Teahon, Kathy
(2012)
Is Quality Improvement the platform on which the ward round system can be transformed?
[Dissertation (University of Nottingham only)]
(Unpublished)
Abstract
IS QUALITY IMPROVEMENT
THE PLATFORM ON WHICH
THE WARD ROUND CAN BE TRANSFORMED?
Quality Improvement initiatives have spawned a great many globally successful industries since the 1940s. There is evidence of their application in health services, albeit in a very simple manner, even before the NHS was conceived. The ward round has become a recent target of such initiatives.
The ward round has evolved from the 1700's as the globally universal system through which health services coordinate the care of inpatients. In secondary healthcare it is ubiquitous across departments, specialities and patient pathways. It is not a process but rather a workflow system involving an inter- and intra-disciplinary team which makes a current state assessment of work in progress and then coordinates and prioritizes further work such as diagnostic tests, operative treatments, discharge plan and outpatient follow-up requirements. As such it is a complex adaptive system which impacts across the entire hospital. In the case of the NHS the ward round annually coordinates the care of 15 million inpatients and the supervision of a "spend" of £20 billion
The study reported herein analyses the ward round practice in one large teaching Hospital from an operations management and quality improvement perspective. The aim of the study is to determine the current quality of the ward round system and to explore the potential for quality improvement as a platform on which the system can change and develop. The study objectives are to:
1. Collect and collate the experiences of doctors, nurses and patients regarding the ward round as a process
2. Review reported system errors to determine the profile of risk involved in the system
3. Use the data collected to describe the operational demographic of the ward round in terms of its timing and frequency of occurrence, its membership, activities performed, recordings made, inherent risks, its educational value and staff and patient "satisfaction"
4. Analyze the data using a grounded theory framework to describe and explain the workflow parameters and elements of the ward round
5. Describe the main themes arising from that analysis in terms of the potential for, barriers to and any risks inherent in QI initiatives
6. Make a determination as to whether or not QI initiatives are a platform on which the ward round system could be transformed
The methodology tools used were; questionnaires to junior doctors, senior nurses and international consultants; focus groups with junior doctors; semi-structured interviews with consultants and a review of reported untoward incidents which had in some way related to the ward round process.
This study results and analysis show that the ward round:
i. in its various formats and considering its clinical and non-clinical impact on health services is poorly described in the literature with respect to the value of its structural features such as office or bedside rounds, whether or not all members of the team need to be present for some all or none of it, or what its best frequency or timing should be;
ii. has eight identifiable formats from a medical perspective;
iii. has much variation in its timing, frequency and speed and some of this variation relates to its place within the consultant's job plan where it is often fitted in serendipitously;
iv. has a membership in terms of junior doctors and nurses who frequently struggle to attend and to participate;
v. has a number of high risk practices, most especially in terms of poor associated communication practices, the frequent lack of handover, the difficulty in having results available and the inaccuracy of documentation;
vi. is perceived to be of poor educational value to junior medical staff;
vii. is associated with varying degrees of dissatisfaction from all grades of medical and nursing staff and from patients;
viii. can be influenced by individual quality improvement tools such as flow (discharge focus), on a single ward or department basis but the flow of junior doctors, through their shift pattern, working across all departments and patient pathways and the multiple ward moves of patients may negate any achievements obtained;
ix. is significantly impacted by external occurrences such as the EWTD, reduced bed capacity with multiple ward locations for ward rounds, consultants' job plans and ward based management systems
x. is associated with many conflicts and divergences generated by such external influences and aggravated by a high degree of internal variation
xi. has some evidence of what appears to be excellent practice but overall is inefficient and unsafe
xii. is therefore in much need of transformation to a more efficient and safer workflow system
xiii. is unlikely to be influenced in a sustained manner by the application of individual QI tools to the entire system or the application of entire QI programmes at individual ward or department level
xiv. to be transformed will require a better evidence base in the literature for any changes suggested and a synchronization of the performance monitoring targets of external agencies to meaningful and measurable ward round characteristics
From the work presented in this report my recommendations are:
i. a list of ward round aims, current formats and broad process maps, as practiced by different specialities and disciplines, should be collated on a national basis by the relevant professional bodies and in this context its dual service and educational roles should be considered
ii. the data generated should be interrogated so that a list of generic ward round types and aims can be described
iii. the types and aims of the systems described can then be used to identify what evidence base is required so that meaningful changes to the ward round system can be recommended
iv. these recommendations can then be implemented using QI systems and tools but implementation will only be successful if the external performance monitoring is aligned
v. while awaiting this evidence base there are a number of processes within the current system which do not meet regulatory requirements, or are so unsafe that their improvement needs to be addressed on a more urgent basis e.g reliable availability of test results, handover and documentation
vi. the study in this report was not designed to identify how such process changes might be achieved but in the short-term an awareness generating campaign for clinical staff might be useful
vii. a number of practices, specific to the ward round require more detailed study from a behavioural and sociological perspective; three practices in particular are relevant here
a. the dynamic thinking and communication process of senior consultants, especially in super-specialist, high throughput services;
b. the unusual but widespread practice of test or treatment ordering involving senior doctors asking junior doctors to ask senior colleagues to complete investigations or treatments. This involves the transmission of complex clinical information and knowledge if the test or treatment is to be carried out efficiently and safely
c. the documentation of the ward round outcomes; again the practice of the most junior trainee member being a recorder is not common to other high risk systems. In the context of the ward round it is not clear who should do the recording, what it should contain or how it should be done in practical termS
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