Context We identified a quality issue related to ward rounds in a 25-bed paediatric unit in a District General Hospital. Paediatric trainees, consultants and nursing team were involved in the improvement process.
Problem A safe and efficient service needs to ensure that there is a structured and high quality ward round (WR) including documentation of activities undertaken during WR. The core team (1 trainee, 1 Consultant and 1 nurse) observed that clinicians vary in their style for conducting ward rounds and trainees give variable emphasis on documenting these activities. We devised a list of 10 activities that needed proper documentation during WR.
Assessment of problem and analysis of its causes An audit was undertaken to review documentation of the post-take ward round. Same trainee looked at 46 medical records on 2 random days over a 7 week period.
Acceptable documentation was found for date, time, signature and name in 97.8%, discussion of management and discharge plans in 89.13% and recording focussed examination in 93.4% case notes.
There was inadequate record of who was present on WR at 78.2%, whether a nurse accompanied WR at 50% and whether the nursing observation chart was reviewed at 56.5%; although these charts were reviewed for nearly all patients.
There was poor documentation for recording parental concerns in 10.8%, recording investigation results in notes in 28.2%, documenting hydration status or fluid balance in 10.8% and whether medication prescription chart was reviewed in 23.9% case notes.
Intervention We reflected on the results of our audit and discussed the core activities that must be documented, creating standards for our unit. A helpful suggestion from discussion between trainees and nurses led to creation of a ‘Ward Round Stamp’ that is a simple tick list of 5 issues (see Figure 1) that is used as part of documenting activities on WR.
Strategy for change The results of our observation were discussed in the monthly departmental governance meeting. There were concerns raised about variable standards of ward rounds and their documentation. Few clinicians expressed a view that documenting key aspects of ward rounds are medico-legally important and a thorough documentation supports investigations when case notes are retrospectively scrutinised. Brainstorming further in a focussed team of trainees, consultants and nurses led to the practical decision to use the WR stamp identifying 5 activities that can be ticked. The use of stamp was easy to implement as it was an idea from trainees that their colleagues readily accepted. The use of WR stamp is now routinely discussed at induction whenever the trainees changeover. We are re-auditing the documentation during ward rounds. Interim results show that trainees remember to use the WR stamp on >80% occasions. At other times, the general improvement in documentation is noticeable.
Effects of changes There has been changeover of trainees and written feedback suggests that all trainees find paediatric ward rounds to be more structured than other departments they had rotated in. There has been no resistance from trainees or nurses in adapting the WR stamp. We still find occasions when trainees don’t use the WR stamp, but these are busier times or locum doctors. Trainees find structured ward rounds are helpful for training future doctors by providing a good example of safe service provision and good documentation.
Lessons learnt I have rotated to another unit and have continued a thorough documentation of all activities during ward rounds.
Message for others I found that lack of structure that can be responsible for poor quality within healthcare and solutions can be simple to devise and implement.
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