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How a simple checklist can help improve teamwork

November 2003

Published in the November 2003 issue of Today’s Hospitalist

When researchers at The Johns Hopkins Hospital questioned nurses and residents who had just rounded on ICU patients about how well they understood what work they needed to do for those particular patients that day, they were surprised by some of the answers they received. Less than 10% of those caregivers understood the goals of the therapy for that day.

“This was in an ICU that probably has the most advanced types of teams, because there is staff dedicated to them,” explains Peter J. Pronovost, MD, an anesthesiologist and intensivist who serves as medical director of the Johns Hopkins Hospital Center for Innovations in Quality Patient Care. “You can imagine what it’s like on a floor where there isn’t a dedicated team.”

Dr. Pronovost and his colleagues used those disturbing findings to create what would be called a “daily goals form.” The idea was to give caregivers–from physicians to nurses “an easy way to focus on goals that they could achieve in a given day.

An article on the form published in the June 2003 issue of the Journal of Critical Care Medicine received attention from both physicians and consumers because of its simplicity “and its effectiveness. And while the form was created with intensivists in mind, it could be a useful model for hospitalists working to improve teamwork and patient safety on general medical floors as well as intensive care units.

In a conversation with Today’s Hospitalist, Dr. Pronovost describes how his ICU checklist can be applicable for hospitalists.

Hospitalists think that nurses, housestaff and other caregivers they work with are all on the same page. Aren’t they?

We found that rounds tended to be provider-centered rather than patient centered. We talked a lot about physiology and pharmacology and evidence-based medicine, but we didn’t talk about managing work. In order to get patients to move through the health care system, there is concrete work that needs to occur. Diagnoses have to be made. Treatments have to be implemented. Monitoring and follow-ups have to be scheduled. And we tended to use nonspecific language to manage things.

You might hear a phrase like, “My goal for the day is to wean the patient from the ventilator.” But what does that really mean? Does that mean extubate today or tomorrow?

How does the daily goals form help clarify the language?

Instead of saying our goal is to wean, we now say our goal is to extubate the patient by noon. If 11 o’clock rolls around, the nurse or the respiratory therapist will say, “Your goal was to get him extubated by noon. It’s 11. We’ve got a lot of work to do. Let’s get going. Or, did something change and we need a new goal?” What was the result of putting seemingly obvious goals like that on the checklist? After we instituted the checklist, which really is very simple–just a column to write down the daily goals and then a few columns representing time periods for checking off if you are meeting your goal–we surveyed the nurses and residents again about whether they understood the goals of care. This time we found that 95% said they did. The form also helped us cut our length of stay in the ICU in half, from 2.2 days to 1.1 days.

How has a simple form helped cut length of stay so dramatically?

In all hospitals, there is a witching hour. If tests or other things don’t get done by a certain time–usually 1 or 2 in the afternoon–you end up adding on a whole other day to the hospital stay. We eliminate that.

A typical example is someone with congestive heart failure. The goal is to diurese him today. Folks go around at the end of the day and say, “Well, I guess we didn’t really diurese him. Let’s diurese him tomorrow.”

What did the patient get for that day in the hospital? All the risk of being in an ICU, all the expense and no benefit.

On this daily goals sheet, we say, “Let’s make him three liters negative today.” By 8 in the morning, the nurse says, “Let’s start a Lasix drip, and I’ll titrate to make my goal.”

The form also helps draw attention to potential complications. Every day we examine patients’ safety risks and how we can reduce them. By proactively addressing hazards, we reduce complications. For example, we now elevate the head of all beds to reduce risk for ventilator-assisted pneumonia. Before we used this form, we did that on 40% of patients.

It really is empowering the team to make sure that we deliver the outcomes that we want. It’s key that the goal is explicitly stated and written down. One of the things we say is that the goal needs to be specific, measurable and attainable.

Does the goals form work simply by forcing people to be specific?

Yes, but it also works by having something on paper. That really helps facilitate communication. I call it a forcing function for teamwork.

Teamwork really boils down to a couple of behaviors: You have to have people speak up when they have concerns and get others to listen when they do. Nurses perhaps need to be encouraged to do the former. And doctors need to be encouraged to do the latter.

In hospitals, there are cultural differences between doctors and nurses. Our nurses love this form. It greatly empowers them. They feel like they are being heard. But you can’t do this if you don’t have the nurses attending rounds and really involved.

How does the form work?

During rounds, a resident or sometimes the nurse practitioner acts as a secretary. That person writes down the goals as we talk about them. Then a discussion ensues about who will do what to accomplish the goal.

The sheet stays at the bedside. Everybody who comes by sees it, and if there is no initial beside something six hours later, it gives the person a way to say, “Here’s what we have to do.” It saves a lot of phone calls throughout the day to clarify what needs to be done.

Are hospitalists at Johns Hopkins using this form?

Hospitalists don’t work in our ICU, but they are on the floors. Our hospitalists heard about the intervention, and they are in the process of modifying it for their own use on their floors.

The form is widely applicable. In most areas of health care, there is not good teamwork going on between all the different caregivers, and this is a way to create that.