Abstract.
The Garling Report, published in November 2008, was a public inquiry into the provision and governance of Acute Care Services in New South Wales Public Hospitals. Garling's 139 recommendations, aimed at modernising clinical care and equipment, include better supervision of junior staff, multidisciplinary teamwork, structured clinical handover and improved culture within health services. Garling also made specific recommendations about ward rounds, arguing that they should be daily, supervised and multidisciplinary. Given the importance of ward rounds in planning and evaluating treatment, implementation of these recommendations will require further evidence, engagement of senior clinicians and cultural change. This article discusses some of the barriers to Garling's recommendations.
Introduction: the Garling Report
The Final Report of the Special Commission of Inquiry into Acute Care Services in New South Wales Public Hospitals, led by Commissioner Peter Garling SC, ('the Report') was published on 27 November 2008.' The Inquiry was initiated after highly publicised adverse incidents occurred at Sydney's Royal North Shore Hospital: one involving a miscarriage in an emergency department toilet.2'3 The full report is 1195 pages long and contains 139 recommendations that aim to modernise clinical processes, management and equipment.2'3 Garling also called for better supervision of junior staff, multidisciplinary teamwork, structured clinical handover and improved culture within health services.2'3
Along with these recommendations, Garling proposed a state-wide policy in NSW that ward rounds be daily, supervised and multidisciplinary. The ward round has been a central activity of hospital life for hundreds of years4: described as a 'parade' led by the senior doctor, with junior doctors, medical students, nursing staff and allied health staff in tow.4 It is a valuable forum in which health care professionals share clinical information, address patient problems, plan and evaluate treatment and provide practical training for staff and students.4
Given the importance of ward rounds in hospital life, clinical managers must carefully plan any proposed changes. This requires evidence, collaboration, engagement and consideration of the cultural, financial and practical challenges. This paper discusses the implications of implementing Garling's ward round recommendations within the Australian acute public hospital setting.
Evaluating these recommendations: are they evidencebased?
Quality and safety should be the first priority when considering clinical change. This requires evidence. Senior doctors are key stakeholders in any change process within public hospitals and are keenly interested in evidence-based practice. They are more likely to engage with management when a proposed change is supported by data that shows better patient outcomes. Not only does this build trust with staff and confidence in management, but this also resolves conflicts of opinion. Unfortunately, not all of Garling's proposed recommendations are supported by evidence from either a quality and safety perspective, or a cost-effectiveness analysis. This will make it challenging to implement many of those recommendations.
First, Garling recommends that ward rounds be multidisciplinary. Multidisciplinary ward rounds are generally thought to be more friendly, open and respectful, and improve staff communication and treatment planning.5'6 In some situations, they also improve patient safety.5 For instance, pharmacists on ward rounds reduce the rate of preventable adverse drug events from medication errors by 66%.7'8 Some multidisciplinary ward rounds have also been shown to reduce the average length of hospital stay without compromising morbidity or mortality,9 suggesting that there are cost savings to be gained. As a result, the US Joint Commission on Accreditation for Health Care Organizations states that patient care, treatment, and rehabilitation should be planned, evaluated, and revised by an interdisciplinary collaborative team."1 Thus, it seems that effective collaboration between health care professionals may produce better patient outcomes and can reduce health expenditure in some situations. Of course, the devil is in the detail. Achieving this will require health services to redesign long-established ward-based routines and practices. Arguably, more direct and rigorous evidence is needed before this could be justified. Moreover, change is seldom easy.
Second, Garling recommends that senior doctors supervise and approve the written records of ward rounds. Research shows that records of ward rounds are often incomplete, especially with respect to documentation of patient questions." Patient care relies on communication and communication failure is the most common cause of adverse events in Australian hospitals.1^ Intuitively, the implementation of Garling's recommendation should improve the accuracy of written communication and, therefore, should improve patient safety. There is overwhelming evidence that closer clinical supervision of junior doctors results in better patient outcomes,14 in the same way that double-checking reduces medication errors in a nursing context.13 There is also evidence that the use of a ward round 'checklist tool' improves trainees' performance during ward rounds, including with respect to communication and documentation. However, none of this evidence directly shows that the additional time and effort invested in this type of supervision and training of junior medical staff results in better outcome for their patients.
Third, to avoid 'bed blocks' and 'traffic jams'1, Garling recommends ward rounds be conducted daily. Currently, there is little evidence to support this recommendation, partly because of the heterogeneity of patients and wards: whilst Intensive Care Units conduct ward rounds several times per day, Coronary Care Units perform ward rounds daily and psychiatric wards might conduct rounds only weekly. Although this recommendation is intuitive, it is unsupported by research. There is even a question of whether the increased time spent conducting daily ward rounds may impair the ability of medical staff to adequately care for all of their patients within existing rostered hours. Clearly, the gaps in our understanding regarding the utility of daily ward rounds provide an opportunity for further health services research.
Unless or until these important questions can be answered, it would be imprudent and premature to consider implementing these recommendations at anything other than the level of the individual health service. However, even at this level, several other barriers to implementation should be considered. These are discussed below.
Implementing these recommendations
Vision
Models of organisational change highlight the importance of both fonnal and informal philosophies to guide the strategic direction of the change process. Articulating a cohesive and unifying vision of patient safety is now firmly embedded into the vision of many Australian health services. Arguably, it is not difficult to see that the implementation of Garling' s recommendations is another way of advancing this vision. The difficulties arise when devising the mission.
Setting priorities
It would be difficult to mandate daily ward rounds across an entire hospital in the short term because this would require employment of additional equivalent full time senior medical staff, particularly over weekends. Such an expense would be financially prohibitive for most health services without the provision of additional funding from the State and Temtory Health Departments. Within each health service, the greatest impact of this recommendation would be felt within the subacute areas, including mental health, where ward rounds may be conducted only weekly. Funding the additional clinical time needed to implement this recommendation in those areas could be particularly challenging, particularly given existing workforce shortages in mental health. Similarly, for small rural hospitals staffed by general practitioners in communities that already face significant medical workforce shortages, this recommendation seems conspicuously unrealistic and burdensome. Greater clarification, planning and leadership would be required from the States before this recommendation could be fully implemented. Although it would seem sensible to conduct daily ward rounds within high acuity units (intensive care and coronary care) in line with current practice, it is difficult to see how this could be expanded to other wards at present, given the current financial and workforce limitations.
Possibly the simpler, quicker and less expensive recommendation to implement would be the creation of systems that facilitate multidisciplinary and supervised ward rounds. Supervision could be linked to existing policies and procedures regarding perfonrrance management and credentialing, whereas the use of multidisciplinary teams could be incorporated into existing clinical guidelines and pathways. Despite this, it is likely that this recommendation could engender disquiet among staff who are unaccustomed to multidisciplinary teamwork and see this process as an unnecessary incursion into existing medical decision-making hierarchies. Indeed, critical to implementing Garling's recommendations at a local level is to successfully engage with doctors, clinicians and executives, and to successfully create an organisation that embraces multidisciplinary teamwork.
Influencing medical culture
The ward round is the centre-piece ofthe apprenticeship model of medical education and training. It typically involves a specialist medical practitioner reviewing selected patients with the junior medical staff (registrar and resident medical officer) attached to that treating team. They may spend anywhere from several minutes to half an hour reviewing each patient. During this time, they may discuss the patient's current medical problems, formulate a treatment plan (including medications) and discuss further diagnostic or therapeutic interventions. This process is often used as an opportunity for specialists to teach junior doctors. Specialists will observe junior doctors perfonning physical examinations and eliciting symptoms. Although this is a valuable experience for junior medical staff, these ward rounds all too often isolate and exclude other health professionals from clinical input.17 Nurses and allied health staff frequently report difficulties raising important issues and feel intimidated by senior doctors.17
Fifty years ago, public hospital doctors were honorary visiting medical officers who 'donated' their services.1 Even today, many doctors working in private hospitals continue to function relatively independently from the hospital. Medical students, often taught by these doctors, are trained to be relatively autonomous decision-makers, rather than employees or team-members. Therefore, both pre-vocational and vocational medical training inculcate personal responsibility for decisions and patient outcomes, which often dissuades doctors from embracing multidisciplinary teamwork.18 If the responsibility that senior doctors feel for their patients could be extended to a holistic team approach that transcends the traditional doctor-patient relationship, junior doctors would likely follow, as they would learn and develop these skills through observation and experience.
Therefore, for ward rounds to become truly multidisciplinary, an egalitarian culture must be embraced by medical staff in which they use their specialised knowledge to guide, rather than control, the multidisciplinary team. They must move from independence to interdependence." After all, today's complex healthcare setting relies on input from not only doctors, but also nurse specialists, pharmacists, technologists and medical administrators.5
Clearly, engaging doctors in organisational quality and safety initiatives is a challenge lx and requires a strong argument for change.19 As champions of evidence-based practice, doctors are more likely to embrace arguments for change that are supported by evidence. Unfortunately, as discussed above, the evidence supporting Garling's proposed changes to ward round practices is indirect and circumstantial. This will only add to the challenge of engaging medical staff on this journey of change. The Report does not specifically identify this as an area of need for further research.
Executive commitment
Visible involvement of the chief executive and senior executive management is essential in setting standards for service delivery and demonstrating a hospital-wide commitment to improving patient safety.20 Executive managers often share the commitment of clinicians to improving clinical outcomes and work practices. They are keen for their hospital to be seen as committed to achieving better outcomes for patients and staff, while maintaining a sharp focus on organisational performance. Often, accreditation is rightfully seen by executive managers as an opportunity to showcase achievements, improvements and organisational perfonnance,"' particularly through benchmarking. However, implementing Garling's recommendations could be viewed by some executives as another opportunity to benchmark, without necessarily having regard for the lack of evidence underpinning those recommendations. This is where executive managers with a clinical background, such as the Chief Medical Officer or Director of Medical Services, can play a pivotal role in championing not only evidence-based clinical care, but also evidence-based management. Otherwise, the risk is that clinical process reforms led by non-clinical managers will continue to lack credibility in the eyes of some clinicians.
Non-medical clinicians
Many nurses and allied health staff often report feeling disempowered during ward rounds, believing that this form of clinical care planning is the sole domain of doctors.22 Many also report wanting to be more involved in clinical decisionmaking.23 Therefore, encouraging and valuing the contributions of all team members and overcoming professional hierarchies and egos leads to clinicians sharing the responsibility for clinical decisions. This not only creates a culture of patient safety,"4 but has been shown to improve employee wellbeing and satisfaction."" Hence, engagement from non-medical clinicians is unlikely to be problematic in effectively implementing these recommendations at a local level. Vocal nursing and allied health staff could become champions and leaders for change.
Conclusions
According to the UK National Health Service, up to 50% of all healthcare redesign is not maintained.26 Without the appropriate planning, prioritisation and funding (all of which require clinical leadership), Garling's recommendations will become yet another one-off, crisis-driven response.20 Ward rounds are an intrinsic and time-honoured part of the hospital routine. Reforming health services at such a fundamental level requires courage, vision, engagement, leadership and an egalitarian philosophy. Garling has been criticised2'3 for commanding a litany of reforms, without fully considering their financial or practical implications. Above all, fundamental health refonri requires evidence. At present, the evidence in support of Garling's recommendations is parsimonious. Despite these shortcomings, the Report champions new models of care delivery that seek to improve patient safety and improve the profile of nursing and allied health staff in ways never previously espoused. However, unless or until the State Departments of Health provide the necessaiy policy frameworks and funding to support these recommendations, including addressing the gaps in the current evidence, the success of the Report as a meaningful catalyst for change will be limited.
[Reference]
References
1 Garling P. Final report of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals. Sydney: NSW Government, 27 November 2008. Available at http://www.lawlink.nsw.gov.au/ lawlink/SpeciaLProjects/ll_splpiOJects.nsf/pages/acsi_finalreport [verified 3 April 2009].
2 Skinner CA, Braithwaite J, Frankum B, Kerridge RK, Goulston KJ. Reforming New South Wales public hospitals: an assessment of the Garling inquiry. Med J Aust 2009; 190(2): 78-9. [On behalf of the Hospital Reform Group]
3 Van Der Weyden MB. In the wake of the Garling inquiry into New South Wales public hospitals: a change of cultures? Med J Aust 2009; 190(2): 51-2.
4 O'Hare JA. Anatomy of the ward round. Eur J Intern Med 2008; 19: 309-13. doi: 10.101 6/j.ejim.2007.09.016
5 Halm MA. Gagner S, Goering M, Sabo J, Smith M. Zaccagnini M. Interdisciplinary rounds: impact on patients, families, staff. Clin Nurse Spec 2003; 17(3): 133 -42. doi: 10. 1097/00002800-200305000-000 13
6 Moroney N, Knowles C. Innovation and teamwork: introducing multidisciplinary team ward rounds. Nurs Manage 2006; 13(1): 28-31.
7 Fertleman M. Barnett N, Patel T. Improving medication management for patients: the effect of a pharmacist on post admission ward rounds. Quul Saf Health Care 2005; 14: 207-11. doi: 10.1136/ qshc.2004.011759
8 Fortescue EB, Kaushal R, Landrigan CP. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003;111:722-9. doi: 10. 1542/peds.111.4.722
9 Zwarenstein M. Bryant W. Interventions to promote collaboration between nurses and doctors. Cochrane Datahase Syst Rev 2000; (2): CD000072.
10 Sierchio GP. A multidisciplinary approach for improving outcomes. ./ Infus Nurs 2003; 26(1): 34-43. doi: 10. 1097/00 129804-20030 100000005
11 Femando KJ. Siriwardena AK. Standard of documentation of the surgeon-patient consultation: current surgical practice. Br J Surg 2001; 88: 309-12. doi: 1 0. 1 046/j. 1 365-2 1 68.200 1 .0 1 666.x
12 Thompson AG, Jacob K, Fulton J, McGavin CR. Do post-take ward round proformas improve communication and influence quality of patient care? Postgrad Med J 2004; 80: 675-6. doi:10.1136/ pgmj. 2003. 01 6097
13 Bomba DT, Prakash R. A description of handover processes in an Australian public hospital. Ausi Health Rev 2005; 29(1): 68-79. doi:10.1071/AH050068
14 Kennedy TJT, Lingard L, Baker GR, Kitchen L, Regehr G. Clinical oversight: conceptualizing the relationship between supervision and safety. ,7 Gen Intern Med 2007; 22: 1080-5. doi: 10.1007/sl 1606-0070179-3
15 O'Connell B. Crawford S, Tuli A, Gaskin CJ. Nurses" attitudes to single checking medications: before and after its use. InI J Nurs Pract 2007; 13:377-82. doi: 10.1 11 1/J.1440-172X.2007.00653.X
16 Norgaard K, Ringsted C, Dolmans D. Validation of a checklist to assess ward round performance in internal medicine. Med Edite 2004; 38: 700-7. doi: 1 0. 1 1 1 1/j. 1 365-2929.2004.01 840.x
17 Manias E, Street A. Nurse-doctor interactions during critical care ward rounds. J Clin Nurs 2001; 10: 442-50. doi: 10. 1046/j. 13652702.2001.00504.x
18 Loh E. How do we engage doctors in quality and safety? The Quarterly 2008; 41(4): 10-3. Available at http://www.racma.edu.au/ index. php?option=com_content&task=view&id=269<emid=523 [verified 30 April 2009].
19 Morjikian RL, Kimball B, Joynt J. Leading change: the nurse executive's role in implementing new care delivery models. J Nurs Adm 2007; 37(9): 399^04. doi: 10. 1097/01. NNA.0000285141.19000.bc
20 McGrath KM, Bennett DM, Ben-Tovim Dl, Boyages SC, Lyons NJ, O'Connell TJ. Implementing and sustaining transformational change in health care: lessons learnt about clinical process redesign. MedJAust 2008; 188(6): S32-5.
21 Australian Council on Healthcare Standards. Available at http://www. achs.org.au/EQUIP4 [verified 24 May 2009].
22 Busby A, Gilchrist B. The role of the nurse in the medical ward round. JAdv Nurs 1992; 17: 339^6. doiTO.l 1 1 1/j. 1 365-2648. 1992.tb0 19 12.x
23 Apker J, Propp KM. Zabava Ford WS, Hofmeister N. Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. J Prof Nurs 2006; 22(3): 180-9. doi:10.1016/j.profnurs.2006.03.002
24 Robinson M, Cottrell D. Health professionals in multidisciplinary and multi-agency teams: changing professional practice. J Interprqf Care 2005; 19(6): 547-60. doi: 1 0. 1 080/1356 1 820500396960
25 Laschinger HK, Finegan J. Empowering nurses for work engagement and health in hospital settings. J Nurs Adm 2005; 35(10): 439^49. doi: 1 0. 1 097/00005 1 1 0-2005 1 0000-00005
26 United Kingdom Department of Health. Policy and guidance. Organisation policy. Health reform. Available at http://www.dh.gov. uk/en/Policyandguidance/Organisationpolicy/Healthreform/index.htm [verified 23 May 2009].
Manuscript received 17 June 2009, accepted 9 February 2010
[Author Affiliation]
Owen M. Bradfield MB BS(Hons), BMedSc(Hons), LLB, MBA
PO Box 2085, Preston, VIC 3072, Australia. Email: owenbrad@yahoo.com.au
No comments:
Post a Comment