Standardized Communication Process Guided by Daily Goals Form Improves Nurse–Physician Communication and Increases Nurse and Patient Satisfaction on Surgical Unit
Standardized Communication Process Guided by Daily Goals Form Improves Nurse–Physician Communication and Increases Nurse and Patient Satisfaction on Surgical Unit
Clinicians on a surgical unit at Johns Hopkins Hospital use a standardized communication process to ensure thorough and timely patient care. Developed from work in the hospital's intensive care unit, this process involves use of a daily goals form to conduct and document standardized discussions about patient-related issues, with the goal of ensuring a prompt response to patient needs to expedite recovery and discharge. This form subsequently guides the ongoing care of the patient, including communication with the family and discharge planning. To facilitate use of this standardized process, patients from one provider team are assigned to the surgical unit whenever possible. The program has enhanced communication, as evidenced by a considerable reduction in daily pages from unit nurses to physicians during a pilot test, and increased nurse and patient satisfaction.
Date First Implemented
Poor communication frequently causes safety and quality problems that can lead to unnecessary deaths, injuries, and expenses.1 Communication challenges become especially significant when many providers are involved in a patient's care. Although standardized communication tools can help, few hospitals use them, especially outside the intensive care unit (ICU).
- A frequent source of error, with negative consequences: Communication failure and deficits in teamwork, particularly between nurses and physicians, represent a major source of medical errors and other safety problems.2 Poor communication has many negative consequences, including delaying care, extending the length of a patient's stay, and causing patient injury and death. 3 , 4
- Special challenges with multiple caregivers: Communication deficits are particularly problematic during patient handoffs between shifts, and when multiple clinicians from various disciplines participate in a patient's care, as commonly occurs on medical/surgical units that do not use unit-based care teams. The greater the number of providers involved, the greater the likelihood of poor communication. As with most academic medical centers, many providers take responsibility for patient care at Johns Hopkins. In fact, Johns Hopkins general surgery patients may be assigned to one of six teams that include three or four providers, including an attending physician, a nurse practitioner or physician assistant, and a rotating roster of residents and medical students. Before the development of this program, any patient from any team could be admitted to three to four inpatient medical/surgical units. As a result, nurses on each unit sometimes had to work with up to 20 different providers. There was no formal plan of care, and nurses had to frequently contact physicians to clarify the care plan or to address patients' needs. Moreover, including these nurses in daily team rounds proved to be impossible because multiple teams rounded simultaneously.2
- Unrealized benefits of communication tools: Although practical, easy-to-use tools that assist in standardizing communications about patient status can improve quality and safety, 1 , 4 few hospitals use them, particularly on medical and surgical units outside the ICU.
Description of the Innovative Activity
Clinicians on a surgical unit at Johns Hopkins Hospital use a standardized communication process to ensure thorough and timely patient care. Developed from work in the hospital's ICU, this process involves use of a daily goals form to conduct and document standardized discussions about patient-related issues, with the goal of ensuring a prompt response to patient needs so as to expedite recovery and discharge. This form subsequently guides the ongoing care of the patient, including communication with the family and discharge planning. To facilitate use of this standardized process, patients from one provider team are assigned to the surgical unit whenever possible. Key elements of the program include the following:
- Consolidation of team's patients on single unit: The unit accepts all patients from one designated provider team (which focuses primarily on gastrointestinal surgery), thus allowing nurses to work with fewer admitting physicians (and vice versa). This approach facilitates the development of relationships and more efficient communication between the unit nurses and the physicians. Although some patients may be admitted to the unit from other teams as necessary, nurses still interact with many fewer physicians than under the old approach.
- Daily goals form: The daily goals form includes the patient's name, date, room number, and a space to list any nursing concerns on the left-hand side. The right-hand side provides space to list daily goals and a checklist to remind team members to discuss key elements of patient care during daily rounding (see next bullet), including diet, physical activity, fluid status, pain issues, wounds/drains, scheduled procedures, needed referrals (e.g., to physical/occupational therapy, social work, home care), anticipated discharge date, prescriptions needed at discharge, and any other issues to be addressed. Thus, the form prompts the team to develop a consistent, actionable, and thorough care plan each day.
- Rounding, ongoing care, and family communication based on form: The form guides daily provider rounds, ongoing care, and communication with the family, as outlined below:
- Daily rounds: Each morning, the unit's charge nurse completes the left-hand column of the daily goals form for each patient, listing any nursing questions/concerns about patient status and care. At 6 a.m., the charge nurse rounds with the provider team, using the form to address nursing concerns and documenting the goals for the day and the plan of care based on team decisionmaking. During rounds, the team accesses a provider order entry system via a wireless computer to place relevant orders, such as laboratory tests and rehabilitation services.
- Ongoing care: After rounds, the charge nurse reviews the daily goals form with the morning shift nurse. Bedside nurses complete their daily patient care duties with a view toward accomplishing the goals listed on the form.
- Family communication: Nurses use the form as a tool to facilitate communication with families. The patient's primary nurse references the form when discussing the patient's clinical status, care plan, and daily goals with the patient and family members, and also writes the goals in patient-friendly language on a white board in the patient's room.
- Special focus on soon-to-be-discharged patients: Patients who will be discharged within the next 48 hours receive special focus to ensure that required care steps are completed to facilitate timely discharge. For example, the nurse may advise the patient or family member to arrange for transportation home if necessary, and/or may schedule a consultation with a social worker or a rehabilitation specialist to determine home care needs and provide timely discharge education. In addition, the physician may write any needed prescriptions and discharge summaries.
Context of the Innovation
The Johns Hopkins Hospital, an urban academic institution located in East Baltimore, is a 1,015-bed tertiary care facility that treats roughly 268,000 inpatients annually, including patients from across the United States and 126 nations. Nurses on one unit (the Weinberg 4C unit, a 18-bed surgical oncology unit with more than 35 staff) developed this program in response to care inefficiencies and suboptimal communication stemming from the need to work with many providers each day. Along with representatives from all Johns Hopkins units/departments, unit staff participate in Johns Hopkins's Comprehensive Unit-based Safety Program (also known as CUSP), a program to improve patient safety via better communication and teamwork. Weinberg 4C nurses believed they could improve unit communication by adapting CUSP initiatives that had been previously implemented successfully in the Johns Hopkins ICU.
The program has enhanced communication, as evidenced by a considerable reduction in daily pages from unit nurses to physicians during a pilot test, and increased nurse and patient satisfaction.
- Fewer pages from nurse to physicians: A pilot test conducted in May 2008 found that the number of daily pages from unit nurses to physicians on the designated care team fell from between 2 and 12 before implementation to between 0 and 4 afterward.2 Because physicians on this team rarely admit patients to other units (and thus do not receive pages from nurses on those units), the total number of daily pages received by the team fell from approximately 60 before implementation to between 0 and 4 afterward.
- Higher nurse satisfaction: Data from the annual National Database of Nursing Quality Indicators survey found that satisfaction increased among nurses on the unit that implemented the program, to levels higher than on other hospital units. Specifically, scores for job enjoyment rose from the 30th percentile in 2007 to the 90th percentile in 2009 (the percentile reflects adult surgical units in hospitals surveyed nationally). Scores on decisionmaking (a measure that reflects nurses' perceptions of empowerment) increased from the 25th to the 90th percentile, while scores on perceived quality of care and on tasks (a measure that reflects nurses' perceptions of various aspects that enable them to do their job well) both increased from the 25th to the 80th percentile.
- Higher patient satisfaction: Overall satisfaction among unit patients rose from approximately 80 percent before program implementation to 99 percent in the first quarter of fiscal year 2010 (July 2009 until October 2009).
Planning and Development Process
Key elements of the planning and development process included the following:
- Obtaining senior management approval: The nurse manager of Weinberg 4C asked hospital administration if they would be willing to “cohort” all patients from one designated provider team on the unit; the Cameron Blue team was selected to pilot test this concept because their average daily census was large enough to occupy the 18-bed surgical oncology unit.
- Educating unit nurses: ICU staff explained to Weinberg 4C nurses how they use the daily goals form in the ICU.
- Adapting the form: A select group of Weinberg 4C nurses adapted the ICU form for use on the Weinberg 4C unit based on input from unit nurses.
- Meeting with the provider team: The Weinberg 4C nurse manager met with Cameron Blue providers to present the goals form and discuss the rounding and communication process.
- Introducing form to unit nurses: The nurse manager introduced and discussed the form and the rounding process with the unit nurses.
- Monthly meetings with new residents: Each month, the nurse manager hosts a breakfast for the nursing staff and new residents to explain the rounding process and daily goals form.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
- Costs: No costs were incurred in the development of this initiative, other than the time and energy of nurses and physicians involved in developing the form and rounding process.
Tools and Resources
A copy of the daily goals form is available in the following article: Holzmueller CG, Timmel J, Kent PS, et al. Implementing a team-based daily goals sheet in a non-ICU setting. Jt Comm J Qual Patient Saf. 2009;35(7):384-8. [PubMed]
More information about CUSP and system redesign is available through the Agency for Healthcare Research and Quality's Resources on System Redesign, available at http://www.ahrq.gov/professionals/systems/system/systemdesign/index.html.
The revised CUSP operations manual is available at http://www.hopkinsmedicine.org/armstrong_institute/training_services/cusp_offerings/cusp_guidance.html.
Getting Started with This Innovation
- Expect resistance to cohorting: Senior hospital administrators may not want to concentrate one team's patients on a single unit, believing it to be more efficient to simply assign a patient to the next available bed regardless of unit. Weinberg 4C nurses convinced hospital administrators that greater efficiencies and better quality could be achieved through the use of cohorting, which allows for the development of greater nurse expertise on a particular patient population and more effective nurse-provider relationships.
- Address nurse resistance to rounding: Nurses may resist rounding because mornings represent a very busy time on most medical/surgical units. However, rounding on Weinberg 4C quickly became popular with unit nurses, who felt more confident about providing care based on the regular, complete information they obtain during daily rounds with providers.
- Encourage use of daily goals form: Some nurses and providers may initially resist writing down all goals on the form; this reluctance can be overcome by emphasizing the value of documentation on the quality of patient care and the effectiveness and efficiency of communication. To further encourage use, keep the form as simple as possible, and allow unit staff to customize it to reflect their unique work processes.
Sustaining This Innovation
- Educate new residents: Ongoing education about the daily goals form and the rounding process will help to ensure that new residents understand expectations related to nurse–physician communication on the unit.
- CUSP was originally developed at Johns Hopkins Hospital for implementation in the ICU, and CUSP has since spread to ICUs around the country. The nurse manager on the Weinberg 4C unit notes that CUSP is now a forum through which staff members on each unit can identify what they believe are the biggest risks or quality problems for their patients; thus, every CUSP initiative is different, based on the needs of the staff and the unit. Executives are assigned oversight of the unit and may not have actual authority over the staff on that unit; however, they bring their administrative power, insight, and influence to the meetings and use that to help the unit accomplish its own goals.
- The use of daily goals forms in the Weinberg 4C surgical unit is one example of how CUSP can empower staff to address the care needs of their particular environments. The success of daily goals forms in the Johns Hopkins ICUs stimulated interest in applying the concept in other hospital units; however the surgical unit faced the unique challenge of coordinating communication with multiple caregiver teams that was not an issue for ICU staff. The adoption of daily goals sheets on Weinberg 4C illustrates that principles of standardized communication and working towards daily goals are applicable to medical surgical units and in other settings, as they can be adapted based on unit needs (i.e., the daily goals form will reflect the daily goals applicable to the particular patient population being served, and the clinician communication process will be designed accordingly).
Contact the Innovator
Note: Innovator contact information is no longer being updated and may not be current.
Joanne Timmel, MSN, RN, NE-BC
Nurse Manager, Weinberg 4C
The Johns Hopkins Hospital
401 North Broadway
Baltimore, MD 21231
Ms. Timmel has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
Holzmueller CG, Timmel J, Kent PS, et al. Implementing a team-based daily goals sheet in a non-ICU setting. Jt Comm J Qual Patient Saf. 2009;35(7):384-8. [PubMed]
Arford PH. Nurse-physician communication: an organizational accountability. Nurs Econ. 2005;23(2):72-7, 55. [PubMed]
Pronovost PJ, King J, Holzmueller CG, et al. A web-based tool for the Comprehensive Unit-based Safety Program (CUSP). Jt Comm J Qual Patient Saf. 2006;32(3):119-29. [PubMed]