A team of surgeons enters the operating theatre. They are supported by a number of experts and professionals and their goal is to ensure a very specific outcome. The results of their work, the hours spent in theatre, are visible, measurable and clear. It would be inconceivable to imagine that a team would disappear for four hours only to emerge with no concept of quality, cost or benefit.
This is exactly what happens with ward rounds, and as such a vital healthcare service and strategic tool, this has to change.
Defined as the sine qua non of the hospital, ward rounds provide both healthcare professional and patients with valuable information and support. The professionals use them to refine a diagnosis, comorbidity and severity of illness, to determine the result of treatment and to plan future treatments and tests. For the patients, it is a time when they feel the centre of attention, that they and their needs are important, all in an unhurried consultation. Rounds should be fulfilling for staff and patient, providing training, information and insight on all levels. And yet there has been very little study into the structure, the processes and outcomes of ward rounds.
So, why the secrecy?
Firstly, the rounds are confidential so managers may feel that they don’t have the right to attend. Secondly, those in managerial roles may not be comfortable with ill patients and the clinical workplace. Thirdly, there may be the assumption that doctors are highly intelligent individuals, who already have optimal systems in place. The problem with all three assumptions is just that, they are assumed not fact.
The true cost of staff resources
The staff resources used in rounds are expensive and there are cost implications in terms of the decisions made during rounds, so the lack of studies into their effectiveness, efficiency, outcomes and costs are indefensible. The challenge is that measuring outcomes from ward rounds is complex, using business case costs to drive improvements is problematic and it isn’t that easy to define quality indicators for rounds, which can encourage further investment into their improvement.
That said, there is one model which could potentially be a good fit for this problem — the Donabedian model of structure, process and outcomes. It provides a useful framework into which the basic elements of ward rounds can be built and around which future study can be structured.
The Donabedian model
Theoretically, the structure element could include all those factors, which determine the context in which care is delivered, the process element would be the sum of all the actions which make up healthcare, and the outcomes element would encompass the effect of healthcare on patients or the population. Each element would then trigger a series of questions – how many inpatients does the hospital accommodate, is there a patient’s sitting room, how much space is around each bed, are clinical notes paper or digital or both, how are nursing notes managed, how are vital signs measured and recorded, and how many direct clinical care senior doctors are available for the number of inpatients?
And that is just the tip of the iceberg
These are just some of the questions which need to be asked around the Donabedian model of ward round analysis and study. Each set introducing new insight and deeper questioning into how ward rounds can be refined and redefined for the future. Each element adding layers of value which can be used to improve the structure of ward rounds and improve understanding of cost, deliverables and capability.