for patient safety.

Lessons Learned

Table 1 provides an example of a Critical Conversation using the sample case scenario. Table 2 lists the most frequent outcomes that resulted from providers engaging in Critical Conversations. These were captured from discussions with bedside nurses and internal medicine residents on our primary medical unit. Both tables highlight how these deliberate and direct communications can create a shared understanding of the patient's medical problems, can help prioritize what tasks should take place (eg, radiology study, medication administration, calling another provider), can improve communication between providers and patients, and potentially accomplish all of these goals in a more efficient manner.

Making Critical Conversations Happen

Integrating Critical Conversations into practice requires both buy‐in among providers and a plan for monitoring the interactions. We recommend beginning with educational efforts (eg, at a physician or nurse staff meeting) and reinforcing them with visual cues, such as posters on the unit (Figure 1). These actions promote awareness and generate expectations that this new clinical policy is being supported by clinical and hospital leadership. Our experiences have demonstrated tremendous learning, including numerous anecdotes about the value of Critical Conversations (Table 3). Our implementation efforts also raised a number of questions that ultimately led to improved clarity in later iterations.

Figure 1

Table 3.Provider Experiences Using Critical Conversations

Nothing is worse than meeting a patient for the first time at admission and not being able to answer the basic question of why they were admitted or what the plan is. It gives the impression that we don't talk to each other in caring for patients. [Critical Conversations] can really minimize that interaction and reassure patients, rather than make them worried about the apparent mixed messages or lack of communication and teamwork.Bedside Nurse
[Critical Conversations] seemed like an additional timely responsibility, and not always a part of my workflow, when sitting in the emergency department admitting patients. But, I found that the often 60 second conversations decreased the number of pages I would get for the same patientactually saving me time.Physician
I don't need to have direct communications for every order written. In fact, it would be inefficient for me and the doctors. On the other hand, being engaged in a Critical Conversation provides an opportunity for me to prioritize not only my tasks for the patient in need, but also in context of the other patients I'm caring for.Bedside Nurse
Late in the afternoon, there will often be several admissions coming to our unit simultaneously. Prioritizing what orders need to be processed or faxed is a typically blind task based on the way charts get organizedrather than someone telling me this is a priority.Unit Clerk
There are so many times when I'm trying to determine what the care plans are for a new admission, and simply having a quick conversation allows me to feel part of the team, and, more importantly, allows me to reinforce education and support for the patients and their family members.Bedside Nurse
Discharge always seems chaotic with everyone racing to fill out forms and meet their own tasks and requirements. Invariably, you get called to fix, change, or add new information to the discharge process that would have been easily averted by actually having a brief conversation with the bedside nurse or case manager. Every time I have [a Critical Conversation], I realize its importance for patient care.Physician

Communication and teamwork failures are the most frequently cited cause of adverse events.1, 2 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.36 For instance, many institutions have adopted SBAR (Situation‐Background‐Assessment‐Recommendation) as a method for providers to deliver critical clinical information in a structured format.7 SBAR focuses on the immediate and urgent event at hand and can occur between any 2 providers. The situation is a brief description of the event (eg, Hi Dr. Smith, this is Paul from 14‐Long, I'm calling about Mrs. Jones in 1427 who is in acute respiratory distress). The background describes details relevant to the situation (eg, She was admitted with a COPD exacerbation yesterday night, and, for the past couple hours, she appears in more distress. Her vital signs are). The assessment (eg, Her breath sounds are diminished and she's moving less air) and recommendation (eg, I'd like to call respiratory therapy and would like you to come assess her now) drive toward having an action defined at the end. Given the professional silos that exist in healthcare, the advent of a shared set of communication tools helps bridge existing gaps in training, experience, and teamwork between different providers.

Regulatory agencies have been heavily invested in attempts to standardize communication in healthcare settings. In 2003, the Joint Commission elevated the concerns for wrong‐site surgery by making its prevention a National Patient Safety Goal, and the following year required compliance with a Universal Protocol (UP).8 In addition to adequate preoperative identification of the patient and marking of their surgical site, the UP called for a time out (TO) just prior to the surgery or procedure. The UP states that a TO requires active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a fail‐safe mode, so that the planned procedure is not started if a member of the team has concerns.8 Simply, the TO provides an opportunity to clarify plans for care and discuss events anticipated during the procedure among all members of the team (eg, surgeons, anesthesiologists, nurses, technicians). This all‐important pause point ensures that each team member is on the same page.

Whereas a TO involves many high‐risk procedural settings, a significant proportion of hospital care occurs outside of procedures. Patients are often evaluated in an emergency department, admitted to a medical/surgical ward, treated without the need for a procedure, and ultimately discharged home or transferred to another healthcare facility (eg, skilled nursing or acute rehabilitation). In this paper, we introduce the concept of Critical Conversations, a form of nonprocedural time out, as a tool, intervention, and policy that promotes communication and teamwork at the most vulnerable junctures in a patient's hospitalization.

Rationale for Critical Conversations: a Case Scenario

An 82‐year‐old man with hypertension and chronic obstructive pulmonary disease (COPD) is admitted to the hospital with community‐acquired pneumonia and an exacerbation of his COPD. The admitting physician evaluates the patient in the emergency department and completes admission orders. The patient arrives on the medical/surgical unit and the unit clerk processes the orders, stimulating a cascade of downstream events for different providers.

Description of a Critical Conversation

In the hours that follow an admission, providers (and often the patients or their family as well) invariably exchange any number of inefficient calls or pages to clarify care plans, discuss a suspected diagnosis, anticipate concerns in the first night, and/or highlight which orders should be prioritized, such as medications or diagnostic studies. A Critical Conversation at time of admission does in this circumstance exactly what a TO attempts to provide before a procedure foster communication and teamwork as a patient is about to be placed at risk for adverse events. The exchange involves discussion of the following:

• Admitting diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any admitting orders

• Guidelines for physician notification when a change in patient condition occurs.

At the other end of a hospitalization, with the known complications arising from a patient's discharge,11, 12 the same process is needed. Rather than having each discipline focus on an individual role or task in getting a patient safely discharged, Critical Conversations allow the entire team, including the patient,13 to ensure that concerns have been addressed. This might help clarify simple measures around follow‐up appointments, whom to call with questions after discharge, or symptoms to watch for that may warrant a repeat evaluation. Nurses anecdotally lament that they first learn about a planned discharge only when the discharge order is written in the chart or if a patient informs them. Both scenarios reflect poorly on the teamwork required to assure patients we're working together, and that key providers are on the same page with respect to discharge planning. The exchange at discharge involves discussion of these elements:

• Discharge diagnosis

• Follow‐up plans

• Need for education/training prior to discharge

• Necessary paperwork completed

• Anticipated time of discharge.

Finally, where many patients are admitted to a hospital, improve, and then return home, others develop acute changes during their hospitalization. For example, the patient in our case scenario could develop respiratory failure and require transfer to the intensive care unit (ICU). Or a different patient might have an acute change in mental status, a new fever, a new abnormal vital sign (eg, tachycardia or hypoxia), or an acute change re existing abdominal painall of which may require a battery of diagnostic tests. These circumstances define the third time for a Critical Conversation: a change in clinical condition. Such situations often require a change in the care plan, a change in priorities for delivering care at that time (for the patient in need and for other patients being cared for by the same nurse and physician), a need for additional resources (eg, respiratory therapist, phlebotomist, pharmacist), and, ultimately, a well‐orchestrated team effort to make it all happen. The specific item prompting the Critical Conversation may impact the nature of the exchange, which involves discussion of these components:

• Suspected diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any new orders

• Guidelines for physician notification when a change in patient condition occurs.

In addition to the above checklist for each Critical Conversation, each exchange should also address two open‐ended questions: 1) what do you anticipate happening in the next 24 hours, and 2) what questions might the patient/family have?

One may ask, and we did, why not have a direct communication daily between a physician and a bedside nurse on each patient? Most physicians and nurses know the importance of direct communication, but there are also times when each is prioritizing work in competing fashions. Adopting Critical Conversations isn't meant to deter from communications that are vital to patient care; rather, it is intended to codify distinct times when a direct communication is required for patient safety.

Lessons Learned

Table 1 provides an example of a Critical Conversation using the sample case scenario. Table 2 lists the most frequent outcomes that resulted from providers engaging in Critical Conversations. These were captured from discussions with bedside nurses and internal medicine residents on our primary medical unit. Both tables highlight how these deliberate and direct communications can create a shared understanding of the patient's medical problems, can help prioritize what tasks should take place (eg, radiology study, medication administration, calling another provider), can improve communication between providers and patients, and potentially accomplish all of these goals in a more efficient manner.

Making Critical Conversations Happen

Integrating Critical Conversations into practice requires both buy‐in among providers and a plan for monitoring the interactions. We recommend beginning with educational efforts (eg, at a physician or nurse staff meeting) and reinforcing them with visual cues, such as posters on the unit (Figure 1). These actions promote awareness and generate expectations that this new clinical policy is being supported by clinical and hospital leadership. Our experiences have demonstrated tremendous learning, including numerous anecdotes about the value of Critical Conversations (Table 3). Our implementation efforts also raised a number of questions that ultimately led to improved clarity in later iterations.

Figure 1

Table 3.Provider Experiences Using Critical Conversations

Nothing is worse than meeting a patient for the first time at admission and not being able to answer the basic question of why they were admitted or what the plan is. It gives the impression that we don't talk to each other in caring for patients. [Critical Conversations] can really minimize that interaction and reassure patients, rather than make them worried about the apparent mixed messages or lack of communication and teamwork.Bedside Nurse
[Critical Conversations] seemed like an additional timely responsibility, and not always a part of my workflow, when sitting in the emergency department admitting patients. But, I found that the often 60 second conversations decreased the number of pages I would get for the same patientactually saving me time.Physician
I don't need to have direct communications for every order written. In fact, it would be inefficient for me and the doctors. On the other hand, being engaged in a Critical Conversation provides an opportunity for me to prioritize not only my tasks for the patient in need, but also in context of the other patients I'm caring for.Bedside Nurse
Late in the afternoon, there will often be several admissions coming to our unit simultaneously. Prioritizing what orders need to be processed or faxed is a typically blind task based on the way charts get organizedrather than someone telling me this is a priority.Unit Clerk
There are so many times when I'm trying to determine what the care plans are for a new admission, and simply having a quick conversation allows me to feel part of the team, and, more importantly, allows me to reinforce education and support for the patients and their family members.Bedside Nurse
Discharge always seems chaotic with everyone racing to fill out forms and meet their own tasks and requirements. Invariably, you get called to fix, change, or add new information to the discharge process that would have been easily averted by actually having a brief conversation with the bedside nurse or case manager. Every time I have [a Critical Conversation], I realize its importance for patient care.Physician

Communication and teamwork failures are the most frequently cited cause of adverse events.1, 2 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.36 For instance, many institutions have adopted SBAR (Situation‐Background‐Assessment‐Recommendation) as a method for providers to deliver critical clinical information in a structured format.7 SBAR focuses on the immediate and urgent event at hand and can occur between any 2 providers. The situation is a brief description of the event (eg, Hi Dr. Smith, this is Paul from 14‐Long, I'm calling about Mrs. Jones in 1427 who is in acute respiratory distress). The background describes details relevant to the situation (eg, She was admitted with a COPD exacerbation yesterday night, and, for the past couple hours, she appears in more distress. Her vital signs are). The assessment (eg, Her breath sounds are diminished and she's moving less air) and recommendation (eg, I'd like to call respiratory therapy and would like you to come assess her now) drive toward having an action defined at the end. Given the professional silos that exist in healthcare, the advent of a shared set of communication tools helps bridge existing gaps in training, experience, and teamwork between different providers.

Regulatory agencies have been heavily invested in attempts to standardize communication in healthcare settings. In 2003, the Joint Commission elevated the concerns for wrong‐site surgery by making its prevention a National Patient Safety Goal, and the following year required compliance with a Universal Protocol (UP).8 In addition to adequate preoperative identification of the patient and marking of their surgical site, the UP called for a time out (TO) just prior to the surgery or procedure. The UP states that a TO requires active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a fail‐safe mode, so that the planned procedure is not started if a member of the team has concerns.8 Simply, the TO provides an opportunity to clarify plans for care and discuss events anticipated during the procedure among all members of the team (eg, surgeons, anesthesiologists, nurses, technicians). This all‐important pause point ensures that each team member is on the same page.

Whereas a TO involves many high‐risk procedural settings, a significant proportion of hospital care occurs outside of procedures. Patients are often evaluated in an emergency department, admitted to a medical/surgical ward, treated without the need for a procedure, and ultimately discharged home or transferred to another healthcare facility (eg, skilled nursing or acute rehabilitation). In this paper, we introduce the concept of Critical Conversations, a form of nonprocedural time out, as a tool, intervention, and policy that promotes communication and teamwork at the most vulnerable junctures in a patient's hospitalization.

Rationale for Critical Conversations: a Case Scenario

An 82‐year‐old man with hypertension and chronic obstructive pulmonary disease (COPD) is admitted to the hospital with community‐acquired pneumonia and an exacerbation of his COPD. The admitting physician evaluates the patient in the emergency department and completes admission orders. The patient arrives on the medical/surgical unit and the unit clerk processes the orders, stimulating a cascade of downstream events for different providers.

Description of a Critical Conversation

In the hours that follow an admission, providers (and often the patients or their family as well) invariably exchange any number of inefficient calls or pages to clarify care plans, discuss a suspected diagnosis, anticipate concerns in the first night, and/or highlight which orders should be prioritized, such as medications or diagnostic studies. A Critical Conversation at time of admission does in this circumstance exactly what a TO attempts to provide before a procedure foster communication and teamwork as a patient is about to be placed at risk for adverse events. The exchange involves discussion of the following:

• Admitting diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any admitting orders

• Guidelines for physician notification when a change in patient condition occurs.

At the other end of a hospitalization, with the known complications arising from a patient's discharge,11, 12 the same process is needed. Rather than having each discipline focus on an individual role or task in getting a patient safely discharged, Critical Conversations allow the entire team, including the patient,13 to ensure that concerns have been addressed. This might help clarify simple measures around follow‐up appointments, whom to call with questions after discharge, or symptoms to watch for that may warrant a repeat evaluation. Nurses anecdotally lament that they first learn about a planned discharge only when the discharge order is written in the chart or if a patient informs them. Both scenarios reflect poorly on the teamwork required to assure patients we're working together, and that key providers are on the same page with respect to discharge planning. The exchange at discharge involves discussion of these elements:

• Discharge diagnosis

• Follow‐up plans

• Need for education/training prior to discharge

• Necessary paperwork completed

• Anticipated time of discharge.

Finally, where many patients are admitted to a hospital, improve, and then return home, others develop acute changes during their hospitalization. For example, the patient in our case scenario could develop respiratory failure and require transfer to the intensive care unit (ICU). Or a different patient might have an acute change in mental status, a new fever, a new abnormal vital sign (eg, tachycardia or hypoxia), or an acute change re existing abdominal painall of which may require a battery of diagnostic tests. These circumstances define the third time for a Critical Conversation: a change in clinical condition. Such situations often require a change in the care plan, a change in priorities for delivering care at that time (for the patient in need and for other patients being cared for by the same nurse and physician), a need for additional resources (eg, respiratory therapist, phlebotomist, pharmacist), and, ultimately, a well‐orchestrated team effort to make it all happen. The specific item prompting the Critical Conversation may impact the nature of the exchange, which involves discussion of these components:

• Suspected diagnosis

• Immediate treatment plan

• Medications ordered (particularly those new to a patient to anticipate an adverse event)

• Priority for completing any new orders

• Guidelines for physician notification when a change in patient condition occurs.

In addition to the above checklist for each Critical Conversation, each exchange should also address two open‐ended questions: 1) what do you anticipate happening in the next 24 hours, and 2) what questions might the patient/family have?

One may ask, and we did, why not have a direct communication daily between a physician and a bedside nurse on each patient? Most physicians and nurses know the importance of direct communication, but there are also times when each is prioritizing work in competing fashions. Adopting Critical Conversations isn't meant to deter from communications that are vital to patient care; rather, it is intended to codify distinct times when a direct communication is required for patient safety.

Lessons Learned

Table 1 provides an example of a Critical Conversation using the sample case scenario. Table 2 lists the most frequent outcomes that resulted from providers engaging in Critical Conversations. These were captured from discussions with bedside nurses and internal medicine residents on our primary medical unit. Both tables highlight how these deliberate and direct communications can create a shared understanding of the patient's medical problems, can help prioritize what tasks should take place (eg, radiology study, medication administration, calling another provider), can improve communication between providers and patients, and potentially accomplish all of these goals in a more efficient manner.

Making Critical Conversations Happen

Integrating Critical Conversations into practice requires both buy‐in among providers and a plan for monitoring the interactions. We recommend beginning with educational efforts (eg, at a physician or nurse staff meeting) and reinforcing them with visual cues, such as posters on the unit (Figure 1). These actions promote awareness and generate expectations that this new clinical policy is being supported by clinical and hospital leadership. Our experiences have demonstrated tremendous learning, including numerous anecdotes about the value of Critical Conversations (Table 3). Our implementation efforts also raised a number of questions that ultimately led to improved clarity in later iterations.

Figure 1

Table 3.Provider Experiences Using Critical Conversations

Nothing is worse than meeting a patient for the first time at admission and not being able to answer the basic question of why they were admitted or what the plan is. It gives the impression that we don't talk to each other in caring for patients. [Critical Conversations] can really minimize that interaction and reassure patients, rather than make them worried about the apparent mixed messages or lack of communication and teamwork.Bedside Nurse
[Critical Conversations] seemed like an additional timely responsibility, and not always a part of my workflow, when sitting in the emergency department admitting patients. But, I found that the often 60 second conversations decreased the number of pages I would get for the same patientactually saving me time.Physician
I don't need to have direct communications for every order written. In fact, it would be inefficient for me and the doctors. On the other hand, being engaged in a Critical Conversation provides an opportunity for me to prioritize not only my tasks for the patient in need, but also in context of the other patients I'm caring for.Bedside Nurse
Late in the afternoon, there will often be several admissions coming to our unit simultaneously. Prioritizing what orders need to be processed or faxed is a typically blind task based on the way charts get organizedrather than someone telling me this is a priority.Unit Clerk
There are so many times when I'm trying to determine what the care plans are for a new admission, and simply having a quick conversation allows me to feel part of the team, and, more importantly, allows me to reinforce education and support for the patients and their family members.Bedside Nurse
Discharge always seems chaotic with everyone racing to fill out forms and meet their own tasks and requirements. Invariably, you get called to fix, change, or add new information to the discharge process that would have been easily averted by actually having a brief conversation with the bedside nurse or case manager. Every time I have [a Critical Conversation], I realize its importance for patient care.Physician

Delivering the highest possible quality of care is among the top priorities of all medical centers. That said, any quality innovation must be seen as adding value from a variety of perspectives. Especially in the current economic climate, a sound business case is paramount to the advancement of any quality innovation. Given the nature of their work, hospitalists are ideally suited to undertake system improvement innovations. To assist hospitalists in successfully implementing quality and safety initiatives, we have designed a framework of elements required for a business case. We describe our experience developing and implementing an electronic discharge summary and utilize a structured framework to articulate the business case for its implementation.

Defining a Business Case Framework

A business case is a structured proposal outlining the qualitative and quantitative factors that justify a course of action. An effective business case for a quality improvement initiative articulates how both factors are aligned with preexisting organizational goals. In modeling the business case framework for the electronic discharge summary, Figure 1 outlines the qualitative and quantitative costs and benefits that can affect institutional decision making.

Figure 1

The Business Case for an Electronic Discharge Summary at University of California San Francisco (UCSF)

Application of the Business Framework to the Case for an Electronic Discharge

Considering the potential improvements in care delivery, the argument for an electronic discharge summary may seem self‐evident. To realize its implementation, however, it is necessary to consider other aspects of organizational decision making. We employed the following structure to articulate a robust and sound business case for e‐discharge.

Qualitative Benefits

Quantitative Benefits

Qualitative Costs

Quantitative Costs

Quantitative Costs will be highly variable across institutions, geographical areas, and software platforms as the infrastructure of existing EMRs are highly variable. The cost of implementation depends heavily on whether inpatient documentation (and thus discharge documentation) is a feature of an institutional EMR, or whether a stand‐alone discharge documentation infrastructure is needed. An explanation of the differences between these types of EMRs and the importance to the cost of infrastructure implementation is further described in the following section. Rather than providing a direct accounting of costs, we have provided a tabular summary of costs that should be considered with the adoption of an electronic discharge summary based on the type of institutional EMR (Table 1).

Conclusion

While many QI initiatives have the potential to improve clinical care, resource limitations and competing priorities necessitate that hospital decision makers see the value of hospitalist driven improvements. A sound business case is the key to successfully influencing decision making and furthering necessary innovations. We have detailed the elements of a business case and applied them to a proposed innovationthe electronic discharge summary. While the cost of multifunctional EMR with full electronic care documentation may be impossible to implement given high initial costs and competing priorities, investing in an e‐discharge solution has real‐time benefits in the impact on patients, system improvements, qualitative benefits, and return on investment. Being able to articulate key qualitative and quantitative elements creates a sound business case that can be applied to QI initiatives in general, and assist hospitalists in garnering support and resources to continue to improve care.

Delivering the highest possible quality of care is among the top priorities of all medical centers. That said, any quality innovation must be seen as adding value from a variety of perspectives. Especially in the current economic climate, a sound business case is paramount to the advancement of any quality innovation. Given the nature of their work, hospitalists are ideally suited to undertake system improvement innovations. To assist hospitalists in successfully implementing quality and safety initiatives, we have designed a framework of elements required for a business case. We describe our experience developing and implementing an electronic discharge summary and utilize a structured framework to articulate the business case for its implementation.

Defining a Business Case Framework

A business case is a structured proposal outlining the qualitative and quantitative factors that justify a course of action. An effective business case for a quality improvement initiative articulates how both factors are aligned with preexisting organizational goals. In modeling the business case framework for the electronic discharge summary, Figure 1 outlines the qualitative and quantitative costs and benefits that can affect institutional decision making.

Figure 1

The Business Case for an Electronic Discharge Summary at University of California San Francisco (UCSF)

Application of the Business Framework to the Case for an Electronic Discharge

Considering the potential improvements in care delivery, the argument for an electronic discharge summary may seem self‐evident. To realize its implementation, however, it is necessary to consider other aspects of organizational decision making. We employed the following structure to articulate a robust and sound business case for e‐discharge.

Qualitative Benefits

Quantitative Benefits

Qualitative Costs

Quantitative Costs

Quantitative Costs will be highly variable across institutions, geographical areas, and software platforms as the infrastructure of existing EMRs are highly variable. The cost of implementation depends heavily on whether inpatient documentation (and thus discharge documentation) is a feature of an institutional EMR, or whether a stand‐alone discharge documentation infrastructure is needed. An explanation of the differences between these types of EMRs and the importance to the cost of infrastructure implementation is further described in the following section. Rather than providing a direct accounting of costs, we have provided a tabular summary of costs that should be considered with the adoption of an electronic discharge summary based on the type of institutional EMR (Table 1).

Conclusion

While many QI initiatives have the potential to improve clinical care, resource limitations and competing priorities necessitate that hospital decision makers see the value of hospitalist driven improvements. A sound business case is the key to successfully influencing decision making and furthering necessary innovations. We have detailed the elements of a business case and applied them to a proposed innovationthe electronic discharge summary. While the cost of multifunctional EMR with full electronic care documentation may be impossible to implement given high initial costs and competing priorities, investing in an e‐discharge solution has real‐time benefits in the impact on patients, system improvements, qualitative benefits, and return on investment. Being able to articulate key qualitative and quantitative elements creates a sound business case that can be applied to QI initiatives in general, and assist hospitalists in garnering support and resources to continue to improve care.

Delivering the highest possible quality of care is among the top priorities of all medical centers. That said, any quality innovation must be seen as adding value from a variety of perspectives. Especially in the current economic climate, a sound business case is paramount to the advancement of any quality innovation. Given the nature of their work, hospitalists are ideally suited to undertake system improvement innovations. To assist hospitalists in successfully implementing quality and safety initiatives, we have designed a framework of elements required for a business case. We describe our experience developing and implementing an electronic discharge summary and utilize a structured framework to articulate the business case for its implementation.

Defining a Business Case Framework

A business case is a structured proposal outlining the qualitative and quantitative factors that justify a course of action. An effective business case for a quality improvement initiative articulates how both factors are aligned with preexisting organizational goals. In modeling the business case framework for the electronic discharge summary, Figure 1 outlines the qualitative and quantitative costs and benefits that can affect institutional decision making.

Figure 1

The Business Case for an Electronic Discharge Summary at University of California San Francisco (UCSF)

Application of the Business Framework to the Case for an Electronic Discharge

Considering the potential improvements in care delivery, the argument for an electronic discharge summary may seem self‐evident. To realize its implementation, however, it is necessary to consider other aspects of organizational decision making. We employed the following structure to articulate a robust and sound business case for e‐discharge.

Qualitative Benefits

Quantitative Benefits

Qualitative Costs

Quantitative Costs

Quantitative Costs will be highly variable across institutions, geographical areas, and software platforms as the infrastructure of existing EMRs are highly variable. The cost of implementation depends heavily on whether inpatient documentation (and thus discharge documentation) is a feature of an institutional EMR, or whether a stand‐alone discharge documentation infrastructure is needed. An explanation of the differences between these types of EMRs and the importance to the cost of infrastructure implementation is further described in the following section. Rather than providing a direct accounting of costs, we have provided a tabular summary of costs that should be considered with the adoption of an electronic discharge summary based on the type of institutional EMR (Table 1).

Conclusion

While many QI initiatives have the potential to improve clinical care, resource limitations and competing priorities necessitate that hospital decision makers see the value of hospitalist driven improvements. A sound business case is the key to successfully influencing decision making and furthering necessary innovations. We have detailed the elements of a business case and applied them to a proposed innovationthe electronic discharge summary. While the cost of multifunctional EMR with full electronic care documentation may be impossible to implement given high initial costs and competing priorities, investing in an e‐discharge solution has real‐time benefits in the impact on patients, system improvements, qualitative benefits, and return on investment. Being able to articulate key qualitative and quantitative elements creates a sound business case that can be applied to QI initiatives in general, and assist hospitalists in garnering support and resources to continue to improve care.

Communication failures are a frequent cause of adverse events14; the Joint Commission (TJC) reports that such failures contributed to 65% of reported sentinel events.5 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.613 While these strategies largely address communication between healthcare providers, there is a growing emphasis on developing strategies to engage patients in their care, and improving communication with them and their families.

In 2007, TJC announced a new National Patient Safety Goal (NPSG) that encourage(s) patients' active involvement in their own care as a patient safety strategy.14 This builds upon a landmark Institute of Medicine report that highlighted patient‐centeredness as 1 of the 6 domains for delivering high‐quality care.15 Current literature on developing such patient‐centered strategies enumerates several approaches, including better access to health information, use of innovative technology solutions, and focused efforts at improving communication.1618

The placement of whiteboards in patient rooms is an increasingly common strategy to improve communication. These boards, typically placed on a wall near a patient's hospital bed, allow any number of providers to communicate a wide range of information. Both Kaiser Permanente's Nurse Knowledge Exchange program and the Institute for Healthcare Improvement's Transforming Care at the Bedside promote whiteboard use, though with little specific guidance about practical implementation.19^,20 Despite their growing prevalence, there is no published literature guiding the most effective uses of whiteboards, or describing their impact on communication, teamwork, or patient satisfaction and care. We present findings from a survey of patient whiteboard use on an academic medical service, and offer a series of recommendations based on our findings and experiences.

Methods

We anonymously surveyed bedside nurses from 3 inpatient medical units, internal medicine housestaff, and faculty from the Division of Hospital Medicine at the University of California, San Francisco (UCSF). We solicited experiences of physician and nursing leaders who were engaged in whiteboard interventions over the past 2 years to identify relevant topics for study. Their experiences were based on isolated unit‐based efforts to implement whiteboards through a variety of strategies (eg, whiteboard templates, simple identification of provider teams, goals for the day). Their input guided the survey development and the suggested recommendations. The topics identified were then translated into multiple‐choice questions, and further edited for clarity by the authors. A Likert scale was used that measured frequency of use, usefulness, and attitudes toward patient whiteboards. An open‐ended question seeking additional comments about patient whiteboards was also asked. The survey was administered to nurses at staff meetings and through physical mailboxes on their respective patient care units with a 1‐month collection period. The survey was administered to housestaff and attendings via e‐mail listserves using an online commercial survey administration tool.21 The nursing surveys were later entered into the same online survey administration tool, which ultimately provided summary reports and descriptive findings to meet the study objectives. Our project was reviewed and approved by the UCSF Committee on Human Research.

Results

Survey responses were collected from 104 nurse respondents (81% response rate), 118 internal medicine housestaff (74% response rate), and 31 hospitalists (86% response rate). Nurses were far more likely to write on whiteboards, read what was written on them, and find the related information useful (Figure 1A‐C). Nurses, housestaff, and attendings all believed the bedside nurse was the single most important provider name listed on a whiteboard. However, the respondents differed in their rated value of other providers listed on the whiteboard (Figure 2). Nurses gave higher ratings to the utility of having patient care assistants (PCAs) listed as compared to housestaff and attendings. Overall, respondents felt it would be less useful to list consultants and pharmacists than the nurse, attending, and housestaff. All of the respondents believed family contact information was the most useful information on a whiteboard, whereas more nurses rated a goal for the day and anticipated discharge date as more useful than housestaff and attendings (Figure 3).

Figure 1

Figure 2

Figure 3

From an operational standpoint, the majority of respondents felt that nurses should be responsible for the information on a whiteboard, nurses and physicians together should create goals for the day, and the greatest barrier to using whiteboards was not having pens easily available (Figure 4A‐C). Most respondents also agreed that using templated whiteboards (with predefined fields) to guide content would increase their use (Figure 4D). All respondents believed that whiteboard use could improve teamwork and communication as well as patient care (Figure 5). Respondents also offered a variety of specific comments in response to an open‐ended question about whiteboard use (Table 1).

Figure 4

Figure 5

Discussion

Our findings demonstrate the potential value of patient whiteboards, which is supported by the vast majority of respondents, who agreed their use may improve patient care and teamwork. It is also clear that whiteboard use is not achieving this potential or being used as a patient‐centered tool. This is best illustrated by findings of their low rate of use and completion among attendings and housestaff (Figure 1A, B) and the lack of consensus as to what information on the whiteboards is useful. Patient whiteboards require defined goals, thoughtful planning, regular monitoring, and ongoing evaluation. The challenges around effective adoption and implementation is perhaps more about ensuring compliance and completion rather than simply gaining buy‐in and engagement for their value.

While the differential use of whiteboards between nurses and physicians was not surprising, a few specific findings warrant further discussion. First, it is interesting that nurses rated their own names and that of PCAs as the most useful, while physicians rated the nurse's name as being of equal value to their own. This may speak to the role PCAs play for nurses in helping the latter provide bedside care, rather than a reflection of the nurses' perception of the value of PCAs for patients. Second, while all respondents rated highly the value of family contact information on the whiteboard, nurses valued a goal for the day and anticipated discharge date more highly than did physicians. These findings likely reflect that nurses desire an understanding about plans of care and if they are not communicated face‐to‐face as the most effective strategy,22 they should at least be spelled out clearly on a whiteboard. This is supported by evidence that better collaboration between nurses and physicians improves patient outcomes.23 It may also be that physicians place more value on their own progress notes (rather than whiteboards) as a vehicle for communicating daily goals and discharge planning.

Other practical considerations involve who owns it and, if we do create goals for the day, whose goals should they represent? The majority of nurse and physician responses advocated for nurses to be responsible for accurate and complete information being updated on whiteboards. A larger percentage of attendings favored shared responsibility of the whiteboard, which was reinforced by their support of having goals for the day created jointly by nurses and physicians. Interestingly, a much smaller percentage of respondents felt goals for the day should be driven by patients (or family members). These data may point to the different perspectives that each individual provider bringsphysician, nurse, pharmacist, discharge plannerwith their respective goals differing in nature. Finally, it is also interesting that while attendings and housestaff believed that whiteboards can improve patient care teamwork/communication (Figure 5), a much smaller percentage actually read what is on them (Figure 1B). This may reflect the unclear goals of whiteboards, its absence as part of daily workflow, the infrequency of updated information on them, or perhaps an institution‐specific phenomenon that we will use to drive further improvement strategies.

Selected respondent comments (Table 1) highlight important messages about whiteboard use and provide helpful context to the survey responses. We found that the goal of whiteboard use is not always clear; is it to improve communication among providers, to improve communication with patients, a tool to engage patients in their care, or some combination of the above? Without a clear goal, providers are left to wonder whether whiteboard use is simply another task or really an intervention to improve care. This may in part, or perhaps fully, explain the differences discovered in whiteboard use and practices among our surveyed providers.

If, however, one were to make clear that the goal of patient whiteboards is to engage patients in their care and help achieve an important NPSG, methods to implement their use become better guided. A limitation of our study is that we did not survey patients about their perceptions of whiteboards use, an important needs assessment that would further drive this patient‐centered intervention. Regardless, we can draw a number of lessons from our findings and devise a set of reasonable recommendations.

Recommendations

We provide the following set of recommendations for hospitals adopting patient whiteboards, drawing on our survey findings and experiences with implementation at our own institution. We also acknowledge the role that local hospital cultures may play in adopting whiteboard use, and our recommendations are simply guidelines that can be applied or used in planning efforts. We believe effective use of a patient whiteboard requires a patient‐centered approach and the following:

• 1

  Whiteboards should be placed in clear view of patients from their hospital bed

  A simple yet critical issue as placing a whiteboard behind a patient's bed or off to the side fails to provide them with a constant visual cue to engage in the information.

• 2

  Buy and fasten erasable pens to the whiteboards themselves

  In our institution, purchasing pens for each provider was a less effective strategy than simply affixing the pen to the whiteboard itself. A supply of erasable pens must be available at the nursing station to quickly replace those with fading ink.

• 3

  Create whiteboard templates

  Our findings and experience suggest that structured formats for whiteboards may be more effective in ensuring both important and accurate information gets included. Blank whiteboards lead to less standardization in practice and fail to create prompts for providers to both write and review the content available. Anecdotally, we created a number of whiteboards with templated information, and this did seem to increase the consistency, standardization, and ease of use.

• 4

  Whiteboard templates should include the following items:
• a

  Day and Date

  This serves to orient patients (and their families) as well as providers with the date of information written on the whiteboard. It is also an important mechanism to ensure information is updated daily.

• b

  Patient's name (or initials)

  With bed turnover (or patient transfers to different beds and units) commonplace in hospital care, we believe that listing the patient's name on the board prevents the potential for patients (and their families) or providers to mistakenly take information from a previous patient's care on the whiteboard for their own.

• c

  Bedside nurse

  This was noted as the most useful provider listed on a patient whiteboard, which is quite logical given the role bedside nurses play for hospitalized patients.

• d

  Primary physician(s) (attending, resident, and intern, if applicable)

  This was noted as the next most important provider(s) and perhaps increasingly important both in teaching and nonteaching settings where shift‐work and signouts are growing in frequency among physicians.

• e

  Goal for the day

  While this was not a consensus from our survey respondents, we believe patients (rather than providers) should ultimately guide determination of their goal for the day as this engages them directly with the planachieving a patient‐centered initiative. In our experience, an effective strategy was having the bedside nurse directly engage patients each morning to help place a goal for the day on their whiteboard.

• f

  Anticipated discharge date

  While understanding the potential for this date to change, we believe the benefits of having patients (and their families) thinking about discharge, rather than feeling surprised by it on the morning of discharge, serves as an important mechanism to bridge communication about the discharge process.24

• g

  Family member's contact information (phone number)

• h

  Questions for providers

  This last entry allows a space for families to engage the healthcare team and, once again, create an opportunity for clarification of treatment and discharge plans.

• 5

  Bedside nurses should facilitate writing and updating information on the whiteboard

  Without our survey findings, this might have generated debate or controversy over whether nurses should be burdened with one more task to their responsibilities. However, our nurse respondents embraced this responsibility with spontaneous comments about their patient advocate role, and stated that whiteboards can serve as a tool to assist in that responsibility. Furthermore, not a single nurse respondent stated as barrier to use that I didn't think it was my responsibility. Nonetheless, whiteboard use must be a shared communication tool and not simply a tool between nurse and patient. Practically, we would recommend that bedside nurses facilitate updating whiteboards each morning, at a time when they are already helping patients create a goal for the day. Other providers must be trained to review information on the whiteboard, engage patients about their specific goal, and share the responsibility of keeping the information on the whiteboard updated.

• 6

  Create a system for auditing utilization and providing feedback early during rollout

  We found that adoption was very slow at the outset. One strategy to consider is having designated auditors check whiteboards in each room, measuring weekly compliance and providing this feedback to nurse managers. This auditing process may help identify barriers that can be addressed quickly (eg, unavailability of pens).

Finally, it is important to comment on the confidentiality concerns often raised in the context of whiteboard use. Confidentiality concerns largely arise from personal health information being used without a patient's explicit consent. If our recommendations are adopted, they require whiteboard use to be a patient‐centered and patient‐driven initiative. The type of information on the whiteboard should be determined with sensitivity but also with consent of the patient. We have not experienced any concerns by patients or providers in this regard because patients are told about the goals of the whiteboard initiative with our above principles in mind.

Conclusions

Patient whiteboards may improve communication among members of the healthcare team (eg, nurses, physicians, and others) and between providers and their patients (and family members). Further investigation is warranted to determine if adopting our recommendations leads to improved communication, teamwork, or patient satisfaction and care. In the meantime, as many hospitals continue to install and implement whiteboards, we hope our recommendations, accompanied by an emphasis on creating a patient‐centered communication tool, offer a roadmap for considering best practices in their use.

Communication failures are a frequent cause of adverse events14; the Joint Commission (TJC) reports that such failures contributed to 65% of reported sentinel events.5 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.613 While these strategies largely address communication between healthcare providers, there is a growing emphasis on developing strategies to engage patients in their care, and improving communication with them and their families.

In 2007, TJC announced a new National Patient Safety Goal (NPSG) that encourage(s) patients' active involvement in their own care as a patient safety strategy.14 This builds upon a landmark Institute of Medicine report that highlighted patient‐centeredness as 1 of the 6 domains for delivering high‐quality care.15 Current literature on developing such patient‐centered strategies enumerates several approaches, including better access to health information, use of innovative technology solutions, and focused efforts at improving communication.1618

The placement of whiteboards in patient rooms is an increasingly common strategy to improve communication. These boards, typically placed on a wall near a patient's hospital bed, allow any number of providers to communicate a wide range of information. Both Kaiser Permanente's Nurse Knowledge Exchange program and the Institute for Healthcare Improvement's Transforming Care at the Bedside promote whiteboard use, though with little specific guidance about practical implementation.19^,20 Despite their growing prevalence, there is no published literature guiding the most effective uses of whiteboards, or describing their impact on communication, teamwork, or patient satisfaction and care. We present findings from a survey of patient whiteboard use on an academic medical service, and offer a series of recommendations based on our findings and experiences.

Methods

We anonymously surveyed bedside nurses from 3 inpatient medical units, internal medicine housestaff, and faculty from the Division of Hospital Medicine at the University of California, San Francisco (UCSF). We solicited experiences of physician and nursing leaders who were engaged in whiteboard interventions over the past 2 years to identify relevant topics for study. Their experiences were based on isolated unit‐based efforts to implement whiteboards through a variety of strategies (eg, whiteboard templates, simple identification of provider teams, goals for the day). Their input guided the survey development and the suggested recommendations. The topics identified were then translated into multiple‐choice questions, and further edited for clarity by the authors. A Likert scale was used that measured frequency of use, usefulness, and attitudes toward patient whiteboards. An open‐ended question seeking additional comments about patient whiteboards was also asked. The survey was administered to nurses at staff meetings and through physical mailboxes on their respective patient care units with a 1‐month collection period. The survey was administered to housestaff and attendings via e‐mail listserves using an online commercial survey administration tool.21 The nursing surveys were later entered into the same online survey administration tool, which ultimately provided summary reports and descriptive findings to meet the study objectives. Our project was reviewed and approved by the UCSF Committee on Human Research.

Results

Survey responses were collected from 104 nurse respondents (81% response rate), 118 internal medicine housestaff (74% response rate), and 31 hospitalists (86% response rate). Nurses were far more likely to write on whiteboards, read what was written on them, and find the related information useful (Figure 1A‐C). Nurses, housestaff, and attendings all believed the bedside nurse was the single most important provider name listed on a whiteboard. However, the respondents differed in their rated value of other providers listed on the whiteboard (Figure 2). Nurses gave higher ratings to the utility of having patient care assistants (PCAs) listed as compared to housestaff and attendings. Overall, respondents felt it would be less useful to list consultants and pharmacists than the nurse, attending, and housestaff. All of the respondents believed family contact information was the most useful information on a whiteboard, whereas more nurses rated a goal for the day and anticipated discharge date as more useful than housestaff and attendings (Figure 3).

Figure 1

Figure 2

Figure 3

From an operational standpoint, the majority of respondents felt that nurses should be responsible for the information on a whiteboard, nurses and physicians together should create goals for the day, and the greatest barrier to using whiteboards was not having pens easily available (Figure 4A‐C). Most respondents also agreed that using templated whiteboards (with predefined fields) to guide content would increase their use (Figure 4D). All respondents believed that whiteboard use could improve teamwork and communication as well as patient care (Figure 5). Respondents also offered a variety of specific comments in response to an open‐ended question about whiteboard use (Table 1).

Figure 4

Figure 5

Discussion

Our findings demonstrate the potential value of patient whiteboards, which is supported by the vast majority of respondents, who agreed their use may improve patient care and teamwork. It is also clear that whiteboard use is not achieving this potential or being used as a patient‐centered tool. This is best illustrated by findings of their low rate of use and completion among attendings and housestaff (Figure 1A, B) and the lack of consensus as to what information on the whiteboards is useful. Patient whiteboards require defined goals, thoughtful planning, regular monitoring, and ongoing evaluation. The challenges around effective adoption and implementation is perhaps more about ensuring compliance and completion rather than simply gaining buy‐in and engagement for their value.

While the differential use of whiteboards between nurses and physicians was not surprising, a few specific findings warrant further discussion. First, it is interesting that nurses rated their own names and that of PCAs as the most useful, while physicians rated the nurse's name as being of equal value to their own. This may speak to the role PCAs play for nurses in helping the latter provide bedside care, rather than a reflection of the nurses' perception of the value of PCAs for patients. Second, while all respondents rated highly the value of family contact information on the whiteboard, nurses valued a goal for the day and anticipated discharge date more highly than did physicians. These findings likely reflect that nurses desire an understanding about plans of care and if they are not communicated face‐to‐face as the most effective strategy,22 they should at least be spelled out clearly on a whiteboard. This is supported by evidence that better collaboration between nurses and physicians improves patient outcomes.23 It may also be that physicians place more value on their own progress notes (rather than whiteboards) as a vehicle for communicating daily goals and discharge planning.

Other practical considerations involve who owns it and, if we do create goals for the day, whose goals should they represent? The majority of nurse and physician responses advocated for nurses to be responsible for accurate and complete information being updated on whiteboards. A larger percentage of attendings favored shared responsibility of the whiteboard, which was reinforced by their support of having goals for the day created jointly by nurses and physicians. Interestingly, a much smaller percentage of respondents felt goals for the day should be driven by patients (or family members). These data may point to the different perspectives that each individual provider bringsphysician, nurse, pharmacist, discharge plannerwith their respective goals differing in nature. Finally, it is also interesting that while attendings and housestaff believed that whiteboards can improve patient care teamwork/communication (Figure 5), a much smaller percentage actually read what is on them (Figure 1B). This may reflect the unclear goals of whiteboards, its absence as part of daily workflow, the infrequency of updated information on them, or perhaps an institution‐specific phenomenon that we will use to drive further improvement strategies.

Selected respondent comments (Table 1) highlight important messages about whiteboard use and provide helpful context to the survey responses. We found that the goal of whiteboard use is not always clear; is it to improve communication among providers, to improve communication with patients, a tool to engage patients in their care, or some combination of the above? Without a clear goal, providers are left to wonder whether whiteboard use is simply another task or really an intervention to improve care. This may in part, or perhaps fully, explain the differences discovered in whiteboard use and practices among our surveyed providers.

If, however, one were to make clear that the goal of patient whiteboards is to engage patients in their care and help achieve an important NPSG, methods to implement their use become better guided. A limitation of our study is that we did not survey patients about their perceptions of whiteboards use, an important needs assessment that would further drive this patient‐centered intervention. Regardless, we can draw a number of lessons from our findings and devise a set of reasonable recommendations.

Recommendations

We provide the following set of recommendations for hospitals adopting patient whiteboards, drawing on our survey findings and experiences with implementation at our own institution. We also acknowledge the role that local hospital cultures may play in adopting whiteboard use, and our recommendations are simply guidelines that can be applied or used in planning efforts. We believe effective use of a patient whiteboard requires a patient‐centered approach and the following:

• 1

  Whiteboards should be placed in clear view of patients from their hospital bed

  A simple yet critical issue as placing a whiteboard behind a patient's bed or off to the side fails to provide them with a constant visual cue to engage in the information.

• 2

  Buy and fasten erasable pens to the whiteboards themselves

  In our institution, purchasing pens for each provider was a less effective strategy than simply affixing the pen to the whiteboard itself. A supply of erasable pens must be available at the nursing station to quickly replace those with fading ink.

• 3

  Create whiteboard templates

  Our findings and experience suggest that structured formats for whiteboards may be more effective in ensuring both important and accurate information gets included. Blank whiteboards lead to less standardization in practice and fail to create prompts for providers to both write and review the content available. Anecdotally, we created a number of whiteboards with templated information, and this did seem to increase the consistency, standardization, and ease of use.

• 4

  Whiteboard templates should include the following items:
• a

  Day and Date

  This serves to orient patients (and their families) as well as providers with the date of information written on the whiteboard. It is also an important mechanism to ensure information is updated daily.

• b

  Patient's name (or initials)

  With bed turnover (or patient transfers to different beds and units) commonplace in hospital care, we believe that listing the patient's name on the board prevents the potential for patients (and their families) or providers to mistakenly take information from a previous patient's care on the whiteboard for their own.

• c

  Bedside nurse

  This was noted as the most useful provider listed on a patient whiteboard, which is quite logical given the role bedside nurses play for hospitalized patients.

• d

  Primary physician(s) (attending, resident, and intern, if applicable)

  This was noted as the next most important provider(s) and perhaps increasingly important both in teaching and nonteaching settings where shift‐work and signouts are growing in frequency among physicians.

• e

  Goal for the day

  While this was not a consensus from our survey respondents, we believe patients (rather than providers) should ultimately guide determination of their goal for the day as this engages them directly with the planachieving a patient‐centered initiative. In our experience, an effective strategy was having the bedside nurse directly engage patients each morning to help place a goal for the day on their whiteboard.

• f

  Anticipated discharge date

  While understanding the potential for this date to change, we believe the benefits of having patients (and their families) thinking about discharge, rather than feeling surprised by it on the morning of discharge, serves as an important mechanism to bridge communication about the discharge process.24

• g

  Family member's contact information (phone number)

• h

  Questions for providers

  This last entry allows a space for families to engage the healthcare team and, once again, create an opportunity for clarification of treatment and discharge plans.

• 5

  Bedside nurses should facilitate writing and updating information on the whiteboard

  Without our survey findings, this might have generated debate or controversy over whether nurses should be burdened with one more task to their responsibilities. However, our nurse respondents embraced this responsibility with spontaneous comments about their patient advocate role, and stated that whiteboards can serve as a tool to assist in that responsibility. Furthermore, not a single nurse respondent stated as barrier to use that I didn't think it was my responsibility. Nonetheless, whiteboard use must be a shared communication tool and not simply a tool between nurse and patient. Practically, we would recommend that bedside nurses facilitate updating whiteboards each morning, at a time when they are already helping patients create a goal for the day. Other providers must be trained to review information on the whiteboard, engage patients about their specific goal, and share the responsibility of keeping the information on the whiteboard updated.

• 6

  Create a system for auditing utilization and providing feedback early during rollout

  We found that adoption was very slow at the outset. One strategy to consider is having designated auditors check whiteboards in each room, measuring weekly compliance and providing this feedback to nurse managers. This auditing process may help identify barriers that can be addressed quickly (eg, unavailability of pens).

Finally, it is important to comment on the confidentiality concerns often raised in the context of whiteboard use. Confidentiality concerns largely arise from personal health information being used without a patient's explicit consent. If our recommendations are adopted, they require whiteboard use to be a patient‐centered and patient‐driven initiative. The type of information on the whiteboard should be determined with sensitivity but also with consent of the patient. We have not experienced any concerns by patients or providers in this regard because patients are told about the goals of the whiteboard initiative with our above principles in mind.

Conclusions

Patient whiteboards may improve communication among members of the healthcare team (eg, nurses, physicians, and others) and between providers and their patients (and family members). Further investigation is warranted to determine if adopting our recommendations leads to improved communication, teamwork, or patient satisfaction and care. In the meantime, as many hospitals continue to install and implement whiteboards, we hope our recommendations, accompanied by an emphasis on creating a patient‐centered communication tool, offer a roadmap for considering best practices in their use.

Communication failures are a frequent cause of adverse events14; the Joint Commission (TJC) reports that such failures contributed to 65% of reported sentinel events.5 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.613 While these strategies largely address communication between healthcare providers, there is a growing emphasis on developing strategies to engage patients in their care, and improving communication with them and their families.

In 2007, TJC announced a new National Patient Safety Goal (NPSG) that encourage(s) patients' active involvement in their own care as a patient safety strategy.14 This builds upon a landmark Institute of Medicine report that highlighted patient‐centeredness as 1 of the 6 domains for delivering high‐quality care.15 Current literature on developing such patient‐centered strategies enumerates several approaches, including better access to health information, use of innovative technology solutions, and focused efforts at improving communication.1618

The placement of whiteboards in patient rooms is an increasingly common strategy to improve communication. These boards, typically placed on a wall near a patient's hospital bed, allow any number of providers to communicate a wide range of information. Both Kaiser Permanente's Nurse Knowledge Exchange program and the Institute for Healthcare Improvement's Transforming Care at the Bedside promote whiteboard use, though with little specific guidance about practical implementation.19^,20 Despite their growing prevalence, there is no published literature guiding the most effective uses of whiteboards, or describing their impact on communication, teamwork, or patient satisfaction and care. We present findings from a survey of patient whiteboard use on an academic medical service, and offer a series of recommendations based on our findings and experiences.

Methods

We anonymously surveyed bedside nurses from 3 inpatient medical units, internal medicine housestaff, and faculty from the Division of Hospital Medicine at the University of California, San Francisco (UCSF). We solicited experiences of physician and nursing leaders who were engaged in whiteboard interventions over the past 2 years to identify relevant topics for study. Their experiences were based on isolated unit‐based efforts to implement whiteboards through a variety of strategies (eg, whiteboard templates, simple identification of provider teams, goals for the day). Their input guided the survey development and the suggested recommendations. The topics identified were then translated into multiple‐choice questions, and further edited for clarity by the authors. A Likert scale was used that measured frequency of use, usefulness, and attitudes toward patient whiteboards. An open‐ended question seeking additional comments about patient whiteboards was also asked. The survey was administered to nurses at staff meetings and through physical mailboxes on their respective patient care units with a 1‐month collection period. The survey was administered to housestaff and attendings via e‐mail listserves using an online commercial survey administration tool.21 The nursing surveys were later entered into the same online survey administration tool, which ultimately provided summary reports and descriptive findings to meet the study objectives. Our project was reviewed and approved by the UCSF Committee on Human Research.

Results

Survey responses were collected from 104 nurse respondents (81% response rate), 118 internal medicine housestaff (74% response rate), and 31 hospitalists (86% response rate). Nurses were far more likely to write on whiteboards, read what was written on them, and find the related information useful (Figure 1A‐C). Nurses, housestaff, and attendings all believed the bedside nurse was the single most important provider name listed on a whiteboard. However, the respondents differed in their rated value of other providers listed on the whiteboard (Figure 2). Nurses gave higher ratings to the utility of having patient care assistants (PCAs) listed as compared to housestaff and attendings. Overall, respondents felt it would be less useful to list consultants and pharmacists than the nurse, attending, and housestaff. All of the respondents believed family contact information was the most useful information on a whiteboard, whereas more nurses rated a goal for the day and anticipated discharge date as more useful than housestaff and attendings (Figure 3).

Figure 1

Figure 2

Figure 3

From an operational standpoint, the majority of respondents felt that nurses should be responsible for the information on a whiteboard, nurses and physicians together should create goals for the day, and the greatest barrier to using whiteboards was not having pens easily available (Figure 4A‐C). Most respondents also agreed that using templated whiteboards (with predefined fields) to guide content would increase their use (Figure 4D). All respondents believed that whiteboard use could improve teamwork and communication as well as patient care (Figure 5). Respondents also offered a variety of specific comments in response to an open‐ended question about whiteboard use (Table 1).

Figure 4

Figure 5

Discussion

Our findings demonstrate the potential value of patient whiteboards, which is supported by the vast majority of respondents, who agreed their use may improve patient care and teamwork. It is also clear that whiteboard use is not achieving this potential or being used as a patient‐centered tool. This is best illustrated by findings of their low rate of use and completion among attendings and housestaff (Figure 1A, B) and the lack of consensus as to what information on the whiteboards is useful. Patient whiteboards require defined goals, thoughtful planning, regular monitoring, and ongoing evaluation. The challenges around effective adoption and implementation is perhaps more about ensuring compliance and completion rather than simply gaining buy‐in and engagement for their value.

While the differential use of whiteboards between nurses and physicians was not surprising, a few specific findings warrant further discussion. First, it is interesting that nurses rated their own names and that of PCAs as the most useful, while physicians rated the nurse's name as being of equal value to their own. This may speak to the role PCAs play for nurses in helping the latter provide bedside care, rather than a reflection of the nurses' perception of the value of PCAs for patients. Second, while all respondents rated highly the value of family contact information on the whiteboard, nurses valued a goal for the day and anticipated discharge date more highly than did physicians. These findings likely reflect that nurses desire an understanding about plans of care and if they are not communicated face‐to‐face as the most effective strategy,22 they should at least be spelled out clearly on a whiteboard. This is supported by evidence that better collaboration between nurses and physicians improves patient outcomes.23 It may also be that physicians place more value on their own progress notes (rather than whiteboards) as a vehicle for communicating daily goals and discharge planning.

Other practical considerations involve who owns it and, if we do create goals for the day, whose goals should they represent? The majority of nurse and physician responses advocated for nurses to be responsible for accurate and complete information being updated on whiteboards. A larger percentage of attendings favored shared responsibility of the whiteboard, which was reinforced by their support of having goals for the day created jointly by nurses and physicians. Interestingly, a much smaller percentage of respondents felt goals for the day should be driven by patients (or family members). These data may point to the different perspectives that each individual provider bringsphysician, nurse, pharmacist, discharge plannerwith their respective goals differing in nature. Finally, it is also interesting that while attendings and housestaff believed that whiteboards can improve patient care teamwork/communication (Figure 5), a much smaller percentage actually read what is on them (Figure 1B). This may reflect the unclear goals of whiteboards, its absence as part of daily workflow, the infrequency of updated information on them, or perhaps an institution‐specific phenomenon that we will use to drive further improvement strategies.

Selected respondent comments (Table 1) highlight important messages about whiteboard use and provide helpful context to the survey responses. We found that the goal of whiteboard use is not always clear; is it to improve communication among providers, to improve communication with patients, a tool to engage patients in their care, or some combination of the above? Without a clear goal, providers are left to wonder whether whiteboard use is simply another task or really an intervention to improve care. This may in part, or perhaps fully, explain the differences discovered in whiteboard use and practices among our surveyed providers.

If, however, one were to make clear that the goal of patient whiteboards is to engage patients in their care and help achieve an important NPSG, methods to implement their use become better guided. A limitation of our study is that we did not survey patients about their perceptions of whiteboards use, an important needs assessment that would further drive this patient‐centered intervention. Regardless, we can draw a number of lessons from our findings and devise a set of reasonable recommendations.

Recommendations

We provide the following set of recommendations for hospitals adopting patient whiteboards, drawing on our survey findings and experiences with implementation at our own institution. We also acknowledge the role that local hospital cultures may play in adopting whiteboard use, and our recommendations are simply guidelines that can be applied or used in planning efforts. We believe effective use of a patient whiteboard requires a patient‐centered approach and the following:

• 1

  Whiteboards should be placed in clear view of patients from their hospital bed

  A simple yet critical issue as placing a whiteboard behind a patient's bed or off to the side fails to provide them with a constant visual cue to engage in the information.

• 2

  Buy and fasten erasable pens to the whiteboards themselves

  In our institution, purchasing pens for each provider was a less effective strategy than simply affixing the pen to the whiteboard itself. A supply of erasable pens must be available at the nursing station to quickly replace those with fading ink.

• 3

  Create whiteboard templates

  Our findings and experience suggest that structured formats for whiteboards may be more effective in ensuring both important and accurate information gets included. Blank whiteboards lead to less standardization in practice and fail to create prompts for providers to both write and review the content available. Anecdotally, we created a number of whiteboards with templated information, and this did seem to increase the consistency, standardization, and ease of use.

• 4

  Whiteboard templates should include the following items:
• a

  Day and Date

  This serves to orient patients (and their families) as well as providers with the date of information written on the whiteboard. It is also an important mechanism to ensure information is updated daily.

• b

  Patient's name (or initials)

  With bed turnover (or patient transfers to different beds and units) commonplace in hospital care, we believe that listing the patient's name on the board prevents the potential for patients (and their families) or providers to mistakenly take information from a previous patient's care on the whiteboard for their own.

• c

  Bedside nurse

  This was noted as the most useful provider listed on a patient whiteboard, which is quite logical given the role bedside nurses play for hospitalized patients.

• d

  Primary physician(s) (attending, resident, and intern, if applicable)

  This was noted as the next most important provider(s) and perhaps increasingly important both in teaching and nonteaching settings where shift‐work and signouts are growing in frequency among physicians.

• e

  Goal for the day

  While this was not a consensus from our survey respondents, we believe patients (rather than providers) should ultimately guide determination of their goal for the day as this engages them directly with the planachieving a patient‐centered initiative. In our experience, an effective strategy was having the bedside nurse directly engage patients each morning to help place a goal for the day on their whiteboard.

• f

  Anticipated discharge date

  While understanding the potential for this date to change, we believe the benefits of having patients (and their families) thinking about discharge, rather than feeling surprised by it on the morning of discharge, serves as an important mechanism to bridge communication about the discharge process.24

• g

  Family member's contact information (phone number)

• h

  Questions for providers

  This last entry allows a space for families to engage the healthcare team and, once again, create an opportunity for clarification of treatment and discharge plans.

• 5

  Bedside nurses should facilitate writing and updating information on the whiteboard

  Without our survey findings, this might have generated debate or controversy over whether nurses should be burdened with one more task to their responsibilities. However, our nurse respondents embraced this responsibility with spontaneous comments about their patient advocate role, and stated that whiteboards can serve as a tool to assist in that responsibility. Furthermore, not a single nurse respondent stated as barrier to use that I didn't think it was my responsibility. Nonetheless, whiteboard use must be a shared communication tool and not simply a tool between nurse and patient. Practically, we would recommend that bedside nurses facilitate updating whiteboards each morning, at a time when they are already helping patients create a goal for the day. Other providers must be trained to review information on the whiteboard, engage patients about their specific goal, and share the responsibility of keeping the information on the whiteboard updated.

• 6

  Create a system for auditing utilization and providing feedback early during rollout

  We found that adoption was very slow at the outset. One strategy to consider is having designated auditors check whiteboards in each room, measuring weekly compliance and providing this feedback to nurse managers. This auditing process may help identify barriers that can be addressed quickly (eg, unavailability of pens).

Finally, it is important to comment on the confidentiality concerns often raised in the context of whiteboard use. Confidentiality concerns largely arise from personal health information being used without a patient's explicit consent. If our recommendations are adopted, they require whiteboard use to be a patient‐centered and patient‐driven initiative. The type of information on the whiteboard should be determined with sensitivity but also with consent of the patient. We have not experienced any concerns by patients or providers in this regard because patients are told about the goals of the whiteboard initiative with our above principles in mind.

Conclusions

Patient whiteboards may improve communication among members of the healthcare team (eg, nurses, physicians, and others) and between providers and their patients (and family members). Further investigation is warranted to determine if adopting our recommendations leads to improved communication, teamwork, or patient satisfaction and care. In the meantime, as many hospitals continue to install and implement whiteboards, we hope our recommendations, accompanied by an emphasis on creating a patient‐centered communication tool, offer a roadmap for considering best practices in their use.