Peter Pronovost, MD, PhD The Johns Hopkins University School of Medicine Baltimore, Maryland, USA

Christine Holzmueller, BLA The Johns Hopkins University School of Medicine Baltimore, Maryland, USA

Communication is the oldest and probably the most studied form of human interaction. Anthropologists and others have been intrigued for centuries by the progression and perfection of all kinds of communication from hieroglyphics to the spoken word. Yet, poor communication or miscommunication was reported as a contributing factor in 31% of incidents submitted to the ICU Safety Reporting System (ICUSRS) from July 1, 2002 to June 30, 2003. Moreover, upon reading these cases, the ICUSRS Team identified that communication problems contributed to most errors, though this factor was often not considered the primary cause by the person reporting the incident. In addition, communication problems contributed significantly to most of the sentinel events reported to the Joint Commission on Accreditation for Healthcare Organizations (JCAHO).

Today, communicating is quick and easy and can be established by emailing, text paging, beeping, or calling on a cell phone. While these methods allow individuals to multitask and accomplish more in a day, they may also be affecting our ability to interact and work as a team. In a hospital setting, particularly in an intensive care unit (ICU), how effectively a team works and communicates is imperative for positive patient outcomes.

It is rarely the case that a patient is solely cared for by one provider. In fact, patient care occurs at the hands of a team of healthcare workers who seek to improve a patient’s quality of life. While providers all have a common goal, the lenses through which they view the world often vary, resulting in an array of work and communication styles. Add to these differences a hierarchical culture, high workloads, sick patients and advanced technology, and it is not surprising that team communication is often ineffective. As a result, the various members of a care team lack clear goals and are unclear about the work needed to achieve those goals.

To pull ICU teams together, Peter Pronovost, MD, PhD, developed a communication tool called the Daily Goals Sheet,1 which is used during patient care rounds. In teaching institutions, rounds have a dual purpose: to educate medical students, residents and fellows about evidence-based medicine and to medically treat the patient. However, traditional rounds tend to be provider- rather than patient-centered, with providers discussing pathophysiology and relevant literature, which frequently lacks clarity for patient care plans.

The need for some form of communication tool was recognized after surveying ICU residents and nurses at Johns Hopkins following patient rounds. They were asked whether they understood the daily tasks and therapies dedicated to their patients. Only 10% answered yes to this question. With input from all ICU care team members, a daily goals sheet was developed. This hybrid checklist prompts the care team to identify the work needed to get the patient to the next level of care, which includes assessing the patient’s greatest safety risk, the care plan, and the communication plan. It also covers issues of pain management, medication changes, other care processes, and whether someone has kept the family informed about their loved one’s care.

The beauty of the daily goals sheet is the ability to modify it to meet the needs of any inpatient unit or medical care facility. For example, one ICU has modified the form to list goal 1, goal 2 and so on, while a separate ICU in the same hospital has initiated a checklist of specific therapies. Not surprisingly, the Daily Goals Sheet is now being used in hundreds of ICUs around the world.

The Daily Goals Sheet was first implemented in the intensive care units at The Johns Hopkins Hospital in July 2001. By week seven, more than 95% of residents and nurses reported they understood the daily goals for their patients. In addition, the ICU length of stay (LOS) dropped by one day in the two ICUs that implemented it. While implementation of the goals sheet correlates with a reduction in LOS, other studies focusing on quality improvements in the ICUs were occurring at the same time and may have contributed to this reduction.

The essence of the Daily Goals Sheet is its ability to structure patient care rounds and facilitate communication between care team members about the desired outcomes for a patient. All members of the multidisciplinary, multiprofessional critical care team—physicians, nurses, respiratory therapists, pharmacists, and others—review the goals for each patient multiple times during the course of the day and leave the form by the patient’s bedside to ensure the plan is explicitly followed. As goals of care change, so does the form. The goals sheet facilitates collaboration and helps practitioners focus on the patient’s needs. Furthermore, the establishment of clear goals improves a provider’s personal effectiveness and efficiency, thereby leading to more effective and efficient patient care.