Article Text

Patient whiteboards to improve patient-centred care in the hospital
  1. Marilyn Tan,
  2. Kambria Hooper Evans,
  3. Clarence H Braddock III,
  4. Lisa Shieh
  1. Department of Medicine, Stanford University Medical Center, Stanford, California, USA
  1. Correspondence to Dr Marilyn Tan, Department of Medicine, Stanford University Medical Center, 300 Pasteur Drive, S025, Stanford, CA 94305, USA; marilyntan{at}gmail.com

Abstract

Background Patient whiteboards facilitate communication between patients and hospital providers, but little is known about their impact on patient satisfaction and awareness. Our objectives were to: measure the impact in improving patients’ understanding of and satisfaction with care; understand barriers for their use by physicians and how these could be overcome; and explore their impact on staff and patients’ families.

Methods In 2012, we conducted a 3-week pilot of multidisciplinary whiteboard use with 104 inpatients on the general medicine service at Stanford University Medical Center. A brief, inperson survey was conducted with two groups: (1) 56 patients on two inpatient units with whiteboards and (2) 48 patients on two inpatient units without whiteboards. Questions included understanding of: physician name, goals of care, discharge date and satisfaction with care. We surveyed 25 internal medicine residents regarding challenges of whiteboard use, along with physical therapists, occupational therapists, case managers, consulting physicians and patients’ family members (n=40).

Results The use of whiteboards significantly increased the proportion of patients who knew: their physician (p≤=0.0001), goals for admission (p≤=0.0016), their estimated discharge date (p≤=0.049) and improved satisfaction with the hospital stay overall (p≤=0.0242). Physicians, ancillary staff and patient families all found the whiteboards to be helpful. In response, residents were also more likely to integrate whiteboard use into their daily work flow.

Conclusions Inpatient whiteboards help physicians and ancillary staff with communication, improve patients’ awareness of their care team, admission plans and duration of admission, and significantly improve patient overall satisfaction.

  • Internal Medicine
View Full Text

Statistics from Altmetric.com

Introduction

Physicians have traditionally focused on providing the best care for patients by tackling medical diagnoses and treatments; however, there are often gaps in patient understanding and awareness of inpatient medical care due to ineffective communication from the healthcare team.1 Thus, the physician's work has gone from focusing solely on the scientific medical issues towards more patient-centred strategies, with a large focus on improving communication between patients and their providers. Promoting patient-centred care at academic medical centres is important for residency training, and it increases patient knowledge, improves transitions of care, and reduces barriers to medication adherence, resulting in higher satisfaction ratings both from care providers and from patients.2 Improving patient satisfaction (overall and with discharge planning) has also been independently associated with lower readmission rates in medical units.3

Physicians communicate frequently among themselves and with ancillary staff to optimise a patient's care during admission and after hospital discharge; however, patients are frequently left out of these discussions. As patients’ plans and care teams change frequently, they are left unsure of who the physicians are, what the goals are for admission and when they can expect to be discharged. Prior studies have demonstrated discrepancies between patient and physician perspectives of whether patients know their diagnoses and whether they know their physicians’ names.4 Inpatients often believe they are not well enough informed of the plan of care and discharge plans, and use of patient whiteboards has been shown to improve patient perception of communication, as patients respond to concrete visual explanations and reminders.5

Whiteboards in patient rooms are being used increasingly at hospitals to keep inpatients updated on this important information. Whiteboards have been present on various inpatient units at our institution for many years, but until our pilot, there was no standardisation of whiteboard templates and whiteboard use. From a study by Sehgal et al at University of California, San Francisco, the recommended whiteboard template included the following information: primary physician name, bedside nurse name, medical assistant name, date, daily goals, estimated discharge date, family contact and patient/family questions. Though Sehgal et al6 showed that patients, nurses and physicians are more satisfied with communication when patient whiteboards are used, no study to date has shown specifically whether there actually is an objective improvement in patient understanding and awareness of these and other components of their care.

The first objective of this study was to determine if the use of whiteboards improved patients’ understanding of and satisfaction with their care. Second, we explored barriers to physicians using whiteboards and how these could be overcome. Third, we examined how ancillary services and patients’ families are impacted by whiteboard use. Finally, we looked at how physician practices in the inpatient setting are affected by knowing the positive results of our study. We present findings from a patient survey that show the positive impact of whiteboard use and how it provides more transparent communication to improve patient awareness and satisfaction.

Methods

We based our project on the Institute for Healthcare Improvement model of the Plan-Do-Study-Act (PDSA) cycle.7

One PDSA cycle was conducted. The ‘plan’ phase included a literature search on prior studies of whiteboards and patient satisfaction. We then began educating medicine attending physicians, resident physicians, registered nurses and nurse managers about best practice from prior studies of whiteboard use and provided formal training on whiteboard use. The ‘do’ phase was our 3-week pilot period of daily inpatient whiteboard use on two of the four inpatient units. The ‘study’ phase involved auditing whiteboard use, conducting patient surveys and identifying barriers to effective whiteboard use. Finally, the ‘act’ phase involved implementing strategies to improve compliance with whiteboard use and to minimise the burden of maintaining a whiteboard.

Study setting

We conducted confidential interviews with patients from four inpatient units on the university general medicine service at Stanford University Medical Center over a 3-week exploratory study period from 15 January 2012 until 4 February 2012. No patient identifiers were used during this process.

Stanford University Medical Center is a quaternary care medical centre with 613 beds and over 25 000 inpatient admissions per year. The population of patients admitted includes insured and uninsured patients. As of 2012, there were 2136 medical staff and 711 house staff (109 of whom were medicine house staff in the 2011–2012 academic year). The nursing staff includes 2154 registered nurses, 15 licensed vocational nurses and 141 nursing assistants8 (box 1).

Box 1

Stanford University Medical Center Statistics as of 2012

  • Level of care: Quaternary care medical centre

  • Beds: 613 beds

  • Inpatient admissions: Over 25 000 per year

  • Patient population: Includes insured and uninsured patients

  • Number of medical staff: 2136

  • Number of house staff: 711 (109 of which were medicine house staff in the 2011–2012 academic year)

  • Number of nursing staff: 2154 registered nurses, 15 licensed vocational nurses and 141 nursing assistants

Units surveyed

Four inpatient medicine units were sampled in our survey. These units were chosen because they were staffed by a consistent set of inpatient general medicine teaching service teams. Two of the surveyed units had whiteboards managed by bedside nurses and resource nurses. Though other units in the hospital also have whiteboards, these two specific units were chosen because they used the same standardised whiteboard template, and the nurses had received the same training. The other two units did not have whiteboards in patient rooms, but patients were cared for by the same medicine teams and same set of nurses. Patients were randomly assigned to general medicine teams on these units based on the admission call schedule.

Whiteboard templates

Our whiteboard templates were based on recommendation from a prior study by Sehgal et al6 (see online supplementary appendix).

Training on use and maintenance of whiteboards

Medical students, residents and nursing staff had roles in maintaining the whiteboards. While the bedside nurses filled out the whiteboard templates, these four units also had medicine residents and medical students on the primary team assigned to ensure board information was complete, up to date and correct. We assigned nurse managers to audit the whiteboards to ensure they were being used.

During work rounds, we individually taught each of the medicine residents and medical students what to look for on the whiteboards and instructed them to correct any wrong information or add in missing information. We encouraged nurses to fill out the board template when the physicians are on rounds with the bedside nurses and the patients, so that all three parties could have input into the care plan.

The nurses on the units were not unit specific, so they could be on a unit with whiteboards one day and then on a unit without whiteboards the next day; however, they were always assigned within the sampled units. All nurses were formally trained on how to fill out the board template at weekly staff meetings led by nurse managers and charge nurses.

Subjects

To be included in the study, patients had to be between the ages of 18 and 91, on a general medicine team, with a non-surgical admission to one of our four study units, and with a minimum length of stay of 3 days. Exclusion criteria were as follows: non-English speaking, vision impairment preventing patients from seeing the board, poor literacy, altered mental status and declining to participate. We excluded the above patients because they had difficulty reading the board and therefore could not truly reflect the impact the whiteboards had on their hospitalisation. All patients on our four designated units who met the inclusion criteria were approached by the principle investigator and were given verbal information about the study. All patients gave verbal consent to participate in the confidential interview.

Patients’ views

During the 3-week survey, we sought the opinions of patients both on two inpatient wards where standardised whiteboards were being used and on two inpatient wards where they were not. We constructed a patient questionnaire using information from Stanford's Quality Improvement Team about aspects of care they found to be important to patients. The questionnaire was administered in person by the principle investigator who completed the questionnaire with the patient on the second or third day of admission. Other providers and ancillary staff were not permitted in the patient's room during the questionnaire. This questionnaire examined a patient's knowledge of the following (for the full questionnaire, see online supplementary appendix):

  1. Primary attending physician

  2. Reasons for admission

  3. Plan of care

  4. Approximate discharge date.

Patients were asked to indicate using a 1–5 Likert scale (5 being ‘strongly agree’) how strongly they agreed with a series of statements about their care (table 1). We then verbally confirmed accuracy by asking the patients to specifically give the name of the attending, the admission complaint and working diagnosis, upcoming studies and treatments, and estimated discharge date.

Table 1

Comparison of average patient scores for questions

We then drew patients to their whiteboard, and they were shown a list of ‘whiteboard information categories’ and asked what, if any, of the list they would like to see on their whiteboard. Finally, they were asked for any additional comments or suggestions. These were noted and then later compiled.

Residents’ views

At a single noon conference 1 week after the survey, the principal investigator presented the data from the patient survey to 25 residents who worked on the four inpatient wards during the pilot. The resident group included 18 first year, four second year and three third year medicine residents. Using an electronic audience polling device, the residents were asked the following:

  1. Having seen the patient data, were they more or less likely to use whiteboards?

  2. Which is the greatest barrier to effective whiteboard use?

    1. Time constraints

    2. The board is too burdensome to update multiple times a day

    3. Estimated discharge is difficult to predict

    4. It is unclear who should be up-dating the whiteboard

    5. Erasable markers are often unavailable

  3. We asked the audience for any suggestions about any insights about the challenges of whiteboard use.

Other views

Between 08:00 and 12:00 on the last day of the 3-week study, we asked for feedback from a convenience sample (n=40) of eight consultants, eight physical therapists, eight occupational therapists, eight case managers and eight family members who were present on the wards where the whiteboards were being used. The principle investigator verbally asked them:

  1. Whether they found the whiteboards very helpful, not helpful or neutral?

  2. Did they have any comments on the use of whiteboards?

Data analysis

We collected patient responses as integers from both groups, performed a rank sum test for each of the four patient interview questions, and compared the mean score from patients on units with whiteboards against the mean score from patients on units without whiteboards (table 1). We chose to use the rank sum test instead of a Student two-sample t test because our data were non-parametric due to heavy left-skewness (figure 1). Because our results had heavy left-skewness and the rank sum test does not account for variance, we ran a MANOVA on our four outcomes. To ensure that our study was adequately powered, we ran a post hoc power analysis using effect size (δ), as well as a Monte Carlo simulation to verify results.

Figure 1

Comparison of Likert scores for questions on units with whiteboards and units without whiteboards.

Project approval

Our project was reviewed and approved by the Stanford University Medical Center Committee for Quality Improvement. Approval from the Institutional Review Board was pursued but not required for this study, as it was deemed not to be human subject research.

Results

During our pilot period, there were 63 inpatients on the units with whiteboards and 58 inpatients on the units without whiteboards. Ultimately, we obtained surveys from 56 patients on units with whiteboards and 48 patients on units without whiteboards. On the units with whiteboards, seven patients were not eligible for our survey due to altered mental status. On the units without whiteboards, four patients were unable to participate because they could not read or speak English, and six additional patients were ineligible due to altered mental status. None of the eligible patients declined to answer the questions.

Patient responses

Patients on wards where whiteboards were used were significantly more likely to know their physician's name (p≤0.001) and understand the goals for their admission (p≤0.0016) than patients on other wards without whiteboards (figure 1). The accuracy of the responses to the questionnaire was confirmed by each patient's ability to name his or her attending doctor and reiterate the treatment plan. Patients on the wards with whiteboards were also more satisfied with their treatment at Stanford (p≤0.0242), which remained statistically significant after MANOVA analysis. Patients with whiteboards in their rooms tended to have higher scores overall.

On initial analysis, it appeared that patients on units with whiteboards were also better able to state their estimated discharge date (p≤0.0049). However, after MANOVA analysis, the question asking about the estimated discharge date was no longer statistically significant (p=0.1343); this is due to higher variance and lower effect size after the other questions are accounted for. This result is likely because only 32 of the 56 boards had the estimated discharge date filled out, as many medicine teams cited the estimated discharge date was difficult to predict.

The majority of patients wanted to see the following information on the board: the physician's name (100%), the bedside nurse's name (100%), the medical assistant's name (100%), tests and studies planned for the day (94%), estimated date of discharge (92%), and reason for admission (87%). Some less commonly suggested items for the whiteboard included lab results (15%), test results (18%) and consultants involved (34%) (figure 2).

Figure 2

Patient responses to specific information they wanted on the whiteboard template.

Resident responses

All of the medicine residents on the inpatient service during this pilot stated that the data encouraged them to use the whiteboards more. There was no noticeable difference between the responses from residents from different years of training. When we surveyed the residents about the biggest challenges to effective whiteboard use, time constraints was the most common answer (64%). Less common responses were that it was burdensome to update the board multiple times per day (8%), the estimated discharge date is difficult to predict (16%), it is unclear who should be in charge of the board (4%) and erasable markers are often unavailable (8%) (figure 3). On further questioning, another potential problem with the whiteboards is having information that is incorrect or not updated, which could cause more confusion with patients and staff.

Figure 3

Biggest challenges to whiteboard use.

Responses from others involved in patient care

All of the 40 consultants, physical therapists, occupational therapists, case managers and family members surveyed during team rounds on the final day of the pilot found the completed whiteboards to be a very helpful resource, and 80% cited the estimated discharge date as the most important piece of information.

Discussion

We have shown that using a whiteboard that is kept up to date with the template that we described improves several aspects of patients’ experiences with their care. This includes better knowledge of who the primary attending physician is, the goals for admission and overall satisfaction with patient care. Not only did patients use the whiteboards for reference, but consultants, family members and other ancillary staff benefited from whiteboards as well. Prior studies have found that nurses and physicians agree on the value of patient whiteboards and have even given recommendations for how to optimise whiteboard use,6 but they have not assessed the specific impact on patients. Based on our results, we recommend that patient whiteboards be part of the standard of care on any inpatient hospital unit.

Challenges and solutions

Our findings were consistent with prior studies in that whiteboard use does require training, task assignment, monitoring and integration into daily work flow. Additional challenges to efficacy also include the patient's mental status, language barriers, visual acuity and literacy.

We implemented several solutions during our pilot to improve compliance with whiteboard use. For the issue of ‘Time Constraints and Burden,’ we wanted to prevent whiteboard management from being a burden, and so we ask our physicians to check on the board only once a day on rounds. Further updates can be done by nurses at the physicians’ request (through text paging, phone calls, verbal requests or electronic medical record nursing communications). For the issue of defining roles in maintaining the whiteboard, refer to the Methods section for delineation of roles. For the estimated discharge date, our study was limited in that only 32 of the 56 whiteboards had estimated discharge dates filled out. The estimated discharge date is indeed difficult to definitively state; nonetheless, patients appreciated even an estimate of when they may be able to leave (eg, 1 week or 3–5 days). We currently have a follow-up project to address improving compliance with filling out the estimated discharge date and its challenges. One last barrier was the lack of whiteboard markers, so we suggest attaching the erasable marker to the whiteboard so that it is readily available for use.

Study limitations

As our survey was conducted on either the second or third day of admission, it was difficult to ascertain whether the information on the whiteboards helped patient knowledge of diagnosis, as the official diagnosis was often undetermined at the time of interview. Therefore, more questioning would have to be done after the diagnosis had been solidified. As we surveyed all patients on the general medicine service, an additional variable that was difficult to control for was the degree of complexity of the diagnosis for a patient, which would impact the patient's ability to understand the care plan and diagnosis. Similarly, medical literacy was another factor we could not control for during this short pilot. Another limitation of our study is that the survey was done while the patients were still admitted, which may positively skew our scores for patient satisfaction. Finally, our study was only over 3 weeks. We will continue to monitor our whiteboard use for sustainability.

Based on our two stage post hoc power analysis, during or pilot period, all questions except ‘I am satisfied with my hospital experience’ were adequately powered. Though the trend for a higher score in rooms with whiteboards was statistically significant, we believe this finding would have a stronger level of significance given more statistical power. As this study was done during an exploratory study period, we will need longer term follow-up to ensure sustainability and appropriate resource utilisation.

Although patients sometimes could not immediately give the name of the attending or list the procedures for the day, the whiteboard served as a resource for the patients and their families. Ultimately, the whiteboard allows for transparent communication.

Conclusions

Our study shows inpatient whiteboards improve patients’ awareness of their care team, plans for admission, duration of admission and significantly improve patient satisfaction overall. Inpatient whiteboards allow for more transparent communication between all those involved in a patient's care. With this knowledge, physicians are more encouraged to use whiteboards in their daily practice. To maximise the benefit of whiteboard use, it must be integrated into daily work flow with clear role responsibilities, and boards must be kept updated and correct. Patient whiteboards serve as a key tool to help bedside nurses and physicians work together with patients to improve patient-centred care.

Main messages

  • Effective whiteboard use requires participation from both nurses and physicians.

  • Inpatient whiteboards serve as reminders and communication tools for patients and providers.

  • Inpatient whiteboards improve patient knowledge, awareness and satisfaction.

Key references

  • Neda R, Federowicz MA, Christmas C, et al. Effects of a focused patient-centered care curriculum on the experiences of internal medicine residents and their patients. J Gen Intern Med 2012;27:473–7.

  • Boulding W, Glickman SW, Manary MP, et al. Relationship between patient satisfaction with inpatient care and hospital readmission within 30—days. Am J Manage Care 2011;17:41–8.

  • Olson DP, Windish DM. Communication discrepancies between physicians and hospitalized patients. Arch Intern Med 2010;170:1302–7.

  • Singh D, Fletcher KE, Pandl GJ, et al. It’s the writing on the wall: whiteboards improve inpatient satisfaction with provider communication. Am J Med Qual 2011;26:127–31.

  • Sehgal NL, Green A, Vidyarthi AR, et al. Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. J Hosp Med 2010;5:234–9.

Current research questions

  • How can a patient's estimated discharge date be better predicted?

  • Do satisfaction scores differ if patients are surveyed after discharge?

  • How would whiteboards impact the care of patients similar to those excluded in our study?

  • How can you sustain whiteboard use?

Acknowledgments

The authors would like to acknowledge Pooja Dagli for her assistance with statistics and also the nurses and residents who participated in this study.

References

View Abstract

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Files in this Data Supplement:

Footnotes

  • Contributors MT designed the project, collected the data and wrote the manuscript. KHE and LS helped in the project design and manuscript editing. CHB assisted in manuscript editing.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.