Whiteboards Key to Improved Communication

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By Karen Cheung

Patient satisfaction is undoubtedly on the minds of hospital administrators in an increasingly consumer-driven healthcare system. With patient satisfaction tied to reimbursements, many wonder how their institutions could improve patient satisfaction.

"Organizations are consistently looking at ways to help do that," said Niraj L. Sehgal, MD, MPH, associate professor of clinical medicine and associate chair for quality improvement and patient safety at the University of California, San Francisco (UCSF). "One of things that patients value is good communication. The whiteboards seem like an intuitive way to do that," he said.

Although there's no exact data correlating whiteboards with better patient satisfaction scores, whiteboards can improve communication among the healthcare team, providers, and patients, according to a new study, "Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations," published in the April issue of Journal of Hospital Medicine. Researchers at the UCSF surveyed 104 nurses, 118 internal medicine housestaff, and 31 hospitalists at their facility. Although they varied in what information was most valuable, most respondents agreed on their importance as a tool to improve teamwork, communication, and patient care.

Taking recommendations from its survey, UCSF is now its fourth month of it pilot program of the revitalized whiteboard system.

Whiteboards white out communication gaps
The Joint Commission states that 65% of reported sentinel events were caused by communication errors, according to the study. In 2007, The Joint Commission declared that one of the National Patient Safety Goals is to engage patients in their care.

With endorsement from Kaiser Permanente's Nurse Knowledge Exchange program and the Institute for Healthcare Improvement's Transforming Care at the Bedside initiative, more organizations are recognizing the importance of whiteboards.

Whiteboards, or dry-erase boards, are typically available at most medical institutions, according to Sehgal. "Whiteboards are ubiquitous… I'm not sure I've been to a hospital that hasn't had a whiteboard," he said.

The problem is that not all institutions use whiteboards to the fullest.

For example, at UCSF before the system was revamped, there was confusion about who the whiteboard was for – the provider or for the patient. "It wasn't very clear what the goal of the whiteboard was," said Sehgal. After the study, UCSF adopted recommendations from its survey. Now UCSF's whiteboard system is driven by a clear focus on the patient, rather than for the provider.

That means the whiteboards are installed so that patients can see them from their bed. Patients and their family members also have the opportunity to write questions for their providers on the whiteboard, which triggers a dialogue.

At UCSF, the bedside nurse manages writing and updating the whiteboard each day. Using a templated board, the displayed information includes day and date, the names of the patient, bedside nurse, and primary physician, attending, resident, and/or intern, and the family member's phone number.

Most importantly, the white board includes a goal of the day that the providers determine with patient. For example, Sehgal saw a patient whose goal of the day was to walk and take four laps around the unit. The family member wrote down a question on the whiteboard about the concern for the patient overextending himself. "When we talk about engaging patients in their care, we implicitly mean family members as well," said Sehgal.

Dusting off the whiteboard process
Based on their findings, researchers recommended creating an audit system of the whiteboard usage when the process is rolled out.

One survey respondent in the study said, "There needs to be specific training to make this a cultural norm across care providers and reinforced on a regular basis. If it's a priority, there should be audits, tracking for performance (accuracy and updated info), and feedback to providers. I would ask patients what info they would like to see, as [whiteboards] should be patient-centered, not provider-centered."

Designated auditors check the whiteboards in each room, measure compliance, and send feedback to the nurse managers. Through this auditing process, UCSF quickly found one of the biggest barriers to effective use was simply the need to buy more markers and fasten them to the boards.

How did the providers react to the new system? In general, nurses found whiteboards more useful than attending physicians or housestaff.

"With any additional task, there's always concern—whether it's a nurse or physician—that's it's just another thing added to their day. In some ways, the whiteboard just reinforces what they already do," said Sehgal about the providers' duties as patient advocates.

For institutions looking to replicate the UCSF's whiteboard system, Sehgal suggested starting small and then expanding.

"Like many things, it starts with the local culture. Start with a unit in which the culture would take on the whiteboard initiative," he said. It's also important to have multidisciplinary team with champions. "Then extrapolate to other units."

The investment—finances and time—could be small or large, depending the existing whiteboard system and the willingness of the staff.

Although UCSF is a large, tertiary academic center, Sehgal said that other institutions can also reinvent their whiteboard system to focus on patients.

"The whiteboard isn't unique to what type of hospital you are. I think all hospitals have a need of patients wanting to communicate with providers," he said. ". . . If the goal is to improve patient satisfaction, white boards are just one vehicle."