Safer Ward Rounds

HIS (Healthcare Improvement Scotland) was formed in 2011 - the same year I graduated from medical school, to support healthcare providers in Scotland to deliver high quality, patient centered, evidence based, safe and effective healthcare in our hospitals. The organisation links in to the pre-existing work which has been carried out in Scotland in this area, such as NHS Quality Improvement Scotland and the Scottish Patient Safety Programme, both of which I have talked about on this blog before. 

So why am I talking about HIS this week? Recently on the news it was reported that the hospital standardised mortality ratios in three Scottish hospitals were above the national average and as a result an inspection was launched by HIS to try and help find out why that may be the case and to offer assistance with improving the hospitals in question. Seeing as I currently work in one of the hospitals mentioned in the report, I have been aware of this visit for the past month or so and I think it is a definitely a welcome exercise. Hospital standardised mortality ratios are probably not a particularly reliable measure on their own to look at how well a hospital is performing as there are a huge number of factors which could lead to a higher mortality ratio in one hospital compared to another. It could reflect, for example, a more elderly or unwell population which are being treated, as opposed to being solely down to the quality of delivery of care in the hospital of note. I do however agree that these measures can be useful to 'flag' areas of potential concern. HIS is potentially an extremely powerful tool to improve healthcare and I think that helping hospitals which are needing extra support is an extremely worthwhile exercise. The team who visited my hospital this week comprised of almost 30 staff (a mixture of medical and non-medical background) and carried out various exercises such as walkarounds and discussion groups. It was great to see people talking about the processes in the hospital which could be improved. I was chatting to the nurses about things we thought were done well and things which could be improved in the ward we're working in, whereas we may not have been having these conversations had the visit not taken place. I look forward to hearing the outcome of the report although I have to say that since I started work in this particular hospital I've been impressed by the focus on improvement which I've seen with a big emphasis on clinical governance - definitely more prominent than in some previous hospitals where I have worked.

I thought about the meeting I had attended, with several other 'trainees' and thought about the various themes which emerged as people were describing areas where they though improvements could be made. I've decided that I need to take on a new improvement project or audit myself this year but up until now I've been quite undecided about what to do. I think what I might do is have a look at the way we do ward rounds in the general wards in the hospital where I work. A lot of the improvement work focusing on patient safety which I have seen being done or been involved in in the past has related to the use of 'bundles' and 'checklists' and I want to see if I can somehow create a safety checklist or bundle to help facilitate safer ward rounds. Already checklists are being adopted for safety purposes in other areas of medicine eg. surgery and I've ordered a copy of Atul Gawande's new book 'The Checklist Manifesto' which looks at exactly this topic. Once I've had a read through the book and perhaps done an audit to see if there is a problem in the first place, I can see if there is scope to improve our system. In the medical HDU unit in our hospital there is already a 'daily ward round' proforma sheet which is completed and prompts important questions ie. is this patient appropriate for escalation to intensive care if required or can this patient be stepped down to ward level. I don't see why an adapted version of this couldn't be employed in the general wards (ie. would it be appropriate to escalate this patient to high dependency or are they an appropriate patient for boarding out to another ward if necessary). A ward round checklist might not be as useful for the consultants who are much more experienced with ward rounds, but would help the junior medical staff who may be less experienced and therefore more likely to potentially miss things. I think that anything that improves overall communication from ward rounds would be an improvement and hope I can try and come up with something helpful.