Improving Surgical Ward Round Quality: Lessons From Studying Communication

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To the Editor:
We read with great interest the article by Pucher et al1 and the responses by both Hakeem2 and Oliphant et al.3 As a group of motivated surgeons, trainees, and students, we are also interested in the effect of ward rounds on patient outcomes and satisfaction. Pucher et al1 should be commended for their study because the impact of ward round quality on patient outcomes is poorly researched in the literature.
An aspect of ward round practice that we feel has not been formally considered in this study is communication. The importance of communication in providing safe and effective patient care is now widely recognized.4 Poor communication is a primary contributor to patient dissatisfaction and has been shown to influence patient outcomes in terms of both morbidity and mortality.4 The evidence base for this is firmly established in the setting of general medicine,5 the surgical operating theater,6 and on the intensive care unit.7 Despite this, there seems to be paucity of reporting of its importance during hospital ward rounds in the literature.
At the Nuffield Department of Surgical Sciences, Oxford University, we have been conducting a quality improvement project on communication in surgical ward rounds. We followed vascular surgical ward rounds over a 3-month period with 2 individuals each independently scoring the communication of the ward round team against agreed criteria. Following this, we delivered a detailed presentation of our findings to the department and circulated agreed recommendations and a ward round framework after discussion. The effectiveness of ward rounds have since significantly improved in a follow-up cycle (unpublished data).
We believe that our study raises 3 important points that are valuable to the discussion of ward round quality.
Firstly, in our study, we developed a quality control checklist to be used during ward rounds (Fig. 1). Our checklist split the typical ward round into 3 crucial stages. The first stage ensures full preparation of patient care information before approaching the patient. The second stage describes the bulk of information relay during the patient-doctor interaction, and the third provides a summary to consolidate vital information and plan for future and, in particular, the plans for discharge.
As suggested by the response of Hakeem,2 a ward round framework may help reduce ward round variability and ensure quality. Indeed, frameworks such as checklists have been used very successfully in other areas of medical practice. Most notably, in the arena of surgery, they are used generically in reducing perioperative adverse events in the form of the WHO Surgical Safety Checklist. The application of checklists in the surgical ward round setting has, to our knowledge, been unexplored until now. Given our promising results, we advocate the further and more widespread use of quality control checklists in surgical ward rounds.
Secondly, the responses2,3 to the original article cite the introduction of observer bias in the study of Pucher et al.1 To reduce the likelihood of observer bias in our study, we employed the use of 2 trained independent observers to score ward rounds. Ward round scores were then assessed and the level of agreeability was determined by calculation of Cohen kappa coefficient. Any discrepancies between the scores awarded by each author were re-evaluated by each author together until a consensus on the score was reached. We believe further studies measuring ward round performance should also take similar steps to ensure the effect of observer bias is minimized.
Finally, the authors of the original article1 chose high dependency unit (HDU) as the setting for their study. Although HDU is a setting in which ward round effectiveness is imperative, it remains that many hospitals in the UK still do not have HDUs.
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