Published in the August 2010 issue of Today’s Hospitalist
CHANCES ARE, every bed in your hospital has a whiteboard tacked up nearby. But according to one hospitalist researcher, physicians and nurses aren’t realizing the full potential of whiteboards to improve communications with patients.
At the University of California, San Francisco (UCSF), hospitalist Niraj L. Sehgal, MD, MPH, surveyed his nursing and hospitalist colleagues to identify the barriers preventing more effective whiteboard use. He realized that fixing the No. 1 complaint “the fact that dry-erase pens disappear “was simple. But figuring out how to solve other problems wasn’t so easy.
Because providers had no template for what information a whiteboard should contain, for instance, they didn’t know what to write. There was confusion about who should keep whiteboard information up-to-date, and even concerns about patient privacy.
Survey results, which were published in the April 2010 issue of the Journal of Hospital Medicine, also revealed a fundamental lack of understanding about what kind of communication the whiteboards should be used for. Should whiteboards be a place where doctors, consultants and nurses exchange patient information? Or should they be preserved for information that patients feel they need?
Dr. Sehgal feels strongly that whiteboards should be “a patient-centered tool,” and he’s on a mission to expand their use. Building on his survey findings, a multidisciplinary team at UCSF Medical Center has piloted a program to gauge the impact of using templated whiteboards on patient satisfaction.
But according to Dr. Sehgal, the survey taught him one overriding lesson: “We need to balance the desire to include everything vs. information that is really high yield.”
For Dr. Sehgal, the most compelling argument in favor of the conscientious use of bedside whiteboards is the potential to enhance patients’ involvement in their own care. That’s why he thinks whiteboards should focus on what patients want to know, not what physicians and nurses want to communicate.
The survey, for example, found that most nurses and many physicians think that a good use for a whiteboard is to state a “goal for the day.” But picking just one goal to write down is easier said than done. After all, each provider “hospitalists, consultants, pharmacists or physical therapists “is likely to name a different goal.
“But when you frame the goal of the day as the question that patients ask most, it’s easier to focus all of the practitioners,” Dr. Sehgal says. “Is it getting out of bed? Is it ‘I want to talk to the physician about medications prescribed’? Or is it walking around the floor a couple of times?”
Taking the patient’s point of view also helps when deciding which providers’ names to jot down. What patients want to see, Dr. Sehgal explains, is the name of their primary bedside nurse and responsible physicians. On a case-by-case basis, he adds, it may be important to write the names of particular consultants, case managers or disciplines.
For instance, Dr. Sehgal recently had a complex patient who felt overwhelmed by visiting specialists. “I put the four consultants’ names up on the whiteboard,” he says, “and named the services they were from.”
Keeping information up-to-date
One major mistake with whiteboards, adds Dr. Sehgal, is trying to cram in too much information.
“You could have a category for planned tests for today or for pending tests,” he says. “But you’re not trying to replace the electronic health record or the daily progress note. The challenge is including those things that help patients understand what’s happening that day.”
Earlier this year, the medical center launched its whiteboard pilot project in five different geographic units. The initiative is testing the following items as part of a template: day and date; patient name (or initials); name of bedside nurse; name of primary physician; goal of the day; anticipated discharge date; family members’ contact information; and a space for patients or families to write questions.
One challenge in the pilot units is how to keep information up-to-date when patients are transferred to different rooms. Having inaccurate or outdated information or just “too much stuff,” Dr. Sehgal says, is worse than having no information at all. “It appears to patients that we as providers aren’t working cohesively.”
The units are also struggling with how to incorporate updating the whiteboard information into the regular workflow so nurses, housestaff and attending physicians don’t feel like the whiteboards create extra work for them.
“More recently, we’ve been able to get a couple of trainees to champion whiteboard use among the other residents,” says Dr. Sehgal. The initiative also has auditors checking on whether the whiteboards are being used, if the information is accurate and up-to-date, and how patients feel about the whiteboards’ usefulness as a communication tool.
Findings from the pilot project demonstrate overwhelmingly positive responses from patients on the use of whiteboards. As a result, the medical center may implement house-wide use of new, templated whiteboards this fall.
One concern “that whiteboard information may compromise patient confidentiality “has turned out to be a non-issue, notes Dr. Sehgal. “As long as patients are driving what is on the whiteboard,” he says, “you are appropriately addressing the privacy issue.”
Another challenge is how to use whiteboards with low-literacy patients or people who don’t speak or read English.
“I’ve had a medical student write information on the whiteboard in Spanish for a family,” says Dr. Sehgal. But most translating services, he adds, are over the telephone, leaving the center with no systematic mechanism for filling in whiteboard information.
Still, Dr. Sehgal notes, the effective use of whiteboards can get patients more involved, and improve communication and teamwork. “It may not be the only strategy,” he says, “but it has us thinking about other ways to creatively engage patients in their care.”
Deborah Gesensway is a freelance writer based in Toronto who reports on U.S. health care.
Tips for optimizing whiteboard use
FINDINGS FROM A SURVEY published in the April 2010 Journal of Hospital Medicine offered the following tips to help hospitalists make better use of bedside whiteboards:
- Location and size matter. Place whiteboards where patients can easily see them from their beds. And write big enough so patients can read what’s on them.
- Fasten pens to the whiteboards. Keep extra pens in nursing stations and have nurses quickly replace pens as needed.
- Create templates. Include day and date; patient name (or initials); name of bedside nurse; name of primary physicians; goal of the day, particularly as stated by patients; anticipated discharge date; family members’ contact information; and a space for families to write down questions as they arise.
- Give bedside nurses the responsibility for writing and updating information.
- Use auditors to survey whiteboard use, identify barriers and provide feedback.
- Ensure that whiteboard information is being used with informed patient consent.
Source: Journal of Hospital Medicine