Transforming Healthcare

Heart failure (HF) carries a high rate of morbidity and mortality.1 In the past decades, the incidence of HF and HF‐related hospital admissions has risen continuously, posing a formidable healthcare and economic burden.24 Extensive evidence has shown that treatment of angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) reduces morbidity and mortality and improves quality of life in patients with HF and left ventricular systolic dysfunction (LVSD).57 Consequently, ACEi/ARB utilization in HF and LVSD has become one of the practice guidelines8 and a nationally required quality performance measure by The Joint Commission (TJC, formally known as JCAHO) and Centers for Medicare & Medicaid Services (CMS).

Despite the well‐demonstrated salutary effects and clear guidelines, under‐utilization of ACEi/ARB for HF patients has repeatedly been demonstrated.911 There seems to be a lasting quality chasm between the lifesaving therapy and its utilization in our practice.12 This chasm is illustrated by a recent study of 54,453 U.S. patients who were hospitalized for HF and discharged alive, showing that use of proven therapies such as ACEi/ARBs remains far from sufficient (48% for the total HF patients and 52% for HF patients with prior myocardial infarction).11 In large academic hospital centers, the ACEi/ARB utilization for HF patients has averaged between 8388%.13

Strides have been made to bridge the chasm;1419 however, these efforts have been impeded by complex and multifaceted problems. One of these problems is the sheer number of HF patients. In the current economic environment, traditional methods of pouring in more resources are unsustainable. Yet, the majority of quality improvement methods tried thus far involve increasing manpower, intensifying the delivery of staff and patient education, applying multiprong intervening systems, and prolonging the duration of the patients' hospital stay.1422

Although most of these measures achieve their intended goals, ongoing cost is required and the sustainability remains doubtful. Health information technology (IT) is emerging as a promising tool for improving care quality and containing cost.23 The electronic medical record (EMR) system at Mayo Clinic Rochester is built upon an IT patient record platform of Last Word (formerly a product of IDX, now General Electric, Fairfield, Connecticut) and has the capability of receiving vast input from databases in each department in our institution. In recent years, Mayo Clinic also has developed an IT hospital rule (algorithm)‐based system (HRBS) for comprehensive, multidisciplinary patient monitoring and cost containment (detailed in ref. 24). Pharmaceutical Care (P‐Care) is 1 of the 6 subsystems under HRBS. P‐care has been used primarily by inpatient pharmacists to detect situations where there is a high probability of suboptimal medication prescribing and where intervention by a pharmacist may be beneficial.

The primary goal of this project was to improve ACEi/ARB adherence for inpatients in a manner that would be sustainable. We intended to incorporate the existing features of our EMR as well as modify and utilize the P‐Care system to create a model that would improve ACEi/ARB adherence and work well with work‐flows of inpatient pharmacists and patient‐care teams.

Methods

Implementation of the Intervention

The intervention Model included three components: a computer‐based daily screening program developed from the existing P‐Care rule,24 inpatient pharmacists, and inpatient care teams. The interventional algorithm is illustrated in Figure 1. The computer‐based screening program that retrieved patients' LVEF data from EMR was up and running by the first quarter of 2006. A major attribute of the existing IT systems at Mayo Clinic has been that, however enormous, the data (input daily from diverse sources within the institution) are entered in a discrete, searchable and extractable format, which is critical for the data utilization. In the second quarter of 2006, we began an intense Plan‐Do‐Study‐Act (PDSA) cycle through multidisciplinary teamwork. To monitor e‐flagging efficiency, we randomly selected five units, manually monitored the number of patients who failed ACEi/ARB adherence and compared the number with that generated by the screening program. We found that the capturing rate was 100%.

Figure 1

Several problems were encountered with the model's operating process during implementation. The flagged list generated by the screening program was examined first by a pharmacist who then prepared a written note, indicating the deficiency along with a concise version of the guidelines. This note was placed in the patients' chart. Alternatively, the pharmacist might notify the patient‐care team by phone or in person during the teams' on their rounds.

However, notes were sometimes lost or overlooked, and verbal communications were inconsistent. In addition, the pharmacists were sometimes unsure whether, under certain clinical conditions (eg, serum creatinine elevation amidst diuresis), a HF patient should receive ACEis/ARBs.

Occasionally, care teams objected to the calls and viewed visits by pharmacists as interruption of their work flow resulting in awkward, and sometimes ineffective communications. Thus, the model seemed to have generated sizable extra work for the pharmacists and there was a notable time‐lag between the generation of the flag‐list and the successful delivery of the message.

To solve these problems, with the advantage of a programmer on the team, we created an electronic message (e‐message) delivery function within our EMR. When a patient‐care physician accesses the patient's information in EMR, a prompt indicating e‐message would appear. This modification allowed pharmacists' verification and an e‐message to be semiautomatically delivered to the patient‐care team. If the problem (non‐compliance to ACEi/ARB guidelines) was not addressed within 24 hours after the e‐message delivery, a pharmacist would then contact the team by phone or face‐to‐face. Additionally, an inpatient nephrologist was made available to answer any clinical questions that the pharmacists might have. We found that with these modifications the vast majority of the flags were corrected within 24 hours and pharmacists' workload was markedly reduced. After several initial communications between pharmacists and the nephrologist, the input by the nephrologist became minimal as pharmacists grew more accustomed to the majority of case scenarios.

Through such PDSA cycles, the operating process improved progressively. By March 2007, the implementation was complete and the model ran smoothly to the satisfaction of the team and other stakeholders.

Results

Percentage ACEi/ARB Adherence With the Intervention

The mean percentages of ACEi/ARB adherence in the periods before, during, and after the model implantation were 88.4%, 88.8%, and 97.6% respectively. Significant differences were detected between the three periods by Pearson's chi‐square test (P < 0.001). Fisher's Exact Test was used for comparing the periods before and after (P < 0.001, Figure 2A) and during and after (P < 0.001). Figure 2B shows the quarterly sensors of the adherence rate. Notably, after the implementation, the compliance rate remained high and the variations lessened.

Figure 2

Discussion

The results of this study show that the computer‐based quality improvement tool was associated with improved adherence to the ACEi/ARB guidelines for patients with LVSD/HF. This was accomplished without the need for additional, ongoing expenses in a system fitting our EMR capabilities and work flow.

Specific studies on the improvement of ACEi/ARB utilization for LVSD patients are limited.16, 21 One randomized controlled trial evaluated an inpatient HF intervention without a post‐discharge care plan.21 The intervention included inpatient guidelines for the use of ACEi, echocardiogram, daily weights and a consultative service provided by a nurse care manager and cardiologist. The consultative service included patient education, treatment recommendations, and discharge planning. This intervention significantly improved ACEi use at discharge.

Another randomized controlled study of 98 patients showed that compared to routine care, those who received multidisciplinary care (inpatient and outpatient education and intense telephone and clinic follow‐up), ACEi usage was maximized and re‐hospitalization and HFrelated death was significantly reduced at three months.16 Although effective, such interventions require substantial ongoing cost and sustainability is again called into question. Our initiative is unique in that incorporating a computer‐based semiautomatic system into the care‐delivery process has enhanced care quality without incurring ongoing extra cost (we have neither hired extra personnel nor created a heavier work burden for pharmacists and patientcare teams, as the model has been diffused into their daily routine) thus maximizing its longterm sustainability.

Notwithstanding the positive aspects, this study has several limitations. First, it is not a randomized, controlled trial, and unidentified external factors may have had some influence. However, in the examination of all potential external effects, we could not identify any factor that would have the capacity to substantially and consistently influence the results. Second, prepost study design is less ideal than randomized, controlled trials on the study design hierarchy. However, given the unsatisfactory adherence rate, anticipated positive effects with the model, and the pressing need for improving the adherence, a randomized trial was not an option at that juncture. Third, we could not precisely compare the difference in the awareness of ACEi/ARB guidelines among different classes of trainees during the study period. We did have a one‐time online, non‐mandatory education program for all providers. However, new trainees rotated in and‐ out on a monthly basis. This factor is unlikely to have caused a sustained change. Fourth, we did not have the outcome data for patients in whom HF was their secondary admission diagnosis. These patients were equally flagged by the model, and their ACEi/ARB status, when flagged, was obliged to be corrected. We suspect that these patients most likely benefited even more by the model because they were likely in a compensated state of HF, and the care‐teams tended to be more focused on their primary issue, leaving room for overlooking LVSD‐related issues.

Finally, we report the outcomes in the first 21 months after the full implementation of the model. We still need to monitor the long‐term outcome, although a reasonable length of time has elapsed. There has been no sign of decay in its effectiveness and we have no compelling reason to anticipate a significant regression.

Under ideal conditions, the outcome should consistently be 100% based on the design. In reality the adherence had been oscillating with an average of 97%. We noted two main scenarios that had contributed to this outcome. First, some LVSD/HF patients were taken off ACEi/ARB temporarily before discharge because of worsening pre‐renal azotemia with diuresis. They were discharged off ACEi/ARB with a plan to resume it. These patients would not have been labeled as ACEi/ARB‐intolerant but were classified as those without meeting the guidelines. Second, some patients had their echocardiogram on the same day or within 24 hours of discharge. A fraction of them had LVEF < 40%, but ACEi/ARB had not been initiated before discharge.

The rising volume of patients with increasing age and co‐morbidities, combined with constraints in healthcare resources, compels us to explore high‐efficiency care‐delivery models. Although computerized technology is well understood and readily available, the challenge we face is how to fully utilize the technology. A recent study shows that the improvement of IT infrastructure and research on implementation are interdependent and both can be translated to better patient care.25 Our experience serves as another example demonstrating that, when carefully conceived and properly executed, computer‐based care‐delivery prompts can be highly efficient and effective, suitable for large hospital settings with a heavy patient load like ours.

Moreover, because of the availability of basic IT platforms, similar algorithm‐based model systems can foreseeably be adopted by hospitals of comparable size and structure and also be applied to other care‐delivery settings including out‐patient clinics, chronic dialysis units and various long‐term care facilities.

Developing efficient, IT‐based quality improvement tools that facilitate the application of evidence‐based care and improve quality without significant additional resources is imperative in today's economic climate. Strategies such as our e‐messaging intervention with ACEi and ARB demonstrate sustainable improvement, can be applied to other conditions, and should be vigorously pursued.

Heart failure (HF) carries a high rate of morbidity and mortality.1 In the past decades, the incidence of HF and HF‐related hospital admissions has risen continuously, posing a formidable healthcare and economic burden.24 Extensive evidence has shown that treatment of angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) reduces morbidity and mortality and improves quality of life in patients with HF and left ventricular systolic dysfunction (LVSD).57 Consequently, ACEi/ARB utilization in HF and LVSD has become one of the practice guidelines8 and a nationally required quality performance measure by The Joint Commission (TJC, formally known as JCAHO) and Centers for Medicare & Medicaid Services (CMS).

Despite the well‐demonstrated salutary effects and clear guidelines, under‐utilization of ACEi/ARB for HF patients has repeatedly been demonstrated.911 There seems to be a lasting quality chasm between the lifesaving therapy and its utilization in our practice.12 This chasm is illustrated by a recent study of 54,453 U.S. patients who were hospitalized for HF and discharged alive, showing that use of proven therapies such as ACEi/ARBs remains far from sufficient (48% for the total HF patients and 52% for HF patients with prior myocardial infarction).11 In large academic hospital centers, the ACEi/ARB utilization for HF patients has averaged between 8388%.13

Strides have been made to bridge the chasm;1419 however, these efforts have been impeded by complex and multifaceted problems. One of these problems is the sheer number of HF patients. In the current economic environment, traditional methods of pouring in more resources are unsustainable. Yet, the majority of quality improvement methods tried thus far involve increasing manpower, intensifying the delivery of staff and patient education, applying multiprong intervening systems, and prolonging the duration of the patients' hospital stay.1422

Although most of these measures achieve their intended goals, ongoing cost is required and the sustainability remains doubtful. Health information technology (IT) is emerging as a promising tool for improving care quality and containing cost.23 The electronic medical record (EMR) system at Mayo Clinic Rochester is built upon an IT patient record platform of Last Word (formerly a product of IDX, now General Electric, Fairfield, Connecticut) and has the capability of receiving vast input from databases in each department in our institution. In recent years, Mayo Clinic also has developed an IT hospital rule (algorithm)‐based system (HRBS) for comprehensive, multidisciplinary patient monitoring and cost containment (detailed in ref. 24). Pharmaceutical Care (P‐Care) is 1 of the 6 subsystems under HRBS. P‐care has been used primarily by inpatient pharmacists to detect situations where there is a high probability of suboptimal medication prescribing and where intervention by a pharmacist may be beneficial.

The primary goal of this project was to improve ACEi/ARB adherence for inpatients in a manner that would be sustainable. We intended to incorporate the existing features of our EMR as well as modify and utilize the P‐Care system to create a model that would improve ACEi/ARB adherence and work well with work‐flows of inpatient pharmacists and patient‐care teams.

Methods

Implementation of the Intervention

The intervention Model included three components: a computer‐based daily screening program developed from the existing P‐Care rule,24 inpatient pharmacists, and inpatient care teams. The interventional algorithm is illustrated in Figure 1. The computer‐based screening program that retrieved patients' LVEF data from EMR was up and running by the first quarter of 2006. A major attribute of the existing IT systems at Mayo Clinic has been that, however enormous, the data (input daily from diverse sources within the institution) are entered in a discrete, searchable and extractable format, which is critical for the data utilization. In the second quarter of 2006, we began an intense Plan‐Do‐Study‐Act (PDSA) cycle through multidisciplinary teamwork. To monitor e‐flagging efficiency, we randomly selected five units, manually monitored the number of patients who failed ACEi/ARB adherence and compared the number with that generated by the screening program. We found that the capturing rate was 100%.

Figure 1

Several problems were encountered with the model's operating process during implementation. The flagged list generated by the screening program was examined first by a pharmacist who then prepared a written note, indicating the deficiency along with a concise version of the guidelines. This note was placed in the patients' chart. Alternatively, the pharmacist might notify the patient‐care team by phone or in person during the teams' on their rounds.

However, notes were sometimes lost or overlooked, and verbal communications were inconsistent. In addition, the pharmacists were sometimes unsure whether, under certain clinical conditions (eg, serum creatinine elevation amidst diuresis), a HF patient should receive ACEis/ARBs.

Occasionally, care teams objected to the calls and viewed visits by pharmacists as interruption of their work flow resulting in awkward, and sometimes ineffective communications. Thus, the model seemed to have generated sizable extra work for the pharmacists and there was a notable time‐lag between the generation of the flag‐list and the successful delivery of the message.

To solve these problems, with the advantage of a programmer on the team, we created an electronic message (e‐message) delivery function within our EMR. When a patient‐care physician accesses the patient's information in EMR, a prompt indicating e‐message would appear. This modification allowed pharmacists' verification and an e‐message to be semiautomatically delivered to the patient‐care team. If the problem (non‐compliance to ACEi/ARB guidelines) was not addressed within 24 hours after the e‐message delivery, a pharmacist would then contact the team by phone or face‐to‐face. Additionally, an inpatient nephrologist was made available to answer any clinical questions that the pharmacists might have. We found that with these modifications the vast majority of the flags were corrected within 24 hours and pharmacists' workload was markedly reduced. After several initial communications between pharmacists and the nephrologist, the input by the nephrologist became minimal as pharmacists grew more accustomed to the majority of case scenarios.

Through such PDSA cycles, the operating process improved progressively. By March 2007, the implementation was complete and the model ran smoothly to the satisfaction of the team and other stakeholders.

Results

Percentage ACEi/ARB Adherence With the Intervention

The mean percentages of ACEi/ARB adherence in the periods before, during, and after the model implantation were 88.4%, 88.8%, and 97.6% respectively. Significant differences were detected between the three periods by Pearson's chi‐square test (P < 0.001). Fisher's Exact Test was used for comparing the periods before and after (P < 0.001, Figure 2A) and during and after (P < 0.001). Figure 2B shows the quarterly sensors of the adherence rate. Notably, after the implementation, the compliance rate remained high and the variations lessened.

Figure 2

Discussion

The results of this study show that the computer‐based quality improvement tool was associated with improved adherence to the ACEi/ARB guidelines for patients with LVSD/HF. This was accomplished without the need for additional, ongoing expenses in a system fitting our EMR capabilities and work flow.

Specific studies on the improvement of ACEi/ARB utilization for LVSD patients are limited.16, 21 One randomized controlled trial evaluated an inpatient HF intervention without a post‐discharge care plan.21 The intervention included inpatient guidelines for the use of ACEi, echocardiogram, daily weights and a consultative service provided by a nurse care manager and cardiologist. The consultative service included patient education, treatment recommendations, and discharge planning. This intervention significantly improved ACEi use at discharge.

Another randomized controlled study of 98 patients showed that compared to routine care, those who received multidisciplinary care (inpatient and outpatient education and intense telephone and clinic follow‐up), ACEi usage was maximized and re‐hospitalization and HFrelated death was significantly reduced at three months.16 Although effective, such interventions require substantial ongoing cost and sustainability is again called into question. Our initiative is unique in that incorporating a computer‐based semiautomatic system into the care‐delivery process has enhanced care quality without incurring ongoing extra cost (we have neither hired extra personnel nor created a heavier work burden for pharmacists and patientcare teams, as the model has been diffused into their daily routine) thus maximizing its longterm sustainability.

Notwithstanding the positive aspects, this study has several limitations. First, it is not a randomized, controlled trial, and unidentified external factors may have had some influence. However, in the examination of all potential external effects, we could not identify any factor that would have the capacity to substantially and consistently influence the results. Second, prepost study design is less ideal than randomized, controlled trials on the study design hierarchy. However, given the unsatisfactory adherence rate, anticipated positive effects with the model, and the pressing need for improving the adherence, a randomized trial was not an option at that juncture. Third, we could not precisely compare the difference in the awareness of ACEi/ARB guidelines among different classes of trainees during the study period. We did have a one‐time online, non‐mandatory education program for all providers. However, new trainees rotated in and‐ out on a monthly basis. This factor is unlikely to have caused a sustained change. Fourth, we did not have the outcome data for patients in whom HF was their secondary admission diagnosis. These patients were equally flagged by the model, and their ACEi/ARB status, when flagged, was obliged to be corrected. We suspect that these patients most likely benefited even more by the model because they were likely in a compensated state of HF, and the care‐teams tended to be more focused on their primary issue, leaving room for overlooking LVSD‐related issues.

Finally, we report the outcomes in the first 21 months after the full implementation of the model. We still need to monitor the long‐term outcome, although a reasonable length of time has elapsed. There has been no sign of decay in its effectiveness and we have no compelling reason to anticipate a significant regression.

Under ideal conditions, the outcome should consistently be 100% based on the design. In reality the adherence had been oscillating with an average of 97%. We noted two main scenarios that had contributed to this outcome. First, some LVSD/HF patients were taken off ACEi/ARB temporarily before discharge because of worsening pre‐renal azotemia with diuresis. They were discharged off ACEi/ARB with a plan to resume it. These patients would not have been labeled as ACEi/ARB‐intolerant but were classified as those without meeting the guidelines. Second, some patients had their echocardiogram on the same day or within 24 hours of discharge. A fraction of them had LVEF < 40%, but ACEi/ARB had not been initiated before discharge.

The rising volume of patients with increasing age and co‐morbidities, combined with constraints in healthcare resources, compels us to explore high‐efficiency care‐delivery models. Although computerized technology is well understood and readily available, the challenge we face is how to fully utilize the technology. A recent study shows that the improvement of IT infrastructure and research on implementation are interdependent and both can be translated to better patient care.25 Our experience serves as another example demonstrating that, when carefully conceived and properly executed, computer‐based care‐delivery prompts can be highly efficient and effective, suitable for large hospital settings with a heavy patient load like ours.

Moreover, because of the availability of basic IT platforms, similar algorithm‐based model systems can foreseeably be adopted by hospitals of comparable size and structure and also be applied to other care‐delivery settings including out‐patient clinics, chronic dialysis units and various long‐term care facilities.

Developing efficient, IT‐based quality improvement tools that facilitate the application of evidence‐based care and improve quality without significant additional resources is imperative in today's economic climate. Strategies such as our e‐messaging intervention with ACEi and ARB demonstrate sustainable improvement, can be applied to other conditions, and should be vigorously pursued.

Heart failure (HF) carries a high rate of morbidity and mortality.1 In the past decades, the incidence of HF and HF‐related hospital admissions has risen continuously, posing a formidable healthcare and economic burden.24 Extensive evidence has shown that treatment of angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) reduces morbidity and mortality and improves quality of life in patients with HF and left ventricular systolic dysfunction (LVSD).57 Consequently, ACEi/ARB utilization in HF and LVSD has become one of the practice guidelines8 and a nationally required quality performance measure by The Joint Commission (TJC, formally known as JCAHO) and Centers for Medicare & Medicaid Services (CMS).

Despite the well‐demonstrated salutary effects and clear guidelines, under‐utilization of ACEi/ARB for HF patients has repeatedly been demonstrated.911 There seems to be a lasting quality chasm between the lifesaving therapy and its utilization in our practice.12 This chasm is illustrated by a recent study of 54,453 U.S. patients who were hospitalized for HF and discharged alive, showing that use of proven therapies such as ACEi/ARBs remains far from sufficient (48% for the total HF patients and 52% for HF patients with prior myocardial infarction).11 In large academic hospital centers, the ACEi/ARB utilization for HF patients has averaged between 8388%.13

Strides have been made to bridge the chasm;1419 however, these efforts have been impeded by complex and multifaceted problems. One of these problems is the sheer number of HF patients. In the current economic environment, traditional methods of pouring in more resources are unsustainable. Yet, the majority of quality improvement methods tried thus far involve increasing manpower, intensifying the delivery of staff and patient education, applying multiprong intervening systems, and prolonging the duration of the patients' hospital stay.1422

Although most of these measures achieve their intended goals, ongoing cost is required and the sustainability remains doubtful. Health information technology (IT) is emerging as a promising tool for improving care quality and containing cost.23 The electronic medical record (EMR) system at Mayo Clinic Rochester is built upon an IT patient record platform of Last Word (formerly a product of IDX, now General Electric, Fairfield, Connecticut) and has the capability of receiving vast input from databases in each department in our institution. In recent years, Mayo Clinic also has developed an IT hospital rule (algorithm)‐based system (HRBS) for comprehensive, multidisciplinary patient monitoring and cost containment (detailed in ref. 24). Pharmaceutical Care (P‐Care) is 1 of the 6 subsystems under HRBS. P‐care has been used primarily by inpatient pharmacists to detect situations where there is a high probability of suboptimal medication prescribing and where intervention by a pharmacist may be beneficial.

The primary goal of this project was to improve ACEi/ARB adherence for inpatients in a manner that would be sustainable. We intended to incorporate the existing features of our EMR as well as modify and utilize the P‐Care system to create a model that would improve ACEi/ARB adherence and work well with work‐flows of inpatient pharmacists and patient‐care teams.

Methods

Implementation of the Intervention

The intervention Model included three components: a computer‐based daily screening program developed from the existing P‐Care rule,24 inpatient pharmacists, and inpatient care teams. The interventional algorithm is illustrated in Figure 1. The computer‐based screening program that retrieved patients' LVEF data from EMR was up and running by the first quarter of 2006. A major attribute of the existing IT systems at Mayo Clinic has been that, however enormous, the data (input daily from diverse sources within the institution) are entered in a discrete, searchable and extractable format, which is critical for the data utilization. In the second quarter of 2006, we began an intense Plan‐Do‐Study‐Act (PDSA) cycle through multidisciplinary teamwork. To monitor e‐flagging efficiency, we randomly selected five units, manually monitored the number of patients who failed ACEi/ARB adherence and compared the number with that generated by the screening program. We found that the capturing rate was 100%.

Figure 1

Several problems were encountered with the model's operating process during implementation. The flagged list generated by the screening program was examined first by a pharmacist who then prepared a written note, indicating the deficiency along with a concise version of the guidelines. This note was placed in the patients' chart. Alternatively, the pharmacist might notify the patient‐care team by phone or in person during the teams' on their rounds.

However, notes were sometimes lost or overlooked, and verbal communications were inconsistent. In addition, the pharmacists were sometimes unsure whether, under certain clinical conditions (eg, serum creatinine elevation amidst diuresis), a HF patient should receive ACEis/ARBs.

Occasionally, care teams objected to the calls and viewed visits by pharmacists as interruption of their work flow resulting in awkward, and sometimes ineffective communications. Thus, the model seemed to have generated sizable extra work for the pharmacists and there was a notable time‐lag between the generation of the flag‐list and the successful delivery of the message.

To solve these problems, with the advantage of a programmer on the team, we created an electronic message (e‐message) delivery function within our EMR. When a patient‐care physician accesses the patient's information in EMR, a prompt indicating e‐message would appear. This modification allowed pharmacists' verification and an e‐message to be semiautomatically delivered to the patient‐care team. If the problem (non‐compliance to ACEi/ARB guidelines) was not addressed within 24 hours after the e‐message delivery, a pharmacist would then contact the team by phone or face‐to‐face. Additionally, an inpatient nephrologist was made available to answer any clinical questions that the pharmacists might have. We found that with these modifications the vast majority of the flags were corrected within 24 hours and pharmacists' workload was markedly reduced. After several initial communications between pharmacists and the nephrologist, the input by the nephrologist became minimal as pharmacists grew more accustomed to the majority of case scenarios.

Through such PDSA cycles, the operating process improved progressively. By March 2007, the implementation was complete and the model ran smoothly to the satisfaction of the team and other stakeholders.

Results

Percentage ACEi/ARB Adherence With the Intervention

The mean percentages of ACEi/ARB adherence in the periods before, during, and after the model implantation were 88.4%, 88.8%, and 97.6% respectively. Significant differences were detected between the three periods by Pearson's chi‐square test (P < 0.001). Fisher's Exact Test was used for comparing the periods before and after (P < 0.001, Figure 2A) and during and after (P < 0.001). Figure 2B shows the quarterly sensors of the adherence rate. Notably, after the implementation, the compliance rate remained high and the variations lessened.

Figure 2

Discussion

The results of this study show that the computer‐based quality improvement tool was associated with improved adherence to the ACEi/ARB guidelines for patients with LVSD/HF. This was accomplished without the need for additional, ongoing expenses in a system fitting our EMR capabilities and work flow.

Specific studies on the improvement of ACEi/ARB utilization for LVSD patients are limited.16, 21 One randomized controlled trial evaluated an inpatient HF intervention without a post‐discharge care plan.21 The intervention included inpatient guidelines for the use of ACEi, echocardiogram, daily weights and a consultative service provided by a nurse care manager and cardiologist. The consultative service included patient education, treatment recommendations, and discharge planning. This intervention significantly improved ACEi use at discharge.

Another randomized controlled study of 98 patients showed that compared to routine care, those who received multidisciplinary care (inpatient and outpatient education and intense telephone and clinic follow‐up), ACEi usage was maximized and re‐hospitalization and HFrelated death was significantly reduced at three months.16 Although effective, such interventions require substantial ongoing cost and sustainability is again called into question. Our initiative is unique in that incorporating a computer‐based semiautomatic system into the care‐delivery process has enhanced care quality without incurring ongoing extra cost (we have neither hired extra personnel nor created a heavier work burden for pharmacists and patientcare teams, as the model has been diffused into their daily routine) thus maximizing its longterm sustainability.

Notwithstanding the positive aspects, this study has several limitations. First, it is not a randomized, controlled trial, and unidentified external factors may have had some influence. However, in the examination of all potential external effects, we could not identify any factor that would have the capacity to substantially and consistently influence the results. Second, prepost study design is less ideal than randomized, controlled trials on the study design hierarchy. However, given the unsatisfactory adherence rate, anticipated positive effects with the model, and the pressing need for improving the adherence, a randomized trial was not an option at that juncture. Third, we could not precisely compare the difference in the awareness of ACEi/ARB guidelines among different classes of trainees during the study period. We did have a one‐time online, non‐mandatory education program for all providers. However, new trainees rotated in and‐ out on a monthly basis. This factor is unlikely to have caused a sustained change. Fourth, we did not have the outcome data for patients in whom HF was their secondary admission diagnosis. These patients were equally flagged by the model, and their ACEi/ARB status, when flagged, was obliged to be corrected. We suspect that these patients most likely benefited even more by the model because they were likely in a compensated state of HF, and the care‐teams tended to be more focused on their primary issue, leaving room for overlooking LVSD‐related issues.

Finally, we report the outcomes in the first 21 months after the full implementation of the model. We still need to monitor the long‐term outcome, although a reasonable length of time has elapsed. There has been no sign of decay in its effectiveness and we have no compelling reason to anticipate a significant regression.

Under ideal conditions, the outcome should consistently be 100% based on the design. In reality the adherence had been oscillating with an average of 97%. We noted two main scenarios that had contributed to this outcome. First, some LVSD/HF patients were taken off ACEi/ARB temporarily before discharge because of worsening pre‐renal azotemia with diuresis. They were discharged off ACEi/ARB with a plan to resume it. These patients would not have been labeled as ACEi/ARB‐intolerant but were classified as those without meeting the guidelines. Second, some patients had their echocardiogram on the same day or within 24 hours of discharge. A fraction of them had LVEF < 40%, but ACEi/ARB had not been initiated before discharge.

The rising volume of patients with increasing age and co‐morbidities, combined with constraints in healthcare resources, compels us to explore high‐efficiency care‐delivery models. Although computerized technology is well understood and readily available, the challenge we face is how to fully utilize the technology. A recent study shows that the improvement of IT infrastructure and research on implementation are interdependent and both can be translated to better patient care.25 Our experience serves as another example demonstrating that, when carefully conceived and properly executed, computer‐based care‐delivery prompts can be highly efficient and effective, suitable for large hospital settings with a heavy patient load like ours.

Moreover, because of the availability of basic IT platforms, similar algorithm‐based model systems can foreseeably be adopted by hospitals of comparable size and structure and also be applied to other care‐delivery settings including out‐patient clinics, chronic dialysis units and various long‐term care facilities.

Developing efficient, IT‐based quality improvement tools that facilitate the application of evidence‐based care and improve quality without significant additional resources is imperative in today's economic climate. Strategies such as our e‐messaging intervention with ACEi and ARB demonstrate sustainable improvement, can be applied to other conditions, and should be vigorously pursued.

Communication failures are a frequent cause of adverse events14; the Joint Commission (TJC) reports that such failures contributed to 65% of reported sentinel events.5 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.613 While these strategies largely address communication between healthcare providers, there is a growing emphasis on developing strategies to engage patients in their care, and improving communication with them and their families.

In 2007, TJC announced a new National Patient Safety Goal (NPSG) that encourage(s) patients' active involvement in their own care as a patient safety strategy.14 This builds upon a landmark Institute of Medicine report that highlighted patient‐centeredness as 1 of the 6 domains for delivering high‐quality care.15 Current literature on developing such patient‐centered strategies enumerates several approaches, including better access to health information, use of innovative technology solutions, and focused efforts at improving communication.1618

The placement of whiteboards in patient rooms is an increasingly common strategy to improve communication. These boards, typically placed on a wall near a patient's hospital bed, allow any number of providers to communicate a wide range of information. Both Kaiser Permanente's Nurse Knowledge Exchange program and the Institute for Healthcare Improvement's Transforming Care at the Bedside promote whiteboard use, though with little specific guidance about practical implementation.19^,20 Despite their growing prevalence, there is no published literature guiding the most effective uses of whiteboards, or describing their impact on communication, teamwork, or patient satisfaction and care. We present findings from a survey of patient whiteboard use on an academic medical service, and offer a series of recommendations based on our findings and experiences.

Methods

We anonymously surveyed bedside nurses from 3 inpatient medical units, internal medicine housestaff, and faculty from the Division of Hospital Medicine at the University of California, San Francisco (UCSF). We solicited experiences of physician and nursing leaders who were engaged in whiteboard interventions over the past 2 years to identify relevant topics for study. Their experiences were based on isolated unit‐based efforts to implement whiteboards through a variety of strategies (eg, whiteboard templates, simple identification of provider teams, goals for the day). Their input guided the survey development and the suggested recommendations. The topics identified were then translated into multiple‐choice questions, and further edited for clarity by the authors. A Likert scale was used that measured frequency of use, usefulness, and attitudes toward patient whiteboards. An open‐ended question seeking additional comments about patient whiteboards was also asked. The survey was administered to nurses at staff meetings and through physical mailboxes on their respective patient care units with a 1‐month collection period. The survey was administered to housestaff and attendings via e‐mail listserves using an online commercial survey administration tool.21 The nursing surveys were later entered into the same online survey administration tool, which ultimately provided summary reports and descriptive findings to meet the study objectives. Our project was reviewed and approved by the UCSF Committee on Human Research.

Results

Survey responses were collected from 104 nurse respondents (81% response rate), 118 internal medicine housestaff (74% response rate), and 31 hospitalists (86% response rate). Nurses were far more likely to write on whiteboards, read what was written on them, and find the related information useful (Figure 1A‐C). Nurses, housestaff, and attendings all believed the bedside nurse was the single most important provider name listed on a whiteboard. However, the respondents differed in their rated value of other providers listed on the whiteboard (Figure 2). Nurses gave higher ratings to the utility of having patient care assistants (PCAs) listed as compared to housestaff and attendings. Overall, respondents felt it would be less useful to list consultants and pharmacists than the nurse, attending, and housestaff. All of the respondents believed family contact information was the most useful information on a whiteboard, whereas more nurses rated a goal for the day and anticipated discharge date as more useful than housestaff and attendings (Figure 3).

Figure 1

Figure 2

Figure 3

From an operational standpoint, the majority of respondents felt that nurses should be responsible for the information on a whiteboard, nurses and physicians together should create goals for the day, and the greatest barrier to using whiteboards was not having pens easily available (Figure 4A‐C). Most respondents also agreed that using templated whiteboards (with predefined fields) to guide content would increase their use (Figure 4D). All respondents believed that whiteboard use could improve teamwork and communication as well as patient care (Figure 5). Respondents also offered a variety of specific comments in response to an open‐ended question about whiteboard use (Table 1).

Figure 4

Figure 5

Discussion

Our findings demonstrate the potential value of patient whiteboards, which is supported by the vast majority of respondents, who agreed their use may improve patient care and teamwork. It is also clear that whiteboard use is not achieving this potential or being used as a patient‐centered tool. This is best illustrated by findings of their low rate of use and completion among attendings and housestaff (Figure 1A, B) and the lack of consensus as to what information on the whiteboards is useful. Patient whiteboards require defined goals, thoughtful planning, regular monitoring, and ongoing evaluation. The challenges around effective adoption and implementation is perhaps more about ensuring compliance and completion rather than simply gaining buy‐in and engagement for their value.

While the differential use of whiteboards between nurses and physicians was not surprising, a few specific findings warrant further discussion. First, it is interesting that nurses rated their own names and that of PCAs as the most useful, while physicians rated the nurse's name as being of equal value to their own. This may speak to the role PCAs play for nurses in helping the latter provide bedside care, rather than a reflection of the nurses' perception of the value of PCAs for patients. Second, while all respondents rated highly the value of family contact information on the whiteboard, nurses valued a goal for the day and anticipated discharge date more highly than did physicians. These findings likely reflect that nurses desire an understanding about plans of care and if they are not communicated face‐to‐face as the most effective strategy,22 they should at least be spelled out clearly on a whiteboard. This is supported by evidence that better collaboration between nurses and physicians improves patient outcomes.23 It may also be that physicians place more value on their own progress notes (rather than whiteboards) as a vehicle for communicating daily goals and discharge planning.

Other practical considerations involve who owns it and, if we do create goals for the day, whose goals should they represent? The majority of nurse and physician responses advocated for nurses to be responsible for accurate and complete information being updated on whiteboards. A larger percentage of attendings favored shared responsibility of the whiteboard, which was reinforced by their support of having goals for the day created jointly by nurses and physicians. Interestingly, a much smaller percentage of respondents felt goals for the day should be driven by patients (or family members). These data may point to the different perspectives that each individual provider bringsphysician, nurse, pharmacist, discharge plannerwith their respective goals differing in nature. Finally, it is also interesting that while attendings and housestaff believed that whiteboards can improve patient care teamwork/communication (Figure 5), a much smaller percentage actually read what is on them (Figure 1B). This may reflect the unclear goals of whiteboards, its absence as part of daily workflow, the infrequency of updated information on them, or perhaps an institution‐specific phenomenon that we will use to drive further improvement strategies.

Selected respondent comments (Table 1) highlight important messages about whiteboard use and provide helpful context to the survey responses. We found that the goal of whiteboard use is not always clear; is it to improve communication among providers, to improve communication with patients, a tool to engage patients in their care, or some combination of the above? Without a clear goal, providers are left to wonder whether whiteboard use is simply another task or really an intervention to improve care. This may in part, or perhaps fully, explain the differences discovered in whiteboard use and practices among our surveyed providers.

If, however, one were to make clear that the goal of patient whiteboards is to engage patients in their care and help achieve an important NPSG, methods to implement their use become better guided. A limitation of our study is that we did not survey patients about their perceptions of whiteboards use, an important needs assessment that would further drive this patient‐centered intervention. Regardless, we can draw a number of lessons from our findings and devise a set of reasonable recommendations.

Recommendations

We provide the following set of recommendations for hospitals adopting patient whiteboards, drawing on our survey findings and experiences with implementation at our own institution. We also acknowledge the role that local hospital cultures may play in adopting whiteboard use, and our recommendations are simply guidelines that can be applied or used in planning efforts. We believe effective use of a patient whiteboard requires a patient‐centered approach and the following:

• 1

  Whiteboards should be placed in clear view of patients from their hospital bed

  A simple yet critical issue as placing a whiteboard behind a patient's bed or off to the side fails to provide them with a constant visual cue to engage in the information.

• 2

  Buy and fasten erasable pens to the whiteboards themselves

  In our institution, purchasing pens for each provider was a less effective strategy than simply affixing the pen to the whiteboard itself. A supply of erasable pens must be available at the nursing station to quickly replace those with fading ink.

• 3

  Create whiteboard templates

  Our findings and experience suggest that structured formats for whiteboards may be more effective in ensuring both important and accurate information gets included. Blank whiteboards lead to less standardization in practice and fail to create prompts for providers to both write and review the content available. Anecdotally, we created a number of whiteboards with templated information, and this did seem to increase the consistency, standardization, and ease of use.

• 4

  Whiteboard templates should include the following items:
• a

  Day and Date

  This serves to orient patients (and their families) as well as providers with the date of information written on the whiteboard. It is also an important mechanism to ensure information is updated daily.

• b

  Patient's name (or initials)

  With bed turnover (or patient transfers to different beds and units) commonplace in hospital care, we believe that listing the patient's name on the board prevents the potential for patients (and their families) or providers to mistakenly take information from a previous patient's care on the whiteboard for their own.

• c

  Bedside nurse

  This was noted as the most useful provider listed on a patient whiteboard, which is quite logical given the role bedside nurses play for hospitalized patients.

• d

  Primary physician(s) (attending, resident, and intern, if applicable)

  This was noted as the next most important provider(s) and perhaps increasingly important both in teaching and nonteaching settings where shift‐work and signouts are growing in frequency among physicians.

• e

  Goal for the day

  While this was not a consensus from our survey respondents, we believe patients (rather than providers) should ultimately guide determination of their goal for the day as this engages them directly with the planachieving a patient‐centered initiative. In our experience, an effective strategy was having the bedside nurse directly engage patients each morning to help place a goal for the day on their whiteboard.

• f

  Anticipated discharge date

  While understanding the potential for this date to change, we believe the benefits of having patients (and their families) thinking about discharge, rather than feeling surprised by it on the morning of discharge, serves as an important mechanism to bridge communication about the discharge process.24

• g

  Family member's contact information (phone number)

• h

  Questions for providers

  This last entry allows a space for families to engage the healthcare team and, once again, create an opportunity for clarification of treatment and discharge plans.

• 5

  Bedside nurses should facilitate writing and updating information on the whiteboard

  Without our survey findings, this might have generated debate or controversy over whether nurses should be burdened with one more task to their responsibilities. However, our nurse respondents embraced this responsibility with spontaneous comments about their patient advocate role, and stated that whiteboards can serve as a tool to assist in that responsibility. Furthermore, not a single nurse respondent stated as barrier to use that I didn't think it was my responsibility. Nonetheless, whiteboard use must be a shared communication tool and not simply a tool between nurse and patient. Practically, we would recommend that bedside nurses facilitate updating whiteboards each morning, at a time when they are already helping patients create a goal for the day. Other providers must be trained to review information on the whiteboard, engage patients about their specific goal, and share the responsibility of keeping the information on the whiteboard updated.

• 6

  Create a system for auditing utilization and providing feedback early during rollout

  We found that adoption was very slow at the outset. One strategy to consider is having designated auditors check whiteboards in each room, measuring weekly compliance and providing this feedback to nurse managers. This auditing process may help identify barriers that can be addressed quickly (eg, unavailability of pens).

Finally, it is important to comment on the confidentiality concerns often raised in the context of whiteboard use. Confidentiality concerns largely arise from personal health information being used without a patient's explicit consent. If our recommendations are adopted, they require whiteboard use to be a patient‐centered and patient‐driven initiative. The type of information on the whiteboard should be determined with sensitivity but also with consent of the patient. We have not experienced any concerns by patients or providers in this regard because patients are told about the goals of the whiteboard initiative with our above principles in mind.

Conclusions

Patient whiteboards may improve communication among members of the healthcare team (eg, nurses, physicians, and others) and between providers and their patients (and family members). Further investigation is warranted to determine if adopting our recommendations leads to improved communication, teamwork, or patient satisfaction and care. In the meantime, as many hospitals continue to install and implement whiteboards, we hope our recommendations, accompanied by an emphasis on creating a patient‐centered communication tool, offer a roadmap for considering best practices in their use.

Communication failures are a frequent cause of adverse events14; the Joint Commission (TJC) reports that such failures contributed to 65% of reported sentinel events.5 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.613 While these strategies largely address communication between healthcare providers, there is a growing emphasis on developing strategies to engage patients in their care, and improving communication with them and their families.

In 2007, TJC announced a new National Patient Safety Goal (NPSG) that encourage(s) patients' active involvement in their own care as a patient safety strategy.14 This builds upon a landmark Institute of Medicine report that highlighted patient‐centeredness as 1 of the 6 domains for delivering high‐quality care.15 Current literature on developing such patient‐centered strategies enumerates several approaches, including better access to health information, use of innovative technology solutions, and focused efforts at improving communication.1618

The placement of whiteboards in patient rooms is an increasingly common strategy to improve communication. These boards, typically placed on a wall near a patient's hospital bed, allow any number of providers to communicate a wide range of information. Both Kaiser Permanente's Nurse Knowledge Exchange program and the Institute for Healthcare Improvement's Transforming Care at the Bedside promote whiteboard use, though with little specific guidance about practical implementation.19^,20 Despite their growing prevalence, there is no published literature guiding the most effective uses of whiteboards, or describing their impact on communication, teamwork, or patient satisfaction and care. We present findings from a survey of patient whiteboard use on an academic medical service, and offer a series of recommendations based on our findings and experiences.

Methods

We anonymously surveyed bedside nurses from 3 inpatient medical units, internal medicine housestaff, and faculty from the Division of Hospital Medicine at the University of California, San Francisco (UCSF). We solicited experiences of physician and nursing leaders who were engaged in whiteboard interventions over the past 2 years to identify relevant topics for study. Their experiences were based on isolated unit‐based efforts to implement whiteboards through a variety of strategies (eg, whiteboard templates, simple identification of provider teams, goals for the day). Their input guided the survey development and the suggested recommendations. The topics identified were then translated into multiple‐choice questions, and further edited for clarity by the authors. A Likert scale was used that measured frequency of use, usefulness, and attitudes toward patient whiteboards. An open‐ended question seeking additional comments about patient whiteboards was also asked. The survey was administered to nurses at staff meetings and through physical mailboxes on their respective patient care units with a 1‐month collection period. The survey was administered to housestaff and attendings via e‐mail listserves using an online commercial survey administration tool.21 The nursing surveys were later entered into the same online survey administration tool, which ultimately provided summary reports and descriptive findings to meet the study objectives. Our project was reviewed and approved by the UCSF Committee on Human Research.

Results

Survey responses were collected from 104 nurse respondents (81% response rate), 118 internal medicine housestaff (74% response rate), and 31 hospitalists (86% response rate). Nurses were far more likely to write on whiteboards, read what was written on them, and find the related information useful (Figure 1A‐C). Nurses, housestaff, and attendings all believed the bedside nurse was the single most important provider name listed on a whiteboard. However, the respondents differed in their rated value of other providers listed on the whiteboard (Figure 2). Nurses gave higher ratings to the utility of having patient care assistants (PCAs) listed as compared to housestaff and attendings. Overall, respondents felt it would be less useful to list consultants and pharmacists than the nurse, attending, and housestaff. All of the respondents believed family contact information was the most useful information on a whiteboard, whereas more nurses rated a goal for the day and anticipated discharge date as more useful than housestaff and attendings (Figure 3).

Figure 1

Figure 2

Figure 3

From an operational standpoint, the majority of respondents felt that nurses should be responsible for the information on a whiteboard, nurses and physicians together should create goals for the day, and the greatest barrier to using whiteboards was not having pens easily available (Figure 4A‐C). Most respondents also agreed that using templated whiteboards (with predefined fields) to guide content would increase their use (Figure 4D). All respondents believed that whiteboard use could improve teamwork and communication as well as patient care (Figure 5). Respondents also offered a variety of specific comments in response to an open‐ended question about whiteboard use (Table 1).

Figure 4

Figure 5

Discussion

Our findings demonstrate the potential value of patient whiteboards, which is supported by the vast majority of respondents, who agreed their use may improve patient care and teamwork. It is also clear that whiteboard use is not achieving this potential or being used as a patient‐centered tool. This is best illustrated by findings of their low rate of use and completion among attendings and housestaff (Figure 1A, B) and the lack of consensus as to what information on the whiteboards is useful. Patient whiteboards require defined goals, thoughtful planning, regular monitoring, and ongoing evaluation. The challenges around effective adoption and implementation is perhaps more about ensuring compliance and completion rather than simply gaining buy‐in and engagement for their value.

While the differential use of whiteboards between nurses and physicians was not surprising, a few specific findings warrant further discussion. First, it is interesting that nurses rated their own names and that of PCAs as the most useful, while physicians rated the nurse's name as being of equal value to their own. This may speak to the role PCAs play for nurses in helping the latter provide bedside care, rather than a reflection of the nurses' perception of the value of PCAs for patients. Second, while all respondents rated highly the value of family contact information on the whiteboard, nurses valued a goal for the day and anticipated discharge date more highly than did physicians. These findings likely reflect that nurses desire an understanding about plans of care and if they are not communicated face‐to‐face as the most effective strategy,22 they should at least be spelled out clearly on a whiteboard. This is supported by evidence that better collaboration between nurses and physicians improves patient outcomes.23 It may also be that physicians place more value on their own progress notes (rather than whiteboards) as a vehicle for communicating daily goals and discharge planning.

Other practical considerations involve who owns it and, if we do create goals for the day, whose goals should they represent? The majority of nurse and physician responses advocated for nurses to be responsible for accurate and complete information being updated on whiteboards. A larger percentage of attendings favored shared responsibility of the whiteboard, which was reinforced by their support of having goals for the day created jointly by nurses and physicians. Interestingly, a much smaller percentage of respondents felt goals for the day should be driven by patients (or family members). These data may point to the different perspectives that each individual provider bringsphysician, nurse, pharmacist, discharge plannerwith their respective goals differing in nature. Finally, it is also interesting that while attendings and housestaff believed that whiteboards can improve patient care teamwork/communication (Figure 5), a much smaller percentage actually read what is on them (Figure 1B). This may reflect the unclear goals of whiteboards, its absence as part of daily workflow, the infrequency of updated information on them, or perhaps an institution‐specific phenomenon that we will use to drive further improvement strategies.

Selected respondent comments (Table 1) highlight important messages about whiteboard use and provide helpful context to the survey responses. We found that the goal of whiteboard use is not always clear; is it to improve communication among providers, to improve communication with patients, a tool to engage patients in their care, or some combination of the above? Without a clear goal, providers are left to wonder whether whiteboard use is simply another task or really an intervention to improve care. This may in part, or perhaps fully, explain the differences discovered in whiteboard use and practices among our surveyed providers.

If, however, one were to make clear that the goal of patient whiteboards is to engage patients in their care and help achieve an important NPSG, methods to implement their use become better guided. A limitation of our study is that we did not survey patients about their perceptions of whiteboards use, an important needs assessment that would further drive this patient‐centered intervention. Regardless, we can draw a number of lessons from our findings and devise a set of reasonable recommendations.

Recommendations

We provide the following set of recommendations for hospitals adopting patient whiteboards, drawing on our survey findings and experiences with implementation at our own institution. We also acknowledge the role that local hospital cultures may play in adopting whiteboard use, and our recommendations are simply guidelines that can be applied or used in planning efforts. We believe effective use of a patient whiteboard requires a patient‐centered approach and the following:

• 1

  Whiteboards should be placed in clear view of patients from their hospital bed

  A simple yet critical issue as placing a whiteboard behind a patient's bed or off to the side fails to provide them with a constant visual cue to engage in the information.

• 2

  Buy and fasten erasable pens to the whiteboards themselves

  In our institution, purchasing pens for each provider was a less effective strategy than simply affixing the pen to the whiteboard itself. A supply of erasable pens must be available at the nursing station to quickly replace those with fading ink.

• 3

  Create whiteboard templates

  Our findings and experience suggest that structured formats for whiteboards may be more effective in ensuring both important and accurate information gets included. Blank whiteboards lead to less standardization in practice and fail to create prompts for providers to both write and review the content available. Anecdotally, we created a number of whiteboards with templated information, and this did seem to increase the consistency, standardization, and ease of use.

• 4

  Whiteboard templates should include the following items:
• a

  Day and Date

  This serves to orient patients (and their families) as well as providers with the date of information written on the whiteboard. It is also an important mechanism to ensure information is updated daily.

• b

  Patient's name (or initials)

  With bed turnover (or patient transfers to different beds and units) commonplace in hospital care, we believe that listing the patient's name on the board prevents the potential for patients (and their families) or providers to mistakenly take information from a previous patient's care on the whiteboard for their own.

• c

  Bedside nurse

  This was noted as the most useful provider listed on a patient whiteboard, which is quite logical given the role bedside nurses play for hospitalized patients.

• d

  Primary physician(s) (attending, resident, and intern, if applicable)

  This was noted as the next most important provider(s) and perhaps increasingly important both in teaching and nonteaching settings where shift‐work and signouts are growing in frequency among physicians.

• e

  Goal for the day

  While this was not a consensus from our survey respondents, we believe patients (rather than providers) should ultimately guide determination of their goal for the day as this engages them directly with the planachieving a patient‐centered initiative. In our experience, an effective strategy was having the bedside nurse directly engage patients each morning to help place a goal for the day on their whiteboard.

• f

  Anticipated discharge date

  While understanding the potential for this date to change, we believe the benefits of having patients (and their families) thinking about discharge, rather than feeling surprised by it on the morning of discharge, serves as an important mechanism to bridge communication about the discharge process.24

• g

  Family member's contact information (phone number)

• h

  Questions for providers

  This last entry allows a space for families to engage the healthcare team and, once again, create an opportunity for clarification of treatment and discharge plans.

• 5

  Bedside nurses should facilitate writing and updating information on the whiteboard

  Without our survey findings, this might have generated debate or controversy over whether nurses should be burdened with one more task to their responsibilities. However, our nurse respondents embraced this responsibility with spontaneous comments about their patient advocate role, and stated that whiteboards can serve as a tool to assist in that responsibility. Furthermore, not a single nurse respondent stated as barrier to use that I didn't think it was my responsibility. Nonetheless, whiteboard use must be a shared communication tool and not simply a tool between nurse and patient. Practically, we would recommend that bedside nurses facilitate updating whiteboards each morning, at a time when they are already helping patients create a goal for the day. Other providers must be trained to review information on the whiteboard, engage patients about their specific goal, and share the responsibility of keeping the information on the whiteboard updated.

• 6

  Create a system for auditing utilization and providing feedback early during rollout

  We found that adoption was very slow at the outset. One strategy to consider is having designated auditors check whiteboards in each room, measuring weekly compliance and providing this feedback to nurse managers. This auditing process may help identify barriers that can be addressed quickly (eg, unavailability of pens).

Finally, it is important to comment on the confidentiality concerns often raised in the context of whiteboard use. Confidentiality concerns largely arise from personal health information being used without a patient's explicit consent. If our recommendations are adopted, they require whiteboard use to be a patient‐centered and patient‐driven initiative. The type of information on the whiteboard should be determined with sensitivity but also with consent of the patient. We have not experienced any concerns by patients or providers in this regard because patients are told about the goals of the whiteboard initiative with our above principles in mind.

Conclusions

Patient whiteboards may improve communication among members of the healthcare team (eg, nurses, physicians, and others) and between providers and their patients (and family members). Further investigation is warranted to determine if adopting our recommendations leads to improved communication, teamwork, or patient satisfaction and care. In the meantime, as many hospitals continue to install and implement whiteboards, we hope our recommendations, accompanied by an emphasis on creating a patient‐centered communication tool, offer a roadmap for considering best practices in their use.

Communication failures are a frequent cause of adverse events14; the Joint Commission (TJC) reports that such failures contributed to 65% of reported sentinel events.5 Strategies to improve communication have focused on implementing formal teamwork training programs and/or teaching specific communication skills.613 While these strategies largely address communication between healthcare providers, there is a growing emphasis on developing strategies to engage patients in their care, and improving communication with them and their families.

In 2007, TJC announced a new National Patient Safety Goal (NPSG) that encourage(s) patients' active involvement in their own care as a patient safety strategy.14 This builds upon a landmark Institute of Medicine report that highlighted patient‐centeredness as 1 of the 6 domains for delivering high‐quality care.15 Current literature on developing such patient‐centered strategies enumerates several approaches, including better access to health information, use of innovative technology solutions, and focused efforts at improving communication.1618

The placement of whiteboards in patient rooms is an increasingly common strategy to improve communication. These boards, typically placed on a wall near a patient's hospital bed, allow any number of providers to communicate a wide range of information. Both Kaiser Permanente's Nurse Knowledge Exchange program and the Institute for Healthcare Improvement's Transforming Care at the Bedside promote whiteboard use, though with little specific guidance about practical implementation.19^,20 Despite their growing prevalence, there is no published literature guiding the most effective uses of whiteboards, or describing their impact on communication, teamwork, or patient satisfaction and care. We present findings from a survey of patient whiteboard use on an academic medical service, and offer a series of recommendations based on our findings and experiences.

Methods

We anonymously surveyed bedside nurses from 3 inpatient medical units, internal medicine housestaff, and faculty from the Division of Hospital Medicine at the University of California, San Francisco (UCSF). We solicited experiences of physician and nursing leaders who were engaged in whiteboard interventions over the past 2 years to identify relevant topics for study. Their experiences were based on isolated unit‐based efforts to implement whiteboards through a variety of strategies (eg, whiteboard templates, simple identification of provider teams, goals for the day). Their input guided the survey development and the suggested recommendations. The topics identified were then translated into multiple‐choice questions, and further edited for clarity by the authors. A Likert scale was used that measured frequency of use, usefulness, and attitudes toward patient whiteboards. An open‐ended question seeking additional comments about patient whiteboards was also asked. The survey was administered to nurses at staff meetings and through physical mailboxes on their respective patient care units with a 1‐month collection period. The survey was administered to housestaff and attendings via e‐mail listserves using an online commercial survey administration tool.21 The nursing surveys were later entered into the same online survey administration tool, which ultimately provided summary reports and descriptive findings to meet the study objectives. Our project was reviewed and approved by the UCSF Committee on Human Research.

Results

Survey responses were collected from 104 nurse respondents (81% response rate), 118 internal medicine housestaff (74% response rate), and 31 hospitalists (86% response rate). Nurses were far more likely to write on whiteboards, read what was written on them, and find the related information useful (Figure 1A‐C). Nurses, housestaff, and attendings all believed the bedside nurse was the single most important provider name listed on a whiteboard. However, the respondents differed in their rated value of other providers listed on the whiteboard (Figure 2). Nurses gave higher ratings to the utility of having patient care assistants (PCAs) listed as compared to housestaff and attendings. Overall, respondents felt it would be less useful to list consultants and pharmacists than the nurse, attending, and housestaff. All of the respondents believed family contact information was the most useful information on a whiteboard, whereas more nurses rated a goal for the day and anticipated discharge date as more useful than housestaff and attendings (Figure 3).

Figure 1

Figure 2

Figure 3

From an operational standpoint, the majority of respondents felt that nurses should be responsible for the information on a whiteboard, nurses and physicians together should create goals for the day, and the greatest barrier to using whiteboards was not having pens easily available (Figure 4A‐C). Most respondents also agreed that using templated whiteboards (with predefined fields) to guide content would increase their use (Figure 4D). All respondents believed that whiteboard use could improve teamwork and communication as well as patient care (Figure 5). Respondents also offered a variety of specific comments in response to an open‐ended question about whiteboard use (Table 1).

Figure 4

Figure 5

Discussion

Our findings demonstrate the potential value of patient whiteboards, which is supported by the vast majority of respondents, who agreed their use may improve patient care and teamwork. It is also clear that whiteboard use is not achieving this potential or being used as a patient‐centered tool. This is best illustrated by findings of their low rate of use and completion among attendings and housestaff (Figure 1A, B) and the lack of consensus as to what information on the whiteboards is useful. Patient whiteboards require defined goals, thoughtful planning, regular monitoring, and ongoing evaluation. The challenges around effective adoption and implementation is perhaps more about ensuring compliance and completion rather than simply gaining buy‐in and engagement for their value.

While the differential use of whiteboards between nurses and physicians was not surprising, a few specific findings warrant further discussion. First, it is interesting that nurses rated their own names and that of PCAs as the most useful, while physicians rated the nurse's name as being of equal value to their own. This may speak to the role PCAs play for nurses in helping the latter provide bedside care, rather than a reflection of the nurses' perception of the value of PCAs for patients. Second, while all respondents rated highly the value of family contact information on the whiteboard, nurses valued a goal for the day and anticipated discharge date more highly than did physicians. These findings likely reflect that nurses desire an understanding about plans of care and if they are not communicated face‐to‐face as the most effective strategy,22 they should at least be spelled out clearly on a whiteboard. This is supported by evidence that better collaboration between nurses and physicians improves patient outcomes.23 It may also be that physicians place more value on their own progress notes (rather than whiteboards) as a vehicle for communicating daily goals and discharge planning.

Other practical considerations involve who owns it and, if we do create goals for the day, whose goals should they represent? The majority of nurse and physician responses advocated for nurses to be responsible for accurate and complete information being updated on whiteboards. A larger percentage of attendings favored shared responsibility of the whiteboard, which was reinforced by their support of having goals for the day created jointly by nurses and physicians. Interestingly, a much smaller percentage of respondents felt goals for the day should be driven by patients (or family members). These data may point to the different perspectives that each individual provider bringsphysician, nurse, pharmacist, discharge plannerwith their respective goals differing in nature. Finally, it is also interesting that while attendings and housestaff believed that whiteboards can improve patient care teamwork/communication (Figure 5), a much smaller percentage actually read what is on them (Figure 1B). This may reflect the unclear goals of whiteboards, its absence as part of daily workflow, the infrequency of updated information on them, or perhaps an institution‐specific phenomenon that we will use to drive further improvement strategies.

Selected respondent comments (Table 1) highlight important messages about whiteboard use and provide helpful context to the survey responses. We found that the goal of whiteboard use is not always clear; is it to improve communication among providers, to improve communication with patients, a tool to engage patients in their care, or some combination of the above? Without a clear goal, providers are left to wonder whether whiteboard use is simply another task or really an intervention to improve care. This may in part, or perhaps fully, explain the differences discovered in whiteboard use and practices among our surveyed providers.

If, however, one were to make clear that the goal of patient whiteboards is to engage patients in their care and help achieve an important NPSG, methods to implement their use become better guided. A limitation of our study is that we did not survey patients about their perceptions of whiteboards use, an important needs assessment that would further drive this patient‐centered intervention. Regardless, we can draw a number of lessons from our findings and devise a set of reasonable recommendations.

Recommendations

We provide the following set of recommendations for hospitals adopting patient whiteboards, drawing on our survey findings and experiences with implementation at our own institution. We also acknowledge the role that local hospital cultures may play in adopting whiteboard use, and our recommendations are simply guidelines that can be applied or used in planning efforts. We believe effective use of a patient whiteboard requires a patient‐centered approach and the following:

• 1

  Whiteboards should be placed in clear view of patients from their hospital bed

  A simple yet critical issue as placing a whiteboard behind a patient's bed or off to the side fails to provide them with a constant visual cue to engage in the information.

• 2

  Buy and fasten erasable pens to the whiteboards themselves

  In our institution, purchasing pens for each provider was a less effective strategy than simply affixing the pen to the whiteboard itself. A supply of erasable pens must be available at the nursing station to quickly replace those with fading ink.

• 3

  Create whiteboard templates

  Our findings and experience suggest that structured formats for whiteboards may be more effective in ensuring both important and accurate information gets included. Blank whiteboards lead to less standardization in practice and fail to create prompts for providers to both write and review the content available. Anecdotally, we created a number of whiteboards with templated information, and this did seem to increase the consistency, standardization, and ease of use.

• 4

  Whiteboard templates should include the following items:
• a

  Day and Date

  This serves to orient patients (and their families) as well as providers with the date of information written on the whiteboard. It is also an important mechanism to ensure information is updated daily.

• b

  Patient's name (or initials)

  With bed turnover (or patient transfers to different beds and units) commonplace in hospital care, we believe that listing the patient's name on the board prevents the potential for patients (and their families) or providers to mistakenly take information from a previous patient's care on the whiteboard for their own.

• c

  Bedside nurse

  This was noted as the most useful provider listed on a patient whiteboard, which is quite logical given the role bedside nurses play for hospitalized patients.

• d

  Primary physician(s) (attending, resident, and intern, if applicable)

  This was noted as the next most important provider(s) and perhaps increasingly important both in teaching and nonteaching settings where shift‐work and signouts are growing in frequency among physicians.

• e

  Goal for the day

  While this was not a consensus from our survey respondents, we believe patients (rather than providers) should ultimately guide determination of their goal for the day as this engages them directly with the planachieving a patient‐centered initiative. In our experience, an effective strategy was having the bedside nurse directly engage patients each morning to help place a goal for the day on their whiteboard.

• f

  Anticipated discharge date

  While understanding the potential for this date to change, we believe the benefits of having patients (and their families) thinking about discharge, rather than feeling surprised by it on the morning of discharge, serves as an important mechanism to bridge communication about the discharge process.24

• g

  Family member's contact information (phone number)

• h

  Questions for providers

  This last entry allows a space for families to engage the healthcare team and, once again, create an opportunity for clarification of treatment and discharge plans.

• 5

  Bedside nurses should facilitate writing and updating information on the whiteboard

  Without our survey findings, this might have generated debate or controversy over whether nurses should be burdened with one more task to their responsibilities. However, our nurse respondents embraced this responsibility with spontaneous comments about their patient advocate role, and stated that whiteboards can serve as a tool to assist in that responsibility. Furthermore, not a single nurse respondent stated as barrier to use that I didn't think it was my responsibility. Nonetheless, whiteboard use must be a shared communication tool and not simply a tool between nurse and patient. Practically, we would recommend that bedside nurses facilitate updating whiteboards each morning, at a time when they are already helping patients create a goal for the day. Other providers must be trained to review information on the whiteboard, engage patients about their specific goal, and share the responsibility of keeping the information on the whiteboard updated.

• 6

  Create a system for auditing utilization and providing feedback early during rollout

  We found that adoption was very slow at the outset. One strategy to consider is having designated auditors check whiteboards in each room, measuring weekly compliance and providing this feedback to nurse managers. This auditing process may help identify barriers that can be addressed quickly (eg, unavailability of pens).

Finally, it is important to comment on the confidentiality concerns often raised in the context of whiteboard use. Confidentiality concerns largely arise from personal health information being used without a patient's explicit consent. If our recommendations are adopted, they require whiteboard use to be a patient‐centered and patient‐driven initiative. The type of information on the whiteboard should be determined with sensitivity but also with consent of the patient. We have not experienced any concerns by patients or providers in this regard because patients are told about the goals of the whiteboard initiative with our above principles in mind.

Conclusions

Patient whiteboards may improve communication among members of the healthcare team (eg, nurses, physicians, and others) and between providers and their patients (and family members). Further investigation is warranted to determine if adopting our recommendations leads to improved communication, teamwork, or patient satisfaction and care. In the meantime, as many hospitals continue to install and implement whiteboards, we hope our recommendations, accompanied by an emphasis on creating a patient‐centered communication tool, offer a roadmap for considering best practices in their use.

Hospitals have important legal and ethical responsibilities for human participant research conducted within their facilities, such as ensuring that research complies with federal regulations and presents minimal risks to patients. Many hospitals accept as sufficient the federal requirement that human participant research studies have Institutional Review Board (IRB) review and approval. IRBs must review proposed research according to numerous criteria, such as scientific soundness, alignment with accepted ethics principles and weighing of benefit vs. risk to study participants.1, 2 The legally required aspects of IRB review do not, however, include considering practical matters in implementing and operating an interventional clinical trial in the complex environment of the modern acute care hospital.

Our hospital system established a broad policy requiring internal review and formal approval of any human participant research conducted within any of its hospitals, including studies that enroll hospital patients or hospital employees, utilize hospital medical records, or request hospital‐provided services for research tests or procedures. The purpose of this paper is to describe this formal hospital system review and approval process, the reasons for implementing it, and the types of issues considered prior to our hospital system granting a principal investigator permission to conduct a study.

Background

Surprisingly little healthcare or medical literature exists regarding hospital responsibilities toward human subject research conducted on its premises. Much of the literature focuses on ethics issues, the nature of informed consent, and study design. As critical as these discussions are, they seldom address the numerous complex operational issues and challenges that implementation of a clinical trial can create in a hospital setting.

Flanders et al.3 make the case for hospitalists and specialists to work together to support research that includes inpatients as study participants. Moore and Goldberg4 discuss the ingredients of successfully developing a research program in a community hospital and mention the need to involve all affected hospital departments in the initial hospital review of a study, evaluating study impact on hospital workflow, and establishing processes related to budgeting and billing. Jamerson5 also makes the case for hospital departmental review and involvement, assessment of the ability to integrate study activities into the hospital structure, assessment of the resources needed to support the research, determination of whether the hospital will contribute financially to the research, and explicit decision making regarding the assumption of institutional risk.

Despite the recognition that US patients increasingly live with multiple chronic conditions6 and that clinical trial protocols have become more procedure and resource intensive and costly,79 there has not been a corollary recognition of the increasing need for hospitals to understand and manage research activities occurring within their facilities.

Our organization is a hospital system with 9 acute care hospitals, including an academic teaching hospital (affiliated with a university medical school) with a Level 1 Trauma Center, 1 specialty rehabilitation hospital, numerous specialized clinics, and a LifeFlight Program with a 6‐helicopter fleet (Geisinger, Danville, PA). This system of hospitals serves the fourth largest metropolitan community in the US (Houston and Harris County in southeastern TX), with a population of nearly four million and a geographic spread of 1778 square miles.10, 11 The hospital system has approximately 140,700 inpatient admissions per year and 586,000 outpatient visits.

Eight years ago, our hospital system adopted a corporate policy requiring that any activity associated with human participant research receive prior hospital system review and approval. Our organization considers this review process vital to: (1) maintaining our commitment to our Federalwide Assurance with the Office for Human Research Protections, (2) abiding by the Joint Commission requirements related to research,12 (3) protecting the safety and confidentiality of patients and employees who are potential or actual research participants, (4) protecting the confidentiality of participants' medical information, (5) assuring that legal fundamentals and good clinical practice (GCH)13 are a part of study plans, (6) assuring that studies are operationally feasible, and (7) evaluating and minimizing risks to patients and risks to the organization.

Review and Approval Process

Overview

An investigator triggers a formal hospital system review by submitting study documents to 1 of the IRBs listed on the system's Federalwide Assurance through the electronic IRB system and completing the required hospital system's Research Application Form. The hospital system review occurs in parallel with the IRB review, not duplicating it but rather focusing separately on patient safety, operational and financial issues, and hospital risk issues.

Our Clinical Innovation and Research Institute manages the hospital system review. Upon electronic notification of a new study submission, an Institute Clinical Research Associate examines all study‐related documents, including the completed Research Application Form and other submitted documents, such as the study protocol, the investigational product's Investigator's Brochure, consent forms, Food and Drug Administration (FDA) letters, survey questions, and diary and other data collection forms. The Associate may spend considerable time communicating with the investigator's research team, collecting missing information and building a complete study file, including identifying the affected hospitals and hospital departments. The Institute then provides study documents to the individuals responsible for hospital‐level research review, and each affected hospital conducts its own internal review and approval process.

The hospital‐level review process varies depending on the hospitals involved. The academic teaching hospital has the most detailed review process, due to the complexities and risks associated with the full spectrum of human participant research which occurs there (Hospital A in Figure 1). If a study affects this hospital, the Institute provides study documents to each affected Department Manager, the affected Service Line Chief, the Chief Medical Officer or Medical Director of each Intensive Care Unit within which the study will recruit and enroll patients, and the Infection Control Officer and Radiation Safety Officer, as appropriate.

Figure 1

The specialty rehabilitation hospital has a long‐standing national reputation for its research programs; its Director of Research knows each investigator, reviews each study, and provides that hospital's administrative review (Hospital B). Seven of the system's community hospitals have either a Chief Executive Officer, Chief Nursing Officer, or Chief Financial Officer serve as the hospital's executive administrator responsible for research review, and this person distributes the study documents to the Chief Medical Officer, if deemed necessary, and to each affected department (Hospitals C‐I). One of the smaller community hospitals participates in relatively few studies; the Chief Nursing Officer reviews and provides hospital‐level approval (Hospital J). For retrospective studies requesting a clinical data set, the Institute provides the study documents to the Director of the Information Systems Department. All studies accessing patient data are provided to the system Privacy Officer for review and approval.

Studies may involve 1 or more hospitals; some have involved as many as 7 at once.

All reviewers also receive a standardized Research Study Evaluation Form for their written comments and recommendations (Approve, Disapprove, or Defer) regarding whether the hospital system should approve the study.

If a study requests hospital‐provided research services, the Institute's Research Financial Coordinator develops a research budget listing the hospital charges that the researcher will incur for these tests and procedures.

Once reviewers return completed Evaluation Forms, the Institute Clinical Research Associate makes an initial determination whether the review process has satisfactorily answered all questions and resolved all outstanding issues. The Manager of Clinical Research Operations then examines the study file to ensure a satisfactory review. Finally, the system Executive Director for Clinical Research provides a Letter of Approval to the Principal Investigator, which serves as the agreement of terms for conducting the study within the hospital system. The letter contains standard stipulations, such as requiring the Principal Investigator to abide by federal law and International Conference on Harmonization (ICH) GCPs and the budget for the hospital‐provided research tests and procedures. Additionally, it includes any stipulations unique to the studyfor example, that the Principal Investigator will provide training to hospital personnel who will be operating nonhospital equipment. The Institute provides affected hospital departments with copies of the approval letter. Upon signing and returning the letter, the Principal Investigator may begin the study in the designated hospitals.

Some details about the hospital system review are discussed in sections below.

Discussion

Our hospital research review and approval process is critical to ensuring that only safe and regulatory‐compliant research activities occur within our hospital system, but the review and approval process, with its many steps and numerous reviewers, can be cumbersome. There is no substitute for human beings reading and understanding the protocol, consent forms for patient involvement in a study, the proposed use of protected health information, Investigator's Brochure, Research Application Form, and other study documents and then identifying pertinent issues and resolving them, and this process does require significant staff time.

We have improved (continuously) the Research Application Form to help in the crucial initial gathering of information about studies' operational needs. We have also converted from a predominantly paper‐based review process to the widespread use of electronic documents, but we have not automated the distribution process for these electronic documents and a staff person must still do this through email.

Despite our efforts to improve the review process, investigators are sometimes frustrated with it, particularly if someone identifies a new issue late in the process, or if the hospital system's approval for the study lags behind the IRB approval by more than a few days.

Currently, the hospital system provides the majority of study approvals to the Principal Investigator within 2 weeks of IRB approval, with some approvals provided within 1 day of IRB approval and others as long as 3 months afterward. Delays in hospital approval can be due to a study lacking required approval from a Department of Defense IRB, the FDA not providing permission to proceed with a study, the absence of an executed contract with a vendor to pick up and dispose of radioactive waste from the investigational product and many other factors. Of course, when the research team can respond in timely fashion to inquiries or issues that we have raised, that assists all of us in completing the review and approval process as quickly as possible.

The review and approval process benefits hospital patients, hospital personnel who will be supporting studies, and hospitals as institutions. Thinking through, planning, and preparing for study operations, particularly for studies taking place in an ICU, benefits the research team, hospital personnel, and the patients. Overall, the hospital system's research review and approval process affords many protections to our patients and reduces risks to the hospital system while permitting research studies to be conducted within its varied healthcare facilities.

We encourage researchers not to view today's modern hospital as bricks and mortar, but as an institution with deep responsibility for safety on hospital premises. Hospitals must meet over a thousand Joint Commission standards, set goals for patient outcomes, measure and report on quality indicators, protect patient confidentiality, maintain the safety an ever‐expanding array of simple and complex equipment, maintain, check and document contents of adult and pediatric crash carts, have 24‐7 code teams at‐the‐ready, create, maintain and store patient medical records securely, transport patients, and much more.

Conclusion

Our hospital system, in accordance with a system‐wide policy, engages in a comprehensive review and approval process for any human participant research that has been proposed to be conducted within one or more of our facilities. The process focuses primarily on patient safety within the hospital premises, operational study issues, financial issues and hospital risk issues. This process decreases risks to the patients, researchers, and hospital facilities engaging in human participant research.

Hospitals have important legal and ethical responsibilities for human participant research conducted within their facilities, such as ensuring that research complies with federal regulations and presents minimal risks to patients. Many hospitals accept as sufficient the federal requirement that human participant research studies have Institutional Review Board (IRB) review and approval. IRBs must review proposed research according to numerous criteria, such as scientific soundness, alignment with accepted ethics principles and weighing of benefit vs. risk to study participants.1, 2 The legally required aspects of IRB review do not, however, include considering practical matters in implementing and operating an interventional clinical trial in the complex environment of the modern acute care hospital.

Our hospital system established a broad policy requiring internal review and formal approval of any human participant research conducted within any of its hospitals, including studies that enroll hospital patients or hospital employees, utilize hospital medical records, or request hospital‐provided services for research tests or procedures. The purpose of this paper is to describe this formal hospital system review and approval process, the reasons for implementing it, and the types of issues considered prior to our hospital system granting a principal investigator permission to conduct a study.

Background

Surprisingly little healthcare or medical literature exists regarding hospital responsibilities toward human subject research conducted on its premises. Much of the literature focuses on ethics issues, the nature of informed consent, and study design. As critical as these discussions are, they seldom address the numerous complex operational issues and challenges that implementation of a clinical trial can create in a hospital setting.

Flanders et al.3 make the case for hospitalists and specialists to work together to support research that includes inpatients as study participants. Moore and Goldberg4 discuss the ingredients of successfully developing a research program in a community hospital and mention the need to involve all affected hospital departments in the initial hospital review of a study, evaluating study impact on hospital workflow, and establishing processes related to budgeting and billing. Jamerson5 also makes the case for hospital departmental review and involvement, assessment of the ability to integrate study activities into the hospital structure, assessment of the resources needed to support the research, determination of whether the hospital will contribute financially to the research, and explicit decision making regarding the assumption of institutional risk.

Despite the recognition that US patients increasingly live with multiple chronic conditions6 and that clinical trial protocols have become more procedure and resource intensive and costly,79 there has not been a corollary recognition of the increasing need for hospitals to understand and manage research activities occurring within their facilities.

Our organization is a hospital system with 9 acute care hospitals, including an academic teaching hospital (affiliated with a university medical school) with a Level 1 Trauma Center, 1 specialty rehabilitation hospital, numerous specialized clinics, and a LifeFlight Program with a 6‐helicopter fleet (Geisinger, Danville, PA). This system of hospitals serves the fourth largest metropolitan community in the US (Houston and Harris County in southeastern TX), with a population of nearly four million and a geographic spread of 1778 square miles.10, 11 The hospital system has approximately 140,700 inpatient admissions per year and 586,000 outpatient visits.

Eight years ago, our hospital system adopted a corporate policy requiring that any activity associated with human participant research receive prior hospital system review and approval. Our organization considers this review process vital to: (1) maintaining our commitment to our Federalwide Assurance with the Office for Human Research Protections, (2) abiding by the Joint Commission requirements related to research,12 (3) protecting the safety and confidentiality of patients and employees who are potential or actual research participants, (4) protecting the confidentiality of participants' medical information, (5) assuring that legal fundamentals and good clinical practice (GCH)13 are a part of study plans, (6) assuring that studies are operationally feasible, and (7) evaluating and minimizing risks to patients and risks to the organization.

Review and Approval Process

Overview

An investigator triggers a formal hospital system review by submitting study documents to 1 of the IRBs listed on the system's Federalwide Assurance through the electronic IRB system and completing the required hospital system's Research Application Form. The hospital system review occurs in parallel with the IRB review, not duplicating it but rather focusing separately on patient safety, operational and financial issues, and hospital risk issues.

Our Clinical Innovation and Research Institute manages the hospital system review. Upon electronic notification of a new study submission, an Institute Clinical Research Associate examines all study‐related documents, including the completed Research Application Form and other submitted documents, such as the study protocol, the investigational product's Investigator's Brochure, consent forms, Food and Drug Administration (FDA) letters, survey questions, and diary and other data collection forms. The Associate may spend considerable time communicating with the investigator's research team, collecting missing information and building a complete study file, including identifying the affected hospitals and hospital departments. The Institute then provides study documents to the individuals responsible for hospital‐level research review, and each affected hospital conducts its own internal review and approval process.

The hospital‐level review process varies depending on the hospitals involved. The academic teaching hospital has the most detailed review process, due to the complexities and risks associated with the full spectrum of human participant research which occurs there (Hospital A in Figure 1). If a study affects this hospital, the Institute provides study documents to each affected Department Manager, the affected Service Line Chief, the Chief Medical Officer or Medical Director of each Intensive Care Unit within which the study will recruit and enroll patients, and the Infection Control Officer and Radiation Safety Officer, as appropriate.

Figure 1

The specialty rehabilitation hospital has a long‐standing national reputation for its research programs; its Director of Research knows each investigator, reviews each study, and provides that hospital's administrative review (Hospital B). Seven of the system's community hospitals have either a Chief Executive Officer, Chief Nursing Officer, or Chief Financial Officer serve as the hospital's executive administrator responsible for research review, and this person distributes the study documents to the Chief Medical Officer, if deemed necessary, and to each affected department (Hospitals C‐I). One of the smaller community hospitals participates in relatively few studies; the Chief Nursing Officer reviews and provides hospital‐level approval (Hospital J). For retrospective studies requesting a clinical data set, the Institute provides the study documents to the Director of the Information Systems Department. All studies accessing patient data are provided to the system Privacy Officer for review and approval.

Studies may involve 1 or more hospitals; some have involved as many as 7 at once.

All reviewers also receive a standardized Research Study Evaluation Form for their written comments and recommendations (Approve, Disapprove, or Defer) regarding whether the hospital system should approve the study.

If a study requests hospital‐provided research services, the Institute's Research Financial Coordinator develops a research budget listing the hospital charges that the researcher will incur for these tests and procedures.

Once reviewers return completed Evaluation Forms, the Institute Clinical Research Associate makes an initial determination whether the review process has satisfactorily answered all questions and resolved all outstanding issues. The Manager of Clinical Research Operations then examines the study file to ensure a satisfactory review. Finally, the system Executive Director for Clinical Research provides a Letter of Approval to the Principal Investigator, which serves as the agreement of terms for conducting the study within the hospital system. The letter contains standard stipulations, such as requiring the Principal Investigator to abide by federal law and International Conference on Harmonization (ICH) GCPs and the budget for the hospital‐provided research tests and procedures. Additionally, it includes any stipulations unique to the studyfor example, that the Principal Investigator will provide training to hospital personnel who will be operating nonhospital equipment. The Institute provides affected hospital departments with copies of the approval letter. Upon signing and returning the letter, the Principal Investigator may begin the study in the designated hospitals.

Some details about the hospital system review are discussed in sections below.

Discussion

Our hospital research review and approval process is critical to ensuring that only safe and regulatory‐compliant research activities occur within our hospital system, but the review and approval process, with its many steps and numerous reviewers, can be cumbersome. There is no substitute for human beings reading and understanding the protocol, consent forms for patient involvement in a study, the proposed use of protected health information, Investigator's Brochure, Research Application Form, and other study documents and then identifying pertinent issues and resolving them, and this process does require significant staff time.

We have improved (continuously) the Research Application Form to help in the crucial initial gathering of information about studies' operational needs. We have also converted from a predominantly paper‐based review process to the widespread use of electronic documents, but we have not automated the distribution process for these electronic documents and a staff person must still do this through email.

Despite our efforts to improve the review process, investigators are sometimes frustrated with it, particularly if someone identifies a new issue late in the process, or if the hospital system's approval for the study lags behind the IRB approval by more than a few days.

Currently, the hospital system provides the majority of study approvals to the Principal Investigator within 2 weeks of IRB approval, with some approvals provided within 1 day of IRB approval and others as long as 3 months afterward. Delays in hospital approval can be due to a study lacking required approval from a Department of Defense IRB, the FDA not providing permission to proceed with a study, the absence of an executed contract with a vendor to pick up and dispose of radioactive waste from the investigational product and many other factors. Of course, when the research team can respond in timely fashion to inquiries or issues that we have raised, that assists all of us in completing the review and approval process as quickly as possible.

The review and approval process benefits hospital patients, hospital personnel who will be supporting studies, and hospitals as institutions. Thinking through, planning, and preparing for study operations, particularly for studies taking place in an ICU, benefits the research team, hospital personnel, and the patients. Overall, the hospital system's research review and approval process affords many protections to our patients and reduces risks to the hospital system while permitting research studies to be conducted within its varied healthcare facilities.

We encourage researchers not to view today's modern hospital as bricks and mortar, but as an institution with deep responsibility for safety on hospital premises. Hospitals must meet over a thousand Joint Commission standards, set goals for patient outcomes, measure and report on quality indicators, protect patient confidentiality, maintain the safety an ever‐expanding array of simple and complex equipment, maintain, check and document contents of adult and pediatric crash carts, have 24‐7 code teams at‐the‐ready, create, maintain and store patient medical records securely, transport patients, and much more.

Conclusion

Our hospital system, in accordance with a system‐wide policy, engages in a comprehensive review and approval process for any human participant research that has been proposed to be conducted within one or more of our facilities. The process focuses primarily on patient safety within the hospital premises, operational study issues, financial issues and hospital risk issues. This process decreases risks to the patients, researchers, and hospital facilities engaging in human participant research.

Hospitals have important legal and ethical responsibilities for human participant research conducted within their facilities, such as ensuring that research complies with federal regulations and presents minimal risks to patients. Many hospitals accept as sufficient the federal requirement that human participant research studies have Institutional Review Board (IRB) review and approval. IRBs must review proposed research according to numerous criteria, such as scientific soundness, alignment with accepted ethics principles and weighing of benefit vs. risk to study participants.1, 2 The legally required aspects of IRB review do not, however, include considering practical matters in implementing and operating an interventional clinical trial in the complex environment of the modern acute care hospital.

Our hospital system established a broad policy requiring internal review and formal approval of any human participant research conducted within any of its hospitals, including studies that enroll hospital patients or hospital employees, utilize hospital medical records, or request hospital‐provided services for research tests or procedures. The purpose of this paper is to describe this formal hospital system review and approval process, the reasons for implementing it, and the types of issues considered prior to our hospital system granting a principal investigator permission to conduct a study.

Background

Surprisingly little healthcare or medical literature exists regarding hospital responsibilities toward human subject research conducted on its premises. Much of the literature focuses on ethics issues, the nature of informed consent, and study design. As critical as these discussions are, they seldom address the numerous complex operational issues and challenges that implementation of a clinical trial can create in a hospital setting.

Flanders et al.3 make the case for hospitalists and specialists to work together to support research that includes inpatients as study participants. Moore and Goldberg4 discuss the ingredients of successfully developing a research program in a community hospital and mention the need to involve all affected hospital departments in the initial hospital review of a study, evaluating study impact on hospital workflow, and establishing processes related to budgeting and billing. Jamerson5 also makes the case for hospital departmental review and involvement, assessment of the ability to integrate study activities into the hospital structure, assessment of the resources needed to support the research, determination of whether the hospital will contribute financially to the research, and explicit decision making regarding the assumption of institutional risk.

Despite the recognition that US patients increasingly live with multiple chronic conditions6 and that clinical trial protocols have become more procedure and resource intensive and costly,79 there has not been a corollary recognition of the increasing need for hospitals to understand and manage research activities occurring within their facilities.

Our organization is a hospital system with 9 acute care hospitals, including an academic teaching hospital (affiliated with a university medical school) with a Level 1 Trauma Center, 1 specialty rehabilitation hospital, numerous specialized clinics, and a LifeFlight Program with a 6‐helicopter fleet (Geisinger, Danville, PA). This system of hospitals serves the fourth largest metropolitan community in the US (Houston and Harris County in southeastern TX), with a population of nearly four million and a geographic spread of 1778 square miles.10, 11 The hospital system has approximately 140,700 inpatient admissions per year and 586,000 outpatient visits.

Eight years ago, our hospital system adopted a corporate policy requiring that any activity associated with human participant research receive prior hospital system review and approval. Our organization considers this review process vital to: (1) maintaining our commitment to our Federalwide Assurance with the Office for Human Research Protections, (2) abiding by the Joint Commission requirements related to research,12 (3) protecting the safety and confidentiality of patients and employees who are potential or actual research participants, (4) protecting the confidentiality of participants' medical information, (5) assuring that legal fundamentals and good clinical practice (GCH)13 are a part of study plans, (6) assuring that studies are operationally feasible, and (7) evaluating and minimizing risks to patients and risks to the organization.

Review and Approval Process

Overview

An investigator triggers a formal hospital system review by submitting study documents to 1 of the IRBs listed on the system's Federalwide Assurance through the electronic IRB system and completing the required hospital system's Research Application Form. The hospital system review occurs in parallel with the IRB review, not duplicating it but rather focusing separately on patient safety, operational and financial issues, and hospital risk issues.

Our Clinical Innovation and Research Institute manages the hospital system review. Upon electronic notification of a new study submission, an Institute Clinical Research Associate examines all study‐related documents, including the completed Research Application Form and other submitted documents, such as the study protocol, the investigational product's Investigator's Brochure, consent forms, Food and Drug Administration (FDA) letters, survey questions, and diary and other data collection forms. The Associate may spend considerable time communicating with the investigator's research team, collecting missing information and building a complete study file, including identifying the affected hospitals and hospital departments. The Institute then provides study documents to the individuals responsible for hospital‐level research review, and each affected hospital conducts its own internal review and approval process.

The hospital‐level review process varies depending on the hospitals involved. The academic teaching hospital has the most detailed review process, due to the complexities and risks associated with the full spectrum of human participant research which occurs there (Hospital A in Figure 1). If a study affects this hospital, the Institute provides study documents to each affected Department Manager, the affected Service Line Chief, the Chief Medical Officer or Medical Director of each Intensive Care Unit within which the study will recruit and enroll patients, and the Infection Control Officer and Radiation Safety Officer, as appropriate.

Figure 1

The specialty rehabilitation hospital has a long‐standing national reputation for its research programs; its Director of Research knows each investigator, reviews each study, and provides that hospital's administrative review (Hospital B). Seven of the system's community hospitals have either a Chief Executive Officer, Chief Nursing Officer, or Chief Financial Officer serve as the hospital's executive administrator responsible for research review, and this person distributes the study documents to the Chief Medical Officer, if deemed necessary, and to each affected department (Hospitals C‐I). One of the smaller community hospitals participates in relatively few studies; the Chief Nursing Officer reviews and provides hospital‐level approval (Hospital J). For retrospective studies requesting a clinical data set, the Institute provides the study documents to the Director of the Information Systems Department. All studies accessing patient data are provided to the system Privacy Officer for review and approval.

Studies may involve 1 or more hospitals; some have involved as many as 7 at once.

All reviewers also receive a standardized Research Study Evaluation Form for their written comments and recommendations (Approve, Disapprove, or Defer) regarding whether the hospital system should approve the study.

If a study requests hospital‐provided research services, the Institute's Research Financial Coordinator develops a research budget listing the hospital charges that the researcher will incur for these tests and procedures.

Once reviewers return completed Evaluation Forms, the Institute Clinical Research Associate makes an initial determination whether the review process has satisfactorily answered all questions and resolved all outstanding issues. The Manager of Clinical Research Operations then examines the study file to ensure a satisfactory review. Finally, the system Executive Director for Clinical Research provides a Letter of Approval to the Principal Investigator, which serves as the agreement of terms for conducting the study within the hospital system. The letter contains standard stipulations, such as requiring the Principal Investigator to abide by federal law and International Conference on Harmonization (ICH) GCPs and the budget for the hospital‐provided research tests and procedures. Additionally, it includes any stipulations unique to the studyfor example, that the Principal Investigator will provide training to hospital personnel who will be operating nonhospital equipment. The Institute provides affected hospital departments with copies of the approval letter. Upon signing and returning the letter, the Principal Investigator may begin the study in the designated hospitals.

Some details about the hospital system review are discussed in sections below.

Discussion

Our hospital research review and approval process is critical to ensuring that only safe and regulatory‐compliant research activities occur within our hospital system, but the review and approval process, with its many steps and numerous reviewers, can be cumbersome. There is no substitute for human beings reading and understanding the protocol, consent forms for patient involvement in a study, the proposed use of protected health information, Investigator's Brochure, Research Application Form, and other study documents and then identifying pertinent issues and resolving them, and this process does require significant staff time.

We have improved (continuously) the Research Application Form to help in the crucial initial gathering of information about studies' operational needs. We have also converted from a predominantly paper‐based review process to the widespread use of electronic documents, but we have not automated the distribution process for these electronic documents and a staff person must still do this through email.

Despite our efforts to improve the review process, investigators are sometimes frustrated with it, particularly if someone identifies a new issue late in the process, or if the hospital system's approval for the study lags behind the IRB approval by more than a few days.

Currently, the hospital system provides the majority of study approvals to the Principal Investigator within 2 weeks of IRB approval, with some approvals provided within 1 day of IRB approval and others as long as 3 months afterward. Delays in hospital approval can be due to a study lacking required approval from a Department of Defense IRB, the FDA not providing permission to proceed with a study, the absence of an executed contract with a vendor to pick up and dispose of radioactive waste from the investigational product and many other factors. Of course, when the research team can respond in timely fashion to inquiries or issues that we have raised, that assists all of us in completing the review and approval process as quickly as possible.

The review and approval process benefits hospital patients, hospital personnel who will be supporting studies, and hospitals as institutions. Thinking through, planning, and preparing for study operations, particularly for studies taking place in an ICU, benefits the research team, hospital personnel, and the patients. Overall, the hospital system's research review and approval process affords many protections to our patients and reduces risks to the hospital system while permitting research studies to be conducted within its varied healthcare facilities.

We encourage researchers not to view today's modern hospital as bricks and mortar, but as an institution with deep responsibility for safety on hospital premises. Hospitals must meet over a thousand Joint Commission standards, set goals for patient outcomes, measure and report on quality indicators, protect patient confidentiality, maintain the safety an ever‐expanding array of simple and complex equipment, maintain, check and document contents of adult and pediatric crash carts, have 24‐7 code teams at‐the‐ready, create, maintain and store patient medical records securely, transport patients, and much more.

Conclusion

Our hospital system, in accordance with a system‐wide policy, engages in a comprehensive review and approval process for any human participant research that has been proposed to be conducted within one or more of our facilities. The process focuses primarily on patient safety within the hospital premises, operational study issues, financial issues and hospital risk issues. This process decreases risks to the patients, researchers, and hospital facilities engaging in human participant research.

Even though imposition of smoke‐free policies and workplaces comprise one of the most effective antismoking strategies,1 hospital administrators hesitate to implement a smoke‐free medical campus policy.2 They fear losing patients who smoke because these patients will opt for other facilities that permit smoking.

Apart from studies evaluating Joint Commission on Accreditation of Healthcare Organizations (JCAHO)‐required indoor smoking bans in hospitals in 1992,3, 4 there are few published studies or formal evaluations of the impact of medical campuses going smoke‐free. One study of the implementation of a smoke‐free medical campus policy at a university hospital in Little Rock, AR, showed that the policy had no impact on employee retention, bed occupancy, or mean daily census; however, inpatient smoking status was not ascertained.5 Most (83%) employees were supportive of the policy. More importantly, employees at 2 university medical centers reported reduced cigarette consumption and increased attempts to quit after implementation of a smoke‐free medical campus policy.6, 7

Our hospital is 180‐bed, acute care inpatient teaching facility in upstate New York. Prior to the implementation of the smoke‐free medical campus policy, it was common to see employees, visitors, and patients lined up outdoors around the main hospital entrances and smoking just beyond the no smoking signage. Inpatients could look out their windows at the main entrance or into the courtyard and see hospital staff, other patients, and visitors smoking.

This study prospectively evaluates the impact of implementing the smoke‐free medical campus policy and starting an inpatient smoking cessation service. It addresses the following questions that have also been raised by the Task Force for Community Preventive Services.8 Does the institution of hospital smoking bans reduce the percentage of inpatients who smoke or increase the percentage who sign out against medical advice? What are the extended effects (beyond 1 year after implementation) of medical campus smoking bans on employee smoking rates?

Materials and Methods

Results

Inpatient Outcomes

An average of 959 patients were admitted per month in the 18‐month period pre‐ban (January 2005 to June 2006) vs. 988 per month in the 23‐month period post‐ban (July 2006 to September 2008). A monthly average of 89% of inpatients were screened for tobacco use when admitted. The monthly average for the percentage of inpatients who currently smoke has been approximately 21.6% following the implementation of the smoke‐free hospital plan. There has been little variation (Figure 1) in the percentage of inpatients who smoke pre‐ban and post‐ban except for the startup period in 2006 and the onset of the 2007 respiratory illness season.

Figure 1

Among all inpatients who currently smoke, 69.8% received a brief nursing intervention at the time of admission and 25% received an inpatient visit from our part‐time smoking cessation specialist.

The percentage of inpatients who signed out against medical advice (AMA) with the reason of having to smoke was 13.8% (4/29) 6 months pre‐ban, and 13.6% (3/22) 6 months post‐ban. In 2007, there were no inpatients who signed out AMA stating that they needed to smoke. Because the reason for signing out AMA may be underreported, we also examined the rate of smoking among all inpatients who sign out AMA. Six months pre‐ban, this percentage was 48.3% (14/29), but increased 6 months post‐ban to 59% (13/22). In 2007, the percentage of smokers among inpatients who sign out AMA leveled off at 50.8% (29/57).

Review of computerized inpatient prescription orders shows that orders for NRT nearly tripled after the inpatient smoking cessation service started April 1, 2006 (3 months prior to the ban) (Figure 2). Inpatient orders for these medications increased from 832 in a 2‐year period before the ban (April 1, 2004 to March 31, 2006) to 2475 in the 2 years following the initiation of the inpatient smoking service (April 1, 2006 to March 31, 2008). The Chow test is highly significant for a break point in June 2006 (P = 0.008), 1 month prior to the ban.

Figure 2

Discussion

Following implementation of a smoke‐free medical campus, no adverse effects were observed on inpatient volume at our hospital. The percentage of inpatients who smoke and the percentage of inpatients signing out AMA have remained stable after the smoke‐free policy went into effect. In addition, self‐reported employee smoking rates decreased significantly. Fears about losing inpatients (who smoke) following the implementation of a smoke‐free hospital plan were unfounded.

This study employs the electronic medical record to not only monitor trends in the proportion of inpatients who smoke pre‐ban and post‐ban, but also to notify our inpatient smoking cessation specialist, on the day of admission, to consult on patients who currently smoke. Unfortunately, our cessation specialist, who is part‐time, was unable to see all inpatients who smoke on account of the inpatient's acuity, pain, hospice status, weekend or night admission, or not being available due to testing, surgery, or other procedures. Nevertheless, use of NRT increased sharply following the initiation of this program. As shown in Figure 2, a linear rise in NRT orders was already underway starting April 2005, probably in anticipation of the ban and coinciding with the start of the inpatient smoking cessation program. However, the Chow test is highly significant for a breakpoint in June 2006 (P = 0.008), 1 month prior to the ban, meaning that the slope was climbing even more steeply after that point.

As hospitalized smokers may be more motivated to stop smoking, the updated 2008 clinical practice guidelines for Treating Tobacco Use and Dependence now recommend that all patients in the hospital be given medications, advised, counseled, and receive follow‐up after discharge.13 Although our inpatient cessation program was started before these clinical practice guidelines were available, we are currently evaluating the efficacy of our inpatient program by assessing self‐reported quit rates 6‐months posthospitalization (data collection in process). Provision of inpatient smoking cessation has been shown to be an effective smoking cessation intervention if combined with outpatient follow‐up.14 Our current program will be expanded to include outpatient follow‐up, if the inpatient's primary care provider is unable to provide it or if the inpatient refuses faxed referral to the New York State quit line program.

This study evaluates the impact of simultaneously introduced interventions such as medical campus smoking ban, inpatient smoking cessation program, hospital staff education, and other elements of the University of Michigan Smoke‐Free Hospital Implementation Plan. The role of individual components of the plan cannot be evaluated in this study as they were intentionally implemented simultaneously in order to achieve a synergistic effect.

Another limitation of this study is that smoking status is self‐reported and not validated biochemically. Although validated smoking status measures such as salivary cotinine testing would be more scientifically valid, it was not feasible to validate the smoking status of inpatients, nor that of employees. Thus smoking status, as ascertained in this study, is subject to underreporting. Social desirability bias has been recognized as potential limitation of self‐reported smoking status in other evaluations of smoke‐free policies.3, 4, 15

In the 1990s, the employee benefits of instituting indoor smoking bans in hospitals were theorized to include reduced employee sick time, break time, and tobacco use, as well as increased motivation for smoking cessation and reduced legitimacy of tobacco use.16, 17 Peer pressure, workplace socialization, and being forced to stay away from cigarettes for the length of entire workdays have been credited with helping hospital workers to quit.4, 7 In our study, extending the ban to the outdoor areas of our medical campus as well as provision of employee smoking cessation services may augment these mechanisms. This study extends findings of older studies that showed hospital smoking bans (primarily indoor) decreased hospital employee smoking rates. Currently, our reduced employee smoking rate approaches the Healthy People 2010 goal of 12%.18

In conclusion, implementing a smoke‐free medical campus does not adversely affect inpatient volume (even among smokers), does not increase inpatient signing out AMA and can significantly increase inpatient NRT use, which in turn can increase the success of a quit attempt.19 In addition, implementing an outdoor smoking ban further reduces hospital employee smoking rates.

Even though imposition of smoke‐free policies and workplaces comprise one of the most effective antismoking strategies,1 hospital administrators hesitate to implement a smoke‐free medical campus policy.2 They fear losing patients who smoke because these patients will opt for other facilities that permit smoking.

Apart from studies evaluating Joint Commission on Accreditation of Healthcare Organizations (JCAHO)‐required indoor smoking bans in hospitals in 1992,3, 4 there are few published studies or formal evaluations of the impact of medical campuses going smoke‐free. One study of the implementation of a smoke‐free medical campus policy at a university hospital in Little Rock, AR, showed that the policy had no impact on employee retention, bed occupancy, or mean daily census; however, inpatient smoking status was not ascertained.5 Most (83%) employees were supportive of the policy. More importantly, employees at 2 university medical centers reported reduced cigarette consumption and increased attempts to quit after implementation of a smoke‐free medical campus policy.6, 7

Our hospital is 180‐bed, acute care inpatient teaching facility in upstate New York. Prior to the implementation of the smoke‐free medical campus policy, it was common to see employees, visitors, and patients lined up outdoors around the main hospital entrances and smoking just beyond the no smoking signage. Inpatients could look out their windows at the main entrance or into the courtyard and see hospital staff, other patients, and visitors smoking.

This study prospectively evaluates the impact of implementing the smoke‐free medical campus policy and starting an inpatient smoking cessation service. It addresses the following questions that have also been raised by the Task Force for Community Preventive Services.8 Does the institution of hospital smoking bans reduce the percentage of inpatients who smoke or increase the percentage who sign out against medical advice? What are the extended effects (beyond 1 year after implementation) of medical campus smoking bans on employee smoking rates?

Materials and Methods

Results

Inpatient Outcomes

An average of 959 patients were admitted per month in the 18‐month period pre‐ban (January 2005 to June 2006) vs. 988 per month in the 23‐month period post‐ban (July 2006 to September 2008). A monthly average of 89% of inpatients were screened for tobacco use when admitted. The monthly average for the percentage of inpatients who currently smoke has been approximately 21.6% following the implementation of the smoke‐free hospital plan. There has been little variation (Figure 1) in the percentage of inpatients who smoke pre‐ban and post‐ban except for the startup period in 2006 and the onset of the 2007 respiratory illness season.

Figure 1

Among all inpatients who currently smoke, 69.8% received a brief nursing intervention at the time of admission and 25% received an inpatient visit from our part‐time smoking cessation specialist.

The percentage of inpatients who signed out against medical advice (AMA) with the reason of having to smoke was 13.8% (4/29) 6 months pre‐ban, and 13.6% (3/22) 6 months post‐ban. In 2007, there were no inpatients who signed out AMA stating that they needed to smoke. Because the reason for signing out AMA may be underreported, we also examined the rate of smoking among all inpatients who sign out AMA. Six months pre‐ban, this percentage was 48.3% (14/29), but increased 6 months post‐ban to 59% (13/22). In 2007, the percentage of smokers among inpatients who sign out AMA leveled off at 50.8% (29/57).

Review of computerized inpatient prescription orders shows that orders for NRT nearly tripled after the inpatient smoking cessation service started April 1, 2006 (3 months prior to the ban) (Figure 2). Inpatient orders for these medications increased from 832 in a 2‐year period before the ban (April 1, 2004 to March 31, 2006) to 2475 in the 2 years following the initiation of the inpatient smoking service (April 1, 2006 to March 31, 2008). The Chow test is highly significant for a break point in June 2006 (P = 0.008), 1 month prior to the ban.

Figure 2

Discussion

Following implementation of a smoke‐free medical campus, no adverse effects were observed on inpatient volume at our hospital. The percentage of inpatients who smoke and the percentage of inpatients signing out AMA have remained stable after the smoke‐free policy went into effect. In addition, self‐reported employee smoking rates decreased significantly. Fears about losing inpatients (who smoke) following the implementation of a smoke‐free hospital plan were unfounded.

This study employs the electronic medical record to not only monitor trends in the proportion of inpatients who smoke pre‐ban and post‐ban, but also to notify our inpatient smoking cessation specialist, on the day of admission, to consult on patients who currently smoke. Unfortunately, our cessation specialist, who is part‐time, was unable to see all inpatients who smoke on account of the inpatient's acuity, pain, hospice status, weekend or night admission, or not being available due to testing, surgery, or other procedures. Nevertheless, use of NRT increased sharply following the initiation of this program. As shown in Figure 2, a linear rise in NRT orders was already underway starting April 2005, probably in anticipation of the ban and coinciding with the start of the inpatient smoking cessation program. However, the Chow test is highly significant for a breakpoint in June 2006 (P = 0.008), 1 month prior to the ban, meaning that the slope was climbing even more steeply after that point.

As hospitalized smokers may be more motivated to stop smoking, the updated 2008 clinical practice guidelines for Treating Tobacco Use and Dependence now recommend that all patients in the hospital be given medications, advised, counseled, and receive follow‐up after discharge.13 Although our inpatient cessation program was started before these clinical practice guidelines were available, we are currently evaluating the efficacy of our inpatient program by assessing self‐reported quit rates 6‐months posthospitalization (data collection in process). Provision of inpatient smoking cessation has been shown to be an effective smoking cessation intervention if combined with outpatient follow‐up.14 Our current program will be expanded to include outpatient follow‐up, if the inpatient's primary care provider is unable to provide it or if the inpatient refuses faxed referral to the New York State quit line program.

This study evaluates the impact of simultaneously introduced interventions such as medical campus smoking ban, inpatient smoking cessation program, hospital staff education, and other elements of the University of Michigan Smoke‐Free Hospital Implementation Plan. The role of individual components of the plan cannot be evaluated in this study as they were intentionally implemented simultaneously in order to achieve a synergistic effect.

Another limitation of this study is that smoking status is self‐reported and not validated biochemically. Although validated smoking status measures such as salivary cotinine testing would be more scientifically valid, it was not feasible to validate the smoking status of inpatients, nor that of employees. Thus smoking status, as ascertained in this study, is subject to underreporting. Social desirability bias has been recognized as potential limitation of self‐reported smoking status in other evaluations of smoke‐free policies.3, 4, 15

In the 1990s, the employee benefits of instituting indoor smoking bans in hospitals were theorized to include reduced employee sick time, break time, and tobacco use, as well as increased motivation for smoking cessation and reduced legitimacy of tobacco use.16, 17 Peer pressure, workplace socialization, and being forced to stay away from cigarettes for the length of entire workdays have been credited with helping hospital workers to quit.4, 7 In our study, extending the ban to the outdoor areas of our medical campus as well as provision of employee smoking cessation services may augment these mechanisms. This study extends findings of older studies that showed hospital smoking bans (primarily indoor) decreased hospital employee smoking rates. Currently, our reduced employee smoking rate approaches the Healthy People 2010 goal of 12%.18

In conclusion, implementing a smoke‐free medical campus does not adversely affect inpatient volume (even among smokers), does not increase inpatient signing out AMA and can significantly increase inpatient NRT use, which in turn can increase the success of a quit attempt.19 In addition, implementing an outdoor smoking ban further reduces hospital employee smoking rates.

Even though imposition of smoke‐free policies and workplaces comprise one of the most effective antismoking strategies,1 hospital administrators hesitate to implement a smoke‐free medical campus policy.2 They fear losing patients who smoke because these patients will opt for other facilities that permit smoking.

Apart from studies evaluating Joint Commission on Accreditation of Healthcare Organizations (JCAHO)‐required indoor smoking bans in hospitals in 1992,3, 4 there are few published studies or formal evaluations of the impact of medical campuses going smoke‐free. One study of the implementation of a smoke‐free medical campus policy at a university hospital in Little Rock, AR, showed that the policy had no impact on employee retention, bed occupancy, or mean daily census; however, inpatient smoking status was not ascertained.5 Most (83%) employees were supportive of the policy. More importantly, employees at 2 university medical centers reported reduced cigarette consumption and increased attempts to quit after implementation of a smoke‐free medical campus policy.6, 7

Our hospital is 180‐bed, acute care inpatient teaching facility in upstate New York. Prior to the implementation of the smoke‐free medical campus policy, it was common to see employees, visitors, and patients lined up outdoors around the main hospital entrances and smoking just beyond the no smoking signage. Inpatients could look out their windows at the main entrance or into the courtyard and see hospital staff, other patients, and visitors smoking.

This study prospectively evaluates the impact of implementing the smoke‐free medical campus policy and starting an inpatient smoking cessation service. It addresses the following questions that have also been raised by the Task Force for Community Preventive Services.8 Does the institution of hospital smoking bans reduce the percentage of inpatients who smoke or increase the percentage who sign out against medical advice? What are the extended effects (beyond 1 year after implementation) of medical campus smoking bans on employee smoking rates?

Materials and Methods

Results

Inpatient Outcomes

An average of 959 patients were admitted per month in the 18‐month period pre‐ban (January 2005 to June 2006) vs. 988 per month in the 23‐month period post‐ban (July 2006 to September 2008). A monthly average of 89% of inpatients were screened for tobacco use when admitted. The monthly average for the percentage of inpatients who currently smoke has been approximately 21.6% following the implementation of the smoke‐free hospital plan. There has been little variation (Figure 1) in the percentage of inpatients who smoke pre‐ban and post‐ban except for the startup period in 2006 and the onset of the 2007 respiratory illness season.

Figure 1

Among all inpatients who currently smoke, 69.8% received a brief nursing intervention at the time of admission and 25% received an inpatient visit from our part‐time smoking cessation specialist.

The percentage of inpatients who signed out against medical advice (AMA) with the reason of having to smoke was 13.8% (4/29) 6 months pre‐ban, and 13.6% (3/22) 6 months post‐ban. In 2007, there were no inpatients who signed out AMA stating that they needed to smoke. Because the reason for signing out AMA may be underreported, we also examined the rate of smoking among all inpatients who sign out AMA. Six months pre‐ban, this percentage was 48.3% (14/29), but increased 6 months post‐ban to 59% (13/22). In 2007, the percentage of smokers among inpatients who sign out AMA leveled off at 50.8% (29/57).

Review of computerized inpatient prescription orders shows that orders for NRT nearly tripled after the inpatient smoking cessation service started April 1, 2006 (3 months prior to the ban) (Figure 2). Inpatient orders for these medications increased from 832 in a 2‐year period before the ban (April 1, 2004 to March 31, 2006) to 2475 in the 2 years following the initiation of the inpatient smoking service (April 1, 2006 to March 31, 2008). The Chow test is highly significant for a break point in June 2006 (P = 0.008), 1 month prior to the ban.

Figure 2

Discussion

Following implementation of a smoke‐free medical campus, no adverse effects were observed on inpatient volume at our hospital. The percentage of inpatients who smoke and the percentage of inpatients signing out AMA have remained stable after the smoke‐free policy went into effect. In addition, self‐reported employee smoking rates decreased significantly. Fears about losing inpatients (who smoke) following the implementation of a smoke‐free hospital plan were unfounded.

This study employs the electronic medical record to not only monitor trends in the proportion of inpatients who smoke pre‐ban and post‐ban, but also to notify our inpatient smoking cessation specialist, on the day of admission, to consult on patients who currently smoke. Unfortunately, our cessation specialist, who is part‐time, was unable to see all inpatients who smoke on account of the inpatient's acuity, pain, hospice status, weekend or night admission, or not being available due to testing, surgery, or other procedures. Nevertheless, use of NRT increased sharply following the initiation of this program. As shown in Figure 2, a linear rise in NRT orders was already underway starting April 2005, probably in anticipation of the ban and coinciding with the start of the inpatient smoking cessation program. However, the Chow test is highly significant for a breakpoint in June 2006 (P = 0.008), 1 month prior to the ban, meaning that the slope was climbing even more steeply after that point.

As hospitalized smokers may be more motivated to stop smoking, the updated 2008 clinical practice guidelines for Treating Tobacco Use and Dependence now recommend that all patients in the hospital be given medications, advised, counseled, and receive follow‐up after discharge.13 Although our inpatient cessation program was started before these clinical practice guidelines were available, we are currently evaluating the efficacy of our inpatient program by assessing self‐reported quit rates 6‐months posthospitalization (data collection in process). Provision of inpatient smoking cessation has been shown to be an effective smoking cessation intervention if combined with outpatient follow‐up.14 Our current program will be expanded to include outpatient follow‐up, if the inpatient's primary care provider is unable to provide it or if the inpatient refuses faxed referral to the New York State quit line program.

This study evaluates the impact of simultaneously introduced interventions such as medical campus smoking ban, inpatient smoking cessation program, hospital staff education, and other elements of the University of Michigan Smoke‐Free Hospital Implementation Plan. The role of individual components of the plan cannot be evaluated in this study as they were intentionally implemented simultaneously in order to achieve a synergistic effect.

Another limitation of this study is that smoking status is self‐reported and not validated biochemically. Although validated smoking status measures such as salivary cotinine testing would be more scientifically valid, it was not feasible to validate the smoking status of inpatients, nor that of employees. Thus smoking status, as ascertained in this study, is subject to underreporting. Social desirability bias has been recognized as potential limitation of self‐reported smoking status in other evaluations of smoke‐free policies.3, 4, 15

In the 1990s, the employee benefits of instituting indoor smoking bans in hospitals were theorized to include reduced employee sick time, break time, and tobacco use, as well as increased motivation for smoking cessation and reduced legitimacy of tobacco use.16, 17 Peer pressure, workplace socialization, and being forced to stay away from cigarettes for the length of entire workdays have been credited with helping hospital workers to quit.4, 7 In our study, extending the ban to the outdoor areas of our medical campus as well as provision of employee smoking cessation services may augment these mechanisms. This study extends findings of older studies that showed hospital smoking bans (primarily indoor) decreased hospital employee smoking rates. Currently, our reduced employee smoking rate approaches the Healthy People 2010 goal of 12%.18

In conclusion, implementing a smoke‐free medical campus does not adversely affect inpatient volume (even among smokers), does not increase inpatient signing out AMA and can significantly increase inpatient NRT use, which in turn can increase the success of a quit attempt.19 In addition, implementing an outdoor smoking ban further reduces hospital employee smoking rates.

Effective communication between healthcare providers is essential to patient safety and quality of care.1, 2 Numeric pagers are commonly used communication devices in healthcare, but cannot convey important information such as the reason for the page, urgency of the page, or sender name. Physicians must respond to numeric pages, often disrupting patient encounters or educational activities.36 In a study of medical interns, disruptions to patient care occurred with up to 65% of pages received, two‐thirds of which were not felt to be urgent.5 In addition to causing frustration, frequent disruptions can contribute to medical errors.7, 8

Alphanumeric pagers can display both numbers and text, and may address some of the communication problems associated with numeric pagers. They also lay the groundwork for other patient safety initiatives such as automated paging of critical laboratory values9 and real‐time reporting of user‐requested laboratory data.10 Implementation of alphanumeric paging on a general surgery teaching service reduced disruptions to patient care and the number of pages requiring a return call.11

Our primary aim was to implement an alphanumeric paging system. We will describe our implementation strategies and barriers identified. We evaluated the implementation of alphanumeric paging by measuring (1) the proportion of pages sent as text pages, (2) the source of the pages (other physicians or from the general medicine [GM] ward), (3) the content of the text pages, (4) the number of pages that disrupted scheduled education activities, and (5) satisfaction with the alphanumeric paging system.

Materials and Methods

Implementation Process

We provided alphanumeric pagers to the residents on the General Internal Medicine service in July 2006. Alphanumeric pagers were limited, so each resident traded their numeric pager for an alphanumeric pager at the start of each rotation. Once their rotation ended, they returned their alphanumeric pager for their original numeric pager. The communications department coordinated this process. The chief medical resident spent 10 minutes to teach the residents how to use the system at the beginning of the rotation. In August and September 2006, a member of the communications department trained the nurses on the 4 GM wards how to send a text page using the Internet‐based paging application. We scheduled these 15‐minute sessions throughout the day and evening in order to capture as many nurses as possible. We encouraged the nurses to include standardized information in the text message (eg, patient ID, issue, level of urgency, sender name, call‐back number).

We used rapid‐cycle change methods12 to implement the alphanumeric system (Figure 1). The first change cycle in August 2006 consisted of providing pagers to residents and training the nurses and physicians to send text pages. Users reported that the paging interface was difficult to use. For the second change cycle in September 2006, the communications department modified the paging interface to improve usability and created shortcut icons on the GM ward computers. While the system was easier to access, the nurses reported that 1‐time training was insufficient. For the next change cycle in September 2006, we developed Internet‐based tutorials that could be accessed at any time, and made expert users (charge nurses) available for just‐in‐time training. We asked these charge nurses what they believed would encourage adoption of the system. They suggested that contests worked well with other initiatives. For the final change cycle in October and November 2006, we held a contest and rewarded the GM ward that sent the highest percentage of text pages with a team lunch.

Figure 1

Our results from November 2006 were presented to our hospital medical leaders, who approved widespread implementation of alphanumeric pagers for all residents and medical students in all programs. The cost of this upgrade was approximately $35,000 per year to lease 500 alphanumeric pagers. By July 2007, all residents and students in our hospital had alphanumeric pagers.

Results

Paging Patterns Before, During, and After Implementation

The number of pages per resident was similar before and during implementation, but higher afterwards. (46 16 pages/resident/week in November 2005, 47 20 pages/resident/week in November 2006, and 59 27 pages/resident/week in January 2008; P = 0.17; Table 1). The mean number of admissions per night was 8.0 2.7 before implementation, compared to 10.2 3.5 after implementation (P = 0.009).

Table 1.Paging Patterns Before, During, and After Implementation of an Alphanumeric Paging System

	Before Implementation (all residents had numeric pagers)	During Implementation (all residents had alphanumeric pagers)		After Implementation (all residents had alphanumeric pagers)
Paging Characteristics	November 2005	October 2006	November 2006	January 2008	P Value
Abbreviations: Doc, physician; GM, general medicine; SD, standard deviation. * Student t test comparing November 2005 with January 2008. Fisher's Exact Test comparing November 2005 with January 2008.
Total number of pages	1431	1879	1813	1269
Total number of resident weeks worked	29	33	33	21
Pages per resident week, mean (SD)	46.2 (16.3)	57.9 (19.2)	46.5 (20.2)	59.0 (26.5)	0.17*
Number of patients admitted per night, mean (SD)	8.0 (2.7)	10.2 (3.5)	11.0 (2.9)	10.2 (3.5)	0.009*
Type of page, n (%)
Numeric pages	751 (53)	462 (25)	580 (32)	374 (30)	<0.001
GM wards‐to‐Doc	584 (41)	393 (21)	538 (30)	352 (28)	<0.001
Doc‐to‐Doc	167 (12)	69 (4)	42 (2)	22 (2)	<0.001
Non‐GM ward/Doc pages	680 (47)	1107 (59)	809 (45)	487 (38)	<0.001
Text pages	0 (0)	310 (16)	424 (23)	408 (32)	<0.001
GM wards‐to‐Doc	0 (0)	175 (9)	221 (12)	129 (10)	<0.001
Doc‐to‐Doc	0 (0)	135 (7)	203 (11)	279 (22)	<0.001

We observed a significant and sustained increase in the use of text paging during the study (Table 1). After implementation, 32% of all pages sent to our residents were text messages (P < 0.001). Physicians almost exclusively sent text pages by the end of implementation (increase from 0% to 83% text paging rate during implementation, and 93% after implementation; P < 0.001; Figure 2). GM ward text paging rates also increased from 0% to 29% during implementation, and 27% after implementation (P < 0.001; Figure 2). The alphanumeric paging system was used to a greater degree by physicians compared to other workers on the GM ward after full implementation (93% vs. 27%; P < 0.001). We explored the proportion of GM ward‐to‐Doc pages sent as text from different GM wards during implementation, and found significant variation, ranging from 14% to 57% (P < 0.001).

Figure 2

The most common reasons for text paging from GM wards were to request a patient assessment or for notification of a patient's clinical status (25%), to clarify written orders (20%), and to request a medication prescription (13%) (Table 2). Among physicians, the most common reasons for text paging were to set up meetings for work or teaching rounds (33%), to relay patient‐care related messages (27%), and to sign‐over patients at the end of the day (23%) (Table 3). The remainder of the other Doc‐to‐Doc pages (18%) were mostly personal messages or team communication that was not related to clinical work.

Table 2.Reasons for Paging the Physicians (GM ward‐to‐Doc)

Reason for Paging	Number (%)	Examples
NOTE: Represents data from November 2006. Abbreviations: BP, blood pressure; CXR, chest X‐ray; Doc, physician; GM, general medicine; INR, international normalized ratio; NG, nasogastric tube.
Requests for patient assessment or notification of a patient's clinical status	55 (25)	Patient X. Temp 38.5. No other symptoms. [Nurse's name].
		The repeat CXR on Patient X has been completed. Please call [ward] if NG can be used. Thank you.
Clarification of a written order	45 (20)	Would you like Patient X to get a second dose of Lasix? He has already had 100 mg and his output thus far is 500 cc. [Nurse's name]
		Patient X. BP = 100/62, pulse 54. Patient is supposed to have metoprolol 50 mg tonight. Do you want me to hold it? [Nurse's name]
Request for a medication prescription	28 (13)	Patient X needs an analgesic for pain in his arms and legs. Please call [ward].
		Patient X has a daily coumadin order. INR 2.14. Please call with dosage for 1800. Ask for [Nurse].
Cosigning written order	25 (11)	Please co‐sign neurology suggested orders for Patient X. [Nurse's name]
		Not urgent at your leisure, please co‐sign Patient X orders on [ward] for medical student. Thanks.
Notification of a recent laboratory result	23 (11)	Patient X's potassium is 3.0 today. Please call [ward].
		Patient X. Sodium 163. Troponin unchanged at 1.54. [ward].
Arranging meetings with patients and/or family	18 (8)	Meeting with Patient X's family and social worker at 2 pm tomorrow on [ward].
		[Social worker] is here. [Physiotherapist] expected any minute. We are going to meet in family room for Patient X.
Request to complete paperwork	15 (7)	Patient X is ready to go home, and just needs discharge orders and prescriptions
		Referral form for community palliative doctor on the front of the chart fill in where marked by arrows. Can you please put on form prognosis as well? [Social worker]
Other	12 (6)
Total	221 (100)

Table 3.Reasons for Paging Among Physicians (Doc‐to‐Doc)

Reason for Paging	Number (%)	Examples
NOTE: Represents data from November 2006. Abbreviations: cath, catheterization; CHF, congestive heart failure; Cr, creatinine; DKA, diabetic ketoacidosis; IV, intravenous; Lytes, electrolytes; NS, normal saline; US, ultrasound; WE, weakend.
Setting up meetings for work or teaching rounds	67 (33)	Confirmed diabetes teaching at 1400 hr in [room]. Please let medical students know. Thanks.
		Please come to [lecture theatre] if you can in the next 10 minutes for the teleconferenced noon rounds. Thanks.
We are in the Emergency Department with [attending staff]. Come to meet us here if you can.
Relaying patient‐care related messages	54 (27)	Patient X US query cholangitis, can we ask for a surgical consult. He may benefit from surgery or percutaneous drain. Please repeat his blood work.
		Patient X in [room X]. Presented with DKA. pH 7.2. pCO2 23, bicarbonate 9. Lytes pending. Got IV insulin and NS. Need to check to clinical stability. [Resident]
Signing‐over patients at the end of the day	46 (23)	I'm ready to sign out to you. Where are you? [Resident].
		Patient X is back from cardiac cath, and is stable. Please check Cr over WE, and watch for CHF.
Other	36 (18)
Total	203 (100)

Discussion

We successfully implemented an alphanumeric paging system on a resident inpatient internal medicine teaching service, with 42% of pages from our GM wards or physicians sent as text pages during implementation period. Six months after widespread use of alphanumeric pagers at our hospital (and 14 months after the initial implementation on the General Internal Medicine service) the text paging rate was 52%. Physicians have nearly universally adopted the use of alphanumeric paging as a means of communicating with one another, while the adoption by nursing staff was modest. The implementation of the alphanumeric paging system was associated with a significant reduction in disruptive pages.

We could identify only one prior study of alphanumeric paging implementation in a hospital setting. A general surgery teaching service in the United States demonstrated that 35% of all pages received by residents were text pages 3 months after implementation,11 similar to our result of 32% text paging rate after full implementation. We found a greater use of text paging among physicians in our study (93% of Doc‐to‐Doc pages were text), compared to 55% in this prior study. This difference may be partially explained by varied methods for identifying Doc‐to‐Doc pages between the studies.

A number of factors influence the adoption of new technology, such as the technology's features, end‐user characteristics, and dissemination strategies.14 During the implementation, even though the web‐based paging system was deemed easy to use, there was a lack of computers available to send text messages at each of our nursing stations. Residents were generally more familiar with technology and the use of computers for communication than nurses, and therefore more likely to use the technology. The presence of innovators influenced the success of adoption, evidenced by the fact that the GM ward that sent the highest percentage of pages as text was also the GM ward where the project leader (B.W.) worked as the attending staff during the implementation period.

Our study has several limitations. First, our method for classifying the source of numeric pages was imperfect. Our method systematically underestimates Doc‐to‐Doc numeric pages, because we assumed that all pages from GM ward phone numbers were not from physicians. We also may have misclassified the origin of some text messages. These limitations would not affect our conclusion that text messaging increased, but may overestimate the increase in Doc‐to‐Doc text messaging, and underestimate the increase in GM ward‐to‐Doc text messaging. The reasons for paging are not known for the numeric pages. The number of pages received per resident increased after implementation, so it is possible that alphanumeric pages increased calls for certain nonurgent issues, such as co‐signing orders. Finally, we assumed that residents were attending scheduled educational rounds, but were unable to confirm attendance, so we cannot be sure that disruptions actually were reduced.

In summary, we implemented an alphanumeric paging system, and observed a sustained use of text messaging after 1 year. The implementation of alphanumeric paging was associated with a reduction in disruptive pages sent during scheduled educational rounds.

Effective communication between healthcare providers is essential to patient safety and quality of care.1, 2 Numeric pagers are commonly used communication devices in healthcare, but cannot convey important information such as the reason for the page, urgency of the page, or sender name. Physicians must respond to numeric pages, often disrupting patient encounters or educational activities.36 In a study of medical interns, disruptions to patient care occurred with up to 65% of pages received, two‐thirds of which were not felt to be urgent.5 In addition to causing frustration, frequent disruptions can contribute to medical errors.7, 8

Alphanumeric pagers can display both numbers and text, and may address some of the communication problems associated with numeric pagers. They also lay the groundwork for other patient safety initiatives such as automated paging of critical laboratory values9 and real‐time reporting of user‐requested laboratory data.10 Implementation of alphanumeric paging on a general surgery teaching service reduced disruptions to patient care and the number of pages requiring a return call.11

Our primary aim was to implement an alphanumeric paging system. We will describe our implementation strategies and barriers identified. We evaluated the implementation of alphanumeric paging by measuring (1) the proportion of pages sent as text pages, (2) the source of the pages (other physicians or from the general medicine [GM] ward), (3) the content of the text pages, (4) the number of pages that disrupted scheduled education activities, and (5) satisfaction with the alphanumeric paging system.

Materials and Methods

Implementation Process

We provided alphanumeric pagers to the residents on the General Internal Medicine service in July 2006. Alphanumeric pagers were limited, so each resident traded their numeric pager for an alphanumeric pager at the start of each rotation. Once their rotation ended, they returned their alphanumeric pager for their original numeric pager. The communications department coordinated this process. The chief medical resident spent 10 minutes to teach the residents how to use the system at the beginning of the rotation. In August and September 2006, a member of the communications department trained the nurses on the 4 GM wards how to send a text page using the Internet‐based paging application. We scheduled these 15‐minute sessions throughout the day and evening in order to capture as many nurses as possible. We encouraged the nurses to include standardized information in the text message (eg, patient ID, issue, level of urgency, sender name, call‐back number).

We used rapid‐cycle change methods12 to implement the alphanumeric system (Figure 1). The first change cycle in August 2006 consisted of providing pagers to residents and training the nurses and physicians to send text pages. Users reported that the paging interface was difficult to use. For the second change cycle in September 2006, the communications department modified the paging interface to improve usability and created shortcut icons on the GM ward computers. While the system was easier to access, the nurses reported that 1‐time training was insufficient. For the next change cycle in September 2006, we developed Internet‐based tutorials that could be accessed at any time, and made expert users (charge nurses) available for just‐in‐time training. We asked these charge nurses what they believed would encourage adoption of the system. They suggested that contests worked well with other initiatives. For the final change cycle in October and November 2006, we held a contest and rewarded the GM ward that sent the highest percentage of text pages with a team lunch.

Figure 1

Our results from November 2006 were presented to our hospital medical leaders, who approved widespread implementation of alphanumeric pagers for all residents and medical students in all programs. The cost of this upgrade was approximately $35,000 per year to lease 500 alphanumeric pagers. By July 2007, all residents and students in our hospital had alphanumeric pagers.

Results

Paging Patterns Before, During, and After Implementation

The number of pages per resident was similar before and during implementation, but higher afterwards. (46 16 pages/resident/week in November 2005, 47 20 pages/resident/week in November 2006, and 59 27 pages/resident/week in January 2008; P = 0.17; Table 1). The mean number of admissions per night was 8.0 2.7 before implementation, compared to 10.2 3.5 after implementation (P = 0.009).

Table 1.Paging Patterns Before, During, and After Implementation of an Alphanumeric Paging System

	Before Implementation (all residents had numeric pagers)	During Implementation (all residents had alphanumeric pagers)		After Implementation (all residents had alphanumeric pagers)
Paging Characteristics	November 2005	October 2006	November 2006	January 2008	P Value
Abbreviations: Doc, physician; GM, general medicine; SD, standard deviation. * Student t test comparing November 2005 with January 2008. Fisher's Exact Test comparing November 2005 with January 2008.
Total number of pages	1431	1879	1813	1269
Total number of resident weeks worked	29	33	33	21
Pages per resident week, mean (SD)	46.2 (16.3)	57.9 (19.2)	46.5 (20.2)	59.0 (26.5)	0.17*
Number of patients admitted per night, mean (SD)	8.0 (2.7)	10.2 (3.5)	11.0 (2.9)	10.2 (3.5)	0.009*
Type of page, n (%)
Numeric pages	751 (53)	462 (25)	580 (32)	374 (30)	<0.001
GM wards‐to‐Doc	584 (41)	393 (21)	538 (30)	352 (28)	<0.001
Doc‐to‐Doc	167 (12)	69 (4)	42 (2)	22 (2)	<0.001
Non‐GM ward/Doc pages	680 (47)	1107 (59)	809 (45)	487 (38)	<0.001
Text pages	0 (0)	310 (16)	424 (23)	408 (32)	<0.001
GM wards‐to‐Doc	0 (0)	175 (9)	221 (12)	129 (10)	<0.001
Doc‐to‐Doc	0 (0)	135 (7)	203 (11)	279 (22)	<0.001

We observed a significant and sustained increase in the use of text paging during the study (Table 1). After implementation, 32% of all pages sent to our residents were text messages (P < 0.001). Physicians almost exclusively sent text pages by the end of implementation (increase from 0% to 83% text paging rate during implementation, and 93% after implementation; P < 0.001; Figure 2). GM ward text paging rates also increased from 0% to 29% during implementation, and 27% after implementation (P < 0.001; Figure 2). The alphanumeric paging system was used to a greater degree by physicians compared to other workers on the GM ward after full implementation (93% vs. 27%; P < 0.001). We explored the proportion of GM ward‐to‐Doc pages sent as text from different GM wards during implementation, and found significant variation, ranging from 14% to 57% (P < 0.001).

Figure 2

The most common reasons for text paging from GM wards were to request a patient assessment or for notification of a patient's clinical status (25%), to clarify written orders (20%), and to request a medication prescription (13%) (Table 2). Among physicians, the most common reasons for text paging were to set up meetings for work or teaching rounds (33%), to relay patient‐care related messages (27%), and to sign‐over patients at the end of the day (23%) (Table 3). The remainder of the other Doc‐to‐Doc pages (18%) were mostly personal messages or team communication that was not related to clinical work.

Table 2.Reasons for Paging the Physicians (GM ward‐to‐Doc)

Reason for Paging	Number (%)	Examples
NOTE: Represents data from November 2006. Abbreviations: BP, blood pressure; CXR, chest X‐ray; Doc, physician; GM, general medicine; INR, international normalized ratio; NG, nasogastric tube.
Requests for patient assessment or notification of a patient's clinical status	55 (25)	Patient X. Temp 38.5. No other symptoms. [Nurse's name].
		The repeat CXR on Patient X has been completed. Please call [ward] if NG can be used. Thank you.
Clarification of a written order	45 (20)	Would you like Patient X to get a second dose of Lasix? He has already had 100 mg and his output thus far is 500 cc. [Nurse's name]
		Patient X. BP = 100/62, pulse 54. Patient is supposed to have metoprolol 50 mg tonight. Do you want me to hold it? [Nurse's name]
Request for a medication prescription	28 (13)	Patient X needs an analgesic for pain in his arms and legs. Please call [ward].
		Patient X has a daily coumadin order. INR 2.14. Please call with dosage for 1800. Ask for [Nurse].
Cosigning written order	25 (11)	Please co‐sign neurology suggested orders for Patient X. [Nurse's name]
		Not urgent at your leisure, please co‐sign Patient X orders on [ward] for medical student. Thanks.
Notification of a recent laboratory result	23 (11)	Patient X's potassium is 3.0 today. Please call [ward].
		Patient X. Sodium 163. Troponin unchanged at 1.54. [ward].
Arranging meetings with patients and/or family	18 (8)	Meeting with Patient X's family and social worker at 2 pm tomorrow on [ward].
		[Social worker] is here. [Physiotherapist] expected any minute. We are going to meet in family room for Patient X.
Request to complete paperwork	15 (7)	Patient X is ready to go home, and just needs discharge orders and prescriptions
		Referral form for community palliative doctor on the front of the chart fill in where marked by arrows. Can you please put on form prognosis as well? [Social worker]
Other	12 (6)
Total	221 (100)

Table 3.Reasons for Paging Among Physicians (Doc‐to‐Doc)

Reason for Paging	Number (%)	Examples
NOTE: Represents data from November 2006. Abbreviations: cath, catheterization; CHF, congestive heart failure; Cr, creatinine; DKA, diabetic ketoacidosis; IV, intravenous; Lytes, electrolytes; NS, normal saline; US, ultrasound; WE, weakend.
Setting up meetings for work or teaching rounds	67 (33)	Confirmed diabetes teaching at 1400 hr in [room]. Please let medical students know. Thanks.
		Please come to [lecture theatre] if you can in the next 10 minutes for the teleconferenced noon rounds. Thanks.
We are in the Emergency Department with [attending staff]. Come to meet us here if you can.
Relaying patient‐care related messages	54 (27)	Patient X US query cholangitis, can we ask for a surgical consult. He may benefit from surgery or percutaneous drain. Please repeat his blood work.
		Patient X in [room X]. Presented with DKA. pH 7.2. pCO2 23, bicarbonate 9. Lytes pending. Got IV insulin and NS. Need to check to clinical stability. [Resident]
Signing‐over patients at the end of the day	46 (23)	I'm ready to sign out to you. Where are you? [Resident].
		Patient X is back from cardiac cath, and is stable. Please check Cr over WE, and watch for CHF.
Other	36 (18)
Total	203 (100)

Discussion

We successfully implemented an alphanumeric paging system on a resident inpatient internal medicine teaching service, with 42% of pages from our GM wards or physicians sent as text pages during implementation period. Six months after widespread use of alphanumeric pagers at our hospital (and 14 months after the initial implementation on the General Internal Medicine service) the text paging rate was 52%. Physicians have nearly universally adopted the use of alphanumeric paging as a means of communicating with one another, while the adoption by nursing staff was modest. The implementation of the alphanumeric paging system was associated with a significant reduction in disruptive pages.

We could identify only one prior study of alphanumeric paging implementation in a hospital setting. A general surgery teaching service in the United States demonstrated that 35% of all pages received by residents were text pages 3 months after implementation,11 similar to our result of 32% text paging rate after full implementation. We found a greater use of text paging among physicians in our study (93% of Doc‐to‐Doc pages were text), compared to 55% in this prior study. This difference may be partially explained by varied methods for identifying Doc‐to‐Doc pages between the studies.

A number of factors influence the adoption of new technology, such as the technology's features, end‐user characteristics, and dissemination strategies.14 During the implementation, even though the web‐based paging system was deemed easy to use, there was a lack of computers available to send text messages at each of our nursing stations. Residents were generally more familiar with technology and the use of computers for communication than nurses, and therefore more likely to use the technology. The presence of innovators influenced the success of adoption, evidenced by the fact that the GM ward that sent the highest percentage of pages as text was also the GM ward where the project leader (B.W.) worked as the attending staff during the implementation period.

Our study has several limitations. First, our method for classifying the source of numeric pages was imperfect. Our method systematically underestimates Doc‐to‐Doc numeric pages, because we assumed that all pages from GM ward phone numbers were not from physicians. We also may have misclassified the origin of some text messages. These limitations would not affect our conclusion that text messaging increased, but may overestimate the increase in Doc‐to‐Doc text messaging, and underestimate the increase in GM ward‐to‐Doc text messaging. The reasons for paging are not known for the numeric pages. The number of pages received per resident increased after implementation, so it is possible that alphanumeric pages increased calls for certain nonurgent issues, such as co‐signing orders. Finally, we assumed that residents were attending scheduled educational rounds, but were unable to confirm attendance, so we cannot be sure that disruptions actually were reduced.

In summary, we implemented an alphanumeric paging system, and observed a sustained use of text messaging after 1 year. The implementation of alphanumeric paging was associated with a reduction in disruptive pages sent during scheduled educational rounds.

Effective communication between healthcare providers is essential to patient safety and quality of care.1, 2 Numeric pagers are commonly used communication devices in healthcare, but cannot convey important information such as the reason for the page, urgency of the page, or sender name. Physicians must respond to numeric pages, often disrupting patient encounters or educational activities.36 In a study of medical interns, disruptions to patient care occurred with up to 65% of pages received, two‐thirds of which were not felt to be urgent.5 In addition to causing frustration, frequent disruptions can contribute to medical errors.7, 8

Alphanumeric pagers can display both numbers and text, and may address some of the communication problems associated with numeric pagers. They also lay the groundwork for other patient safety initiatives such as automated paging of critical laboratory values9 and real‐time reporting of user‐requested laboratory data.10 Implementation of alphanumeric paging on a general surgery teaching service reduced disruptions to patient care and the number of pages requiring a return call.11

Our primary aim was to implement an alphanumeric paging system. We will describe our implementation strategies and barriers identified. We evaluated the implementation of alphanumeric paging by measuring (1) the proportion of pages sent as text pages, (2) the source of the pages (other physicians or from the general medicine [GM] ward), (3) the content of the text pages, (4) the number of pages that disrupted scheduled education activities, and (5) satisfaction with the alphanumeric paging system.

Materials and Methods

Implementation Process

We provided alphanumeric pagers to the residents on the General Internal Medicine service in July 2006. Alphanumeric pagers were limited, so each resident traded their numeric pager for an alphanumeric pager at the start of each rotation. Once their rotation ended, they returned their alphanumeric pager for their original numeric pager. The communications department coordinated this process. The chief medical resident spent 10 minutes to teach the residents how to use the system at the beginning of the rotation. In August and September 2006, a member of the communications department trained the nurses on the 4 GM wards how to send a text page using the Internet‐based paging application. We scheduled these 15‐minute sessions throughout the day and evening in order to capture as many nurses as possible. We encouraged the nurses to include standardized information in the text message (eg, patient ID, issue, level of urgency, sender name, call‐back number).

We used rapid‐cycle change methods12 to implement the alphanumeric system (Figure 1). The first change cycle in August 2006 consisted of providing pagers to residents and training the nurses and physicians to send text pages. Users reported that the paging interface was difficult to use. For the second change cycle in September 2006, the communications department modified the paging interface to improve usability and created shortcut icons on the GM ward computers. While the system was easier to access, the nurses reported that 1‐time training was insufficient. For the next change cycle in September 2006, we developed Internet‐based tutorials that could be accessed at any time, and made expert users (charge nurses) available for just‐in‐time training. We asked these charge nurses what they believed would encourage adoption of the system. They suggested that contests worked well with other initiatives. For the final change cycle in October and November 2006, we held a contest and rewarded the GM ward that sent the highest percentage of text pages with a team lunch.

Figure 1

Our results from November 2006 were presented to our hospital medical leaders, who approved widespread implementation of alphanumeric pagers for all residents and medical students in all programs. The cost of this upgrade was approximately $35,000 per year to lease 500 alphanumeric pagers. By July 2007, all residents and students in our hospital had alphanumeric pagers.

Results

Paging Patterns Before, During, and After Implementation

The number of pages per resident was similar before and during implementation, but higher afterwards. (46 16 pages/resident/week in November 2005, 47 20 pages/resident/week in November 2006, and 59 27 pages/resident/week in January 2008; P = 0.17; Table 1). The mean number of admissions per night was 8.0 2.7 before implementation, compared to 10.2 3.5 after implementation (P = 0.009).

Table 1.Paging Patterns Before, During, and After Implementation of an Alphanumeric Paging System

	Before Implementation (all residents had numeric pagers)	During Implementation (all residents had alphanumeric pagers)		After Implementation (all residents had alphanumeric pagers)
Paging Characteristics	November 2005	October 2006	November 2006	January 2008	P Value
Abbreviations: Doc, physician; GM, general medicine; SD, standard deviation. * Student t test comparing November 2005 with January 2008. Fisher's Exact Test comparing November 2005 with January 2008.
Total number of pages	1431	1879	1813	1269
Total number of resident weeks worked	29	33	33	21
Pages per resident week, mean (SD)	46.2 (16.3)	57.9 (19.2)	46.5 (20.2)	59.0 (26.5)	0.17*
Number of patients admitted per night, mean (SD)	8.0 (2.7)	10.2 (3.5)	11.0 (2.9)	10.2 (3.5)	0.009*
Type of page, n (%)
Numeric pages	751 (53)	462 (25)	580 (32)	374 (30)	<0.001
GM wards‐to‐Doc	584 (41)	393 (21)	538 (30)	352 (28)	<0.001
Doc‐to‐Doc	167 (12)	69 (4)	42 (2)	22 (2)	<0.001
Non‐GM ward/Doc pages	680 (47)	1107 (59)	809 (45)	487 (38)	<0.001
Text pages	0 (0)	310 (16)	424 (23)	408 (32)	<0.001
GM wards‐to‐Doc	0 (0)	175 (9)	221 (12)	129 (10)	<0.001
Doc‐to‐Doc	0 (0)	135 (7)	203 (11)	279 (22)	<0.001

We observed a significant and sustained increase in the use of text paging during the study (Table 1). After implementation, 32% of all pages sent to our residents were text messages (P < 0.001). Physicians almost exclusively sent text pages by the end of implementation (increase from 0% to 83% text paging rate during implementation, and 93% after implementation; P < 0.001; Figure 2). GM ward text paging rates also increased from 0% to 29% during implementation, and 27% after implementation (P < 0.001; Figure 2). The alphanumeric paging system was used to a greater degree by physicians compared to other workers on the GM ward after full implementation (93% vs. 27%; P < 0.001). We explored the proportion of GM ward‐to‐Doc pages sent as text from different GM wards during implementation, and found significant variation, ranging from 14% to 57% (P < 0.001).

Figure 2

The most common reasons for text paging from GM wards were to request a patient assessment or for notification of a patient's clinical status (25%), to clarify written orders (20%), and to request a medication prescription (13%) (Table 2). Among physicians, the most common reasons for text paging were to set up meetings for work or teaching rounds (33%), to relay patient‐care related messages (27%), and to sign‐over patients at the end of the day (23%) (Table 3). The remainder of the other Doc‐to‐Doc pages (18%) were mostly personal messages or team communication that was not related to clinical work.

Table 2.Reasons for Paging the Physicians (GM ward‐to‐Doc)

Reason for Paging	Number (%)	Examples
NOTE: Represents data from November 2006. Abbreviations: BP, blood pressure; CXR, chest X‐ray; Doc, physician; GM, general medicine; INR, international normalized ratio; NG, nasogastric tube.
Requests for patient assessment or notification of a patient's clinical status	55 (25)	Patient X. Temp 38.5. No other symptoms. [Nurse's name].
		The repeat CXR on Patient X has been completed. Please call [ward] if NG can be used. Thank you.
Clarification of a written order	45 (20)	Would you like Patient X to get a second dose of Lasix? He has already had 100 mg and his output thus far is 500 cc. [Nurse's name]
		Patient X. BP = 100/62, pulse 54. Patient is supposed to have metoprolol 50 mg tonight. Do you want me to hold it? [Nurse's name]
Request for a medication prescription	28 (13)	Patient X needs an analgesic for pain in his arms and legs. Please call [ward].
		Patient X has a daily coumadin order. INR 2.14. Please call with dosage for 1800. Ask for [Nurse].
Cosigning written order	25 (11)	Please co‐sign neurology suggested orders for Patient X. [Nurse's name]
		Not urgent at your leisure, please co‐sign Patient X orders on [ward] for medical student. Thanks.
Notification of a recent laboratory result	23 (11)	Patient X's potassium is 3.0 today. Please call [ward].
		Patient X. Sodium 163. Troponin unchanged at 1.54. [ward].
Arranging meetings with patients and/or family	18 (8)	Meeting with Patient X's family and social worker at 2 pm tomorrow on [ward].
		[Social worker] is here. [Physiotherapist] expected any minute. We are going to meet in family room for Patient X.
Request to complete paperwork	15 (7)	Patient X is ready to go home, and just needs discharge orders and prescriptions
		Referral form for community palliative doctor on the front of the chart fill in where marked by arrows. Can you please put on form prognosis as well? [Social worker]
Other	12 (6)
Total	221 (100)

Table 3.Reasons for Paging Among Physicians (Doc‐to‐Doc)

Reason for Paging	Number (%)	Examples
NOTE: Represents data from November 2006. Abbreviations: cath, catheterization; CHF, congestive heart failure; Cr, creatinine; DKA, diabetic ketoacidosis; IV, intravenous; Lytes, electrolytes; NS, normal saline; US, ultrasound; WE, weakend.
Setting up meetings for work or teaching rounds	67 (33)	Confirmed diabetes teaching at 1400 hr in [room]. Please let medical students know. Thanks.
		Please come to [lecture theatre] if you can in the next 10 minutes for the teleconferenced noon rounds. Thanks.
We are in the Emergency Department with [attending staff]. Come to meet us here if you can.
Relaying patient‐care related messages	54 (27)	Patient X US query cholangitis, can we ask for a surgical consult. He may benefit from surgery or percutaneous drain. Please repeat his blood work.
		Patient X in [room X]. Presented with DKA. pH 7.2. pCO2 23, bicarbonate 9. Lytes pending. Got IV insulin and NS. Need to check to clinical stability. [Resident]
Signing‐over patients at the end of the day	46 (23)	I'm ready to sign out to you. Where are you? [Resident].
		Patient X is back from cardiac cath, and is stable. Please check Cr over WE, and watch for CHF.
Other	36 (18)
Total	203 (100)

Discussion

We successfully implemented an alphanumeric paging system on a resident inpatient internal medicine teaching service, with 42% of pages from our GM wards or physicians sent as text pages during implementation period. Six months after widespread use of alphanumeric pagers at our hospital (and 14 months after the initial implementation on the General Internal Medicine service) the text paging rate was 52%. Physicians have nearly universally adopted the use of alphanumeric paging as a means of communicating with one another, while the adoption by nursing staff was modest. The implementation of the alphanumeric paging system was associated with a significant reduction in disruptive pages.

We could identify only one prior study of alphanumeric paging implementation in a hospital setting. A general surgery teaching service in the United States demonstrated that 35% of all pages received by residents were text pages 3 months after implementation,11 similar to our result of 32% text paging rate after full implementation. We found a greater use of text paging among physicians in our study (93% of Doc‐to‐Doc pages were text), compared to 55% in this prior study. This difference may be partially explained by varied methods for identifying Doc‐to‐Doc pages between the studies.

A number of factors influence the adoption of new technology, such as the technology's features, end‐user characteristics, and dissemination strategies.14 During the implementation, even though the web‐based paging system was deemed easy to use, there was a lack of computers available to send text messages at each of our nursing stations. Residents were generally more familiar with technology and the use of computers for communication than nurses, and therefore more likely to use the technology. The presence of innovators influenced the success of adoption, evidenced by the fact that the GM ward that sent the highest percentage of pages as text was also the GM ward where the project leader (B.W.) worked as the attending staff during the implementation period.

Our study has several limitations. First, our method for classifying the source of numeric pages was imperfect. Our method systematically underestimates Doc‐to‐Doc numeric pages, because we assumed that all pages from GM ward phone numbers were not from physicians. We also may have misclassified the origin of some text messages. These limitations would not affect our conclusion that text messaging increased, but may overestimate the increase in Doc‐to‐Doc text messaging, and underestimate the increase in GM ward‐to‐Doc text messaging. The reasons for paging are not known for the numeric pages. The number of pages received per resident increased after implementation, so it is possible that alphanumeric pages increased calls for certain nonurgent issues, such as co‐signing orders. Finally, we assumed that residents were attending scheduled educational rounds, but were unable to confirm attendance, so we cannot be sure that disruptions actually were reduced.

In summary, we implemented an alphanumeric paging system, and observed a sustained use of text messaging after 1 year. The implementation of alphanumeric paging was associated with a reduction in disruptive pages sent during scheduled educational rounds.

In recent years, medical educators have recognized the importance of the inclusion of patient‐centered care in the medical school curriculum.1 There is an increased awareness of the importance of patient involvement in medical decision‐making, as well as a realization that patient‐centered care positively affects patient satisfaction and outcomes measures.2 The Institute of Medicine, in its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, included patient‐centered care as one of the areas for the development of quality measures, defining it as providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.3 Several organizations, such as the Institute for Healthcare Improvement,4 have initiatives related to achieving the goals of patient‐centered care. While not a new phenomenon, patient‐centered care is permeating many areas of the healthcare delivery system.5 The recognition of patient‐centered care as both a desirable and measurable outcome of the healthcare enterprise has also renewed interest in the field of medical humanities as a valid tool for the advancement of patient‐centered initiatives and goals.

The Basis for Patient‐centered Care

Stewart et al.,6 in their book Patient‐Centered Medicine: Transforming the Clinical Method, identify 6 essential components of the patient‐centered clinical method: exploration of the disease and illness experience; understanding of the whole person; finding common ground; incorporating prevention and health promotion; enhancing the patient‐doctor relationship; and being realistic. These recommendations seek to improve the patient‐physician relationship by empowering the patient to be an active participant in his/her own health care.

The American Academy of Pediatrics recently released a policy statement7 outlining the benefits of family‐centered care in patient‐family outcomes, as well as in staff satisfaction. The statement also highlights the importance of bedside rounding by the attending physician and the healthcare team. Bedside rounding involves the patient in management discussions and decision making, while allowing for the unfiltered exchange of information. Nurses, therapists, and ancillary staff involved in the care of the patient also participate in the presentation. After the presentation, goals for the hospitalization are established, and the patient and family are asked for permission to implement the plan of care. Educational discussions regarding the patient's diagnosis usually take place outside the room, unless the patient's physical exam warrants a bedside teaching moment. Regardless of the format, patient‐involvement in the decision process is the central objective.

The Basis for the Medical Humanities

At the same time, there is renewed interest in the inclusion of the humanities in medicine. There is a perceived gap between the technological emphasis of the current medical school curriculum and the human values integral to the patient‐physician relationship.8 Namely, there is a growing concern that medical technology has suffused medical education with a sort of trade mentality in which doctors are trained in the latest scientific medical breakthroughs without the proper contextualization of the patient as the center of the healthcare enterprise.9 The National Endowment for the Humanities, the Association of American Medical Colleges, the Accreditation Council on Graduate Medical Education, and the Society for Health and Human Values have all called for increased emphasis of the humanities in medical education.10

What are the medical humanities? There is no clear‐cut definition. Felice Aull11 correlates the term with various so‐called liberal arts disciplines and their application to medical education and practice. She develops the notion that the medical humanities contribute to medical education in areas pertinent to patient‐centered care: insight into the human condition, development of observational and analytical skills, development of empathy and self‐reflection, and intercultural understanding.

In general, the medical humanities provide broad educational perspectives, and allow learners to develop skills critical to the development of a humane approach to patients.12 The paradigm relies on the assumption that exposure to the humanities in medical schoolin the form of formal lectures dealing with topics such as philosophy and literature, or through the role‐modeling interactions of teaching physicians and their perceived empathy to their patientswill allow the students to become more humane, and therefore, better doctors.13 The medical humanities seek to equip doctors with the critical thinking incumbent to the conversation about human values in a scientific field, and to explore questions of value and purpose critical in the medical setting.14

Shared Values

What are the values associated with the medical humanities that make them ideal for the teaching of patient‐centered care? Lester Friedman15 delineates 2 domains pertaining to the intrinsic values of the medical humanities. He identifies an affective domain, corresponding to a loose interpretation of the traditional affective perspective identified in the patient‐physician relationship; and a cognitive domain, a refocusing of medicine to its so‐called traditional professional roots, contrasted with the trade mentality of some in the profession today. Donnie Self16 identifies 2 currents of thought regarding the medical humanities: the affective approach, related to the development of compassion, sensitivity, empathy between the patients and their care providers; and the cognitive approach, which pertains to the development of logical and critical thinking required by medical education. These correspond to the integral attributes of patient‐centered care: incorporating the patients' ideas and affective responses to their illness; and establishing common ground and goals agreed upon by both patient and physician.17

The medical humanities are used to address such patient‐centered issues as end‐of‐life care in children,18 the physician‐patient narrative interaction,19 and the patients' role in their own health care.20 Medical humanities courses are also used in the training of cultural competence.21 Of course, the best‐known contribution of the medical humanities to patient‐centered care is the continuing importance of bioethics programs and their interrelation with other humanities fields.22

One of the goals of patient‐centered care is the elimination of perceived barriers of communication between patient and healthcare providers, in order to create a partnership aimed at improving healthcare outcomes.2 Since one of the fundamental aspects of medical training is learning the language of medicine,23 enhancing the communication skills of future physicians is part of the educational goals pursued by medical humanities programs.24 Language and its applicationsfor example, courses on medical interviewing or narrative medicineserve as the link between patient care and the medical humanities. Effective communication with patients is a measurable predictor of patient satisfaction, patient outcomes, and occurrences of malpractice litigation.17 For example, a study examining communication behaviors between physicians and the occurrence of malpractice claims25 found that doctors who were not sued spent more time with patients, educating patients about what to expect, and asking patients their understanding and opinion of the situation. Another study26 demonstrated that a patient‐focused approach improved the management of asthma, decreasing emergency room visits and hospitalizations. Therefore, it is not surprising that the Institute of Medicine's Committee on Behavioral and Social Sciences in Medical School Curricula identified basic and complex communications skills as priorities for inclusion in the medical curriculum.27

Doubts About the Process

There are doubts as to whether the medical humanities can really instill humanistic qualities in doctors. There are also questions about the physician‐centric focus of the medical humanities.28 This physician‐centric attitude runs counter to the intent of the medical humanities. Edmund Pellegrino and David Thomasma29 define the patient‐physician interaction as a human relationship where 1 person in need of healing seeks out another who professes to heal, or to assist in healing. The act of medicine ties these 2 persons together. While acknowledging the basic imbalance of the physician‐patient relationship, Pellegrino and Thomasma29 strive to close the gap by establishing medicine as a relation of mutual consent to effect individualized well‐being by working in, with, and through the body. The individualized exercise of well‐being, framed in, with, and through the body of the patient is similar to the description used by Stewart et al.6 of the patient as the unit of analysis delineating patient‐centered care, as it incorporates the interactive components proposed for a successful patient‐centered interaction.

There is also confusion between the teaching of humanities in medical schoolfor example, courses in history of medicine, narrative medicine, and medicine and the artsand the attempt to train humanistic physicians.30 Although an examination of humanities texts is certainly useful, the focus of the teaching of the medical humanities should evolve beyond a simple lucubration based on liberal studies, to a focused interaction between patient and physician, and a recentralization of the patient as the focus of that relationship.31

Conclusions

There is general agreement that a humane doctor is a better doctor. There is less agreement on how to measure the impact of a humanities education, as a qualitative assessment of satisfactory health care.19, 22, 25 There has been great growth in the teaching of medical humanities in medical schools. Most of the focus has been on the inclusion of humanities textssuch as literary, philosophical, and historical documentsas tools to establish a correlation between the arts and medicine, in hopes that the clarification of such association will provide medical students a broad‐based assessment, a so‐called world‐view, from which they can become introspective and humanistic when faced with their patients.³² Although this is a desirable goal, the driving force behind the medical humanities should shift to a quantifiable, evidence‐based assessment of its goals. A tool to achieve this verification is through the process of patient‐centered care. There is evidence to suggest patient‐centered care improves satisfaction and outcomes measures. It also refocuses care on the patient, which is the same goal of the medical humanities. By focusing on the patient, instead of the physician, the medical humanities will gain verification and validation within the academic healthcare environment.

In recent years, medical educators have recognized the importance of the inclusion of patient‐centered care in the medical school curriculum.1 There is an increased awareness of the importance of patient involvement in medical decision‐making, as well as a realization that patient‐centered care positively affects patient satisfaction and outcomes measures.2 The Institute of Medicine, in its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, included patient‐centered care as one of the areas for the development of quality measures, defining it as providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.3 Several organizations, such as the Institute for Healthcare Improvement,4 have initiatives related to achieving the goals of patient‐centered care. While not a new phenomenon, patient‐centered care is permeating many areas of the healthcare delivery system.5 The recognition of patient‐centered care as both a desirable and measurable outcome of the healthcare enterprise has also renewed interest in the field of medical humanities as a valid tool for the advancement of patient‐centered initiatives and goals.

The Basis for Patient‐centered Care

Stewart et al.,6 in their book Patient‐Centered Medicine: Transforming the Clinical Method, identify 6 essential components of the patient‐centered clinical method: exploration of the disease and illness experience; understanding of the whole person; finding common ground; incorporating prevention and health promotion; enhancing the patient‐doctor relationship; and being realistic. These recommendations seek to improve the patient‐physician relationship by empowering the patient to be an active participant in his/her own health care.

The American Academy of Pediatrics recently released a policy statement7 outlining the benefits of family‐centered care in patient‐family outcomes, as well as in staff satisfaction. The statement also highlights the importance of bedside rounding by the attending physician and the healthcare team. Bedside rounding involves the patient in management discussions and decision making, while allowing for the unfiltered exchange of information. Nurses, therapists, and ancillary staff involved in the care of the patient also participate in the presentation. After the presentation, goals for the hospitalization are established, and the patient and family are asked for permission to implement the plan of care. Educational discussions regarding the patient's diagnosis usually take place outside the room, unless the patient's physical exam warrants a bedside teaching moment. Regardless of the format, patient‐involvement in the decision process is the central objective.

The Basis for the Medical Humanities

At the same time, there is renewed interest in the inclusion of the humanities in medicine. There is a perceived gap between the technological emphasis of the current medical school curriculum and the human values integral to the patient‐physician relationship.8 Namely, there is a growing concern that medical technology has suffused medical education with a sort of trade mentality in which doctors are trained in the latest scientific medical breakthroughs without the proper contextualization of the patient as the center of the healthcare enterprise.9 The National Endowment for the Humanities, the Association of American Medical Colleges, the Accreditation Council on Graduate Medical Education, and the Society for Health and Human Values have all called for increased emphasis of the humanities in medical education.10

What are the medical humanities? There is no clear‐cut definition. Felice Aull11 correlates the term with various so‐called liberal arts disciplines and their application to medical education and practice. She develops the notion that the medical humanities contribute to medical education in areas pertinent to patient‐centered care: insight into the human condition, development of observational and analytical skills, development of empathy and self‐reflection, and intercultural understanding.

In general, the medical humanities provide broad educational perspectives, and allow learners to develop skills critical to the development of a humane approach to patients.12 The paradigm relies on the assumption that exposure to the humanities in medical schoolin the form of formal lectures dealing with topics such as philosophy and literature, or through the role‐modeling interactions of teaching physicians and their perceived empathy to their patientswill allow the students to become more humane, and therefore, better doctors.13 The medical humanities seek to equip doctors with the critical thinking incumbent to the conversation about human values in a scientific field, and to explore questions of value and purpose critical in the medical setting.14

Shared Values

What are the values associated with the medical humanities that make them ideal for the teaching of patient‐centered care? Lester Friedman15 delineates 2 domains pertaining to the intrinsic values of the medical humanities. He identifies an affective domain, corresponding to a loose interpretation of the traditional affective perspective identified in the patient‐physician relationship; and a cognitive domain, a refocusing of medicine to its so‐called traditional professional roots, contrasted with the trade mentality of some in the profession today. Donnie Self16 identifies 2 currents of thought regarding the medical humanities: the affective approach, related to the development of compassion, sensitivity, empathy between the patients and their care providers; and the cognitive approach, which pertains to the development of logical and critical thinking required by medical education. These correspond to the integral attributes of patient‐centered care: incorporating the patients' ideas and affective responses to their illness; and establishing common ground and goals agreed upon by both patient and physician.17

The medical humanities are used to address such patient‐centered issues as end‐of‐life care in children,18 the physician‐patient narrative interaction,19 and the patients' role in their own health care.20 Medical humanities courses are also used in the training of cultural competence.21 Of course, the best‐known contribution of the medical humanities to patient‐centered care is the continuing importance of bioethics programs and their interrelation with other humanities fields.22

One of the goals of patient‐centered care is the elimination of perceived barriers of communication between patient and healthcare providers, in order to create a partnership aimed at improving healthcare outcomes.2 Since one of the fundamental aspects of medical training is learning the language of medicine,23 enhancing the communication skills of future physicians is part of the educational goals pursued by medical humanities programs.24 Language and its applicationsfor example, courses on medical interviewing or narrative medicineserve as the link between patient care and the medical humanities. Effective communication with patients is a measurable predictor of patient satisfaction, patient outcomes, and occurrences of malpractice litigation.17 For example, a study examining communication behaviors between physicians and the occurrence of malpractice claims25 found that doctors who were not sued spent more time with patients, educating patients about what to expect, and asking patients their understanding and opinion of the situation. Another study26 demonstrated that a patient‐focused approach improved the management of asthma, decreasing emergency room visits and hospitalizations. Therefore, it is not surprising that the Institute of Medicine's Committee on Behavioral and Social Sciences in Medical School Curricula identified basic and complex communications skills as priorities for inclusion in the medical curriculum.27

Doubts About the Process

There are doubts as to whether the medical humanities can really instill humanistic qualities in doctors. There are also questions about the physician‐centric focus of the medical humanities.28 This physician‐centric attitude runs counter to the intent of the medical humanities. Edmund Pellegrino and David Thomasma29 define the patient‐physician interaction as a human relationship where 1 person in need of healing seeks out another who professes to heal, or to assist in healing. The act of medicine ties these 2 persons together. While acknowledging the basic imbalance of the physician‐patient relationship, Pellegrino and Thomasma29 strive to close the gap by establishing medicine as a relation of mutual consent to effect individualized well‐being by working in, with, and through the body. The individualized exercise of well‐being, framed in, with, and through the body of the patient is similar to the description used by Stewart et al.6 of the patient as the unit of analysis delineating patient‐centered care, as it incorporates the interactive components proposed for a successful patient‐centered interaction.

There is also confusion between the teaching of humanities in medical schoolfor example, courses in history of medicine, narrative medicine, and medicine and the artsand the attempt to train humanistic physicians.30 Although an examination of humanities texts is certainly useful, the focus of the teaching of the medical humanities should evolve beyond a simple lucubration based on liberal studies, to a focused interaction between patient and physician, and a recentralization of the patient as the focus of that relationship.31

Conclusions

There is general agreement that a humane doctor is a better doctor. There is less agreement on how to measure the impact of a humanities education, as a qualitative assessment of satisfactory health care.19, 22, 25 There has been great growth in the teaching of medical humanities in medical schools. Most of the focus has been on the inclusion of humanities textssuch as literary, philosophical, and historical documentsas tools to establish a correlation between the arts and medicine, in hopes that the clarification of such association will provide medical students a broad‐based assessment, a so‐called world‐view, from which they can become introspective and humanistic when faced with their patients.³² Although this is a desirable goal, the driving force behind the medical humanities should shift to a quantifiable, evidence‐based assessment of its goals. A tool to achieve this verification is through the process of patient‐centered care. There is evidence to suggest patient‐centered care improves satisfaction and outcomes measures. It also refocuses care on the patient, which is the same goal of the medical humanities. By focusing on the patient, instead of the physician, the medical humanities will gain verification and validation within the academic healthcare environment.

In recent years, medical educators have recognized the importance of the inclusion of patient‐centered care in the medical school curriculum.1 There is an increased awareness of the importance of patient involvement in medical decision‐making, as well as a realization that patient‐centered care positively affects patient satisfaction and outcomes measures.2 The Institute of Medicine, in its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, included patient‐centered care as one of the areas for the development of quality measures, defining it as providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.3 Several organizations, such as the Institute for Healthcare Improvement,4 have initiatives related to achieving the goals of patient‐centered care. While not a new phenomenon, patient‐centered care is permeating many areas of the healthcare delivery system.5 The recognition of patient‐centered care as both a desirable and measurable outcome of the healthcare enterprise has also renewed interest in the field of medical humanities as a valid tool for the advancement of patient‐centered initiatives and goals.

The Basis for Patient‐centered Care

Stewart et al.,6 in their book Patient‐Centered Medicine: Transforming the Clinical Method, identify 6 essential components of the patient‐centered clinical method: exploration of the disease and illness experience; understanding of the whole person; finding common ground; incorporating prevention and health promotion; enhancing the patient‐doctor relationship; and being realistic. These recommendations seek to improve the patient‐physician relationship by empowering the patient to be an active participant in his/her own health care.

The American Academy of Pediatrics recently released a policy statement7 outlining the benefits of family‐centered care in patient‐family outcomes, as well as in staff satisfaction. The statement also highlights the importance of bedside rounding by the attending physician and the healthcare team. Bedside rounding involves the patient in management discussions and decision making, while allowing for the unfiltered exchange of information. Nurses, therapists, and ancillary staff involved in the care of the patient also participate in the presentation. After the presentation, goals for the hospitalization are established, and the patient and family are asked for permission to implement the plan of care. Educational discussions regarding the patient's diagnosis usually take place outside the room, unless the patient's physical exam warrants a bedside teaching moment. Regardless of the format, patient‐involvement in the decision process is the central objective.

The Basis for the Medical Humanities

At the same time, there is renewed interest in the inclusion of the humanities in medicine. There is a perceived gap between the technological emphasis of the current medical school curriculum and the human values integral to the patient‐physician relationship.8 Namely, there is a growing concern that medical technology has suffused medical education with a sort of trade mentality in which doctors are trained in the latest scientific medical breakthroughs without the proper contextualization of the patient as the center of the healthcare enterprise.9 The National Endowment for the Humanities, the Association of American Medical Colleges, the Accreditation Council on Graduate Medical Education, and the Society for Health and Human Values have all called for increased emphasis of the humanities in medical education.10

What are the medical humanities? There is no clear‐cut definition. Felice Aull11 correlates the term with various so‐called liberal arts disciplines and their application to medical education and practice. She develops the notion that the medical humanities contribute to medical education in areas pertinent to patient‐centered care: insight into the human condition, development of observational and analytical skills, development of empathy and self‐reflection, and intercultural understanding.

In general, the medical humanities provide broad educational perspectives, and allow learners to develop skills critical to the development of a humane approach to patients.12 The paradigm relies on the assumption that exposure to the humanities in medical schoolin the form of formal lectures dealing with topics such as philosophy and literature, or through the role‐modeling interactions of teaching physicians and their perceived empathy to their patientswill allow the students to become more humane, and therefore, better doctors.13 The medical humanities seek to equip doctors with the critical thinking incumbent to the conversation about human values in a scientific field, and to explore questions of value and purpose critical in the medical setting.14

Shared Values

What are the values associated with the medical humanities that make them ideal for the teaching of patient‐centered care? Lester Friedman15 delineates 2 domains pertaining to the intrinsic values of the medical humanities. He identifies an affective domain, corresponding to a loose interpretation of the traditional affective perspective identified in the patient‐physician relationship; and a cognitive domain, a refocusing of medicine to its so‐called traditional professional roots, contrasted with the trade mentality of some in the profession today. Donnie Self16 identifies 2 currents of thought regarding the medical humanities: the affective approach, related to the development of compassion, sensitivity, empathy between the patients and their care providers; and the cognitive approach, which pertains to the development of logical and critical thinking required by medical education. These correspond to the integral attributes of patient‐centered care: incorporating the patients' ideas and affective responses to their illness; and establishing common ground and goals agreed upon by both patient and physician.17

The medical humanities are used to address such patient‐centered issues as end‐of‐life care in children,18 the physician‐patient narrative interaction,19 and the patients' role in their own health care.20 Medical humanities courses are also used in the training of cultural competence.21 Of course, the best‐known contribution of the medical humanities to patient‐centered care is the continuing importance of bioethics programs and their interrelation with other humanities fields.22

One of the goals of patient‐centered care is the elimination of perceived barriers of communication between patient and healthcare providers, in order to create a partnership aimed at improving healthcare outcomes.2 Since one of the fundamental aspects of medical training is learning the language of medicine,23 enhancing the communication skills of future physicians is part of the educational goals pursued by medical humanities programs.24 Language and its applicationsfor example, courses on medical interviewing or narrative medicineserve as the link between patient care and the medical humanities. Effective communication with patients is a measurable predictor of patient satisfaction, patient outcomes, and occurrences of malpractice litigation.17 For example, a study examining communication behaviors between physicians and the occurrence of malpractice claims25 found that doctors who were not sued spent more time with patients, educating patients about what to expect, and asking patients their understanding and opinion of the situation. Another study26 demonstrated that a patient‐focused approach improved the management of asthma, decreasing emergency room visits and hospitalizations. Therefore, it is not surprising that the Institute of Medicine's Committee on Behavioral and Social Sciences in Medical School Curricula identified basic and complex communications skills as priorities for inclusion in the medical curriculum.27

Doubts About the Process

There are doubts as to whether the medical humanities can really instill humanistic qualities in doctors. There are also questions about the physician‐centric focus of the medical humanities.28 This physician‐centric attitude runs counter to the intent of the medical humanities. Edmund Pellegrino and David Thomasma29 define the patient‐physician interaction as a human relationship where 1 person in need of healing seeks out another who professes to heal, or to assist in healing. The act of medicine ties these 2 persons together. While acknowledging the basic imbalance of the physician‐patient relationship, Pellegrino and Thomasma29 strive to close the gap by establishing medicine as a relation of mutual consent to effect individualized well‐being by working in, with, and through the body. The individualized exercise of well‐being, framed in, with, and through the body of the patient is similar to the description used by Stewart et al.6 of the patient as the unit of analysis delineating patient‐centered care, as it incorporates the interactive components proposed for a successful patient‐centered interaction.

There is also confusion between the teaching of humanities in medical schoolfor example, courses in history of medicine, narrative medicine, and medicine and the artsand the attempt to train humanistic physicians.30 Although an examination of humanities texts is certainly useful, the focus of the teaching of the medical humanities should evolve beyond a simple lucubration based on liberal studies, to a focused interaction between patient and physician, and a recentralization of the patient as the focus of that relationship.31

Conclusions

There is general agreement that a humane doctor is a better doctor. There is less agreement on how to measure the impact of a humanities education, as a qualitative assessment of satisfactory health care.19, 22, 25 There has been great growth in the teaching of medical humanities in medical schools. Most of the focus has been on the inclusion of humanities textssuch as literary, philosophical, and historical documentsas tools to establish a correlation between the arts and medicine, in hopes that the clarification of such association will provide medical students a broad‐based assessment, a so‐called world‐view, from which they can become introspective and humanistic when faced with their patients.³² Although this is a desirable goal, the driving force behind the medical humanities should shift to a quantifiable, evidence‐based assessment of its goals. A tool to achieve this verification is through the process of patient‐centered care. There is evidence to suggest patient‐centered care improves satisfaction and outcomes measures. It also refocuses care on the patient, which is the same goal of the medical humanities. By focusing on the patient, instead of the physician, the medical humanities will gain verification and validation within the academic healthcare environment.