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Improving Surgical Ward Care: Development and Psychometric Properties of a Global Assessment Toolkit

Hull, Louise PhD*; Birnbach, David MD, MPH*,†; Arora, Sonal PhD*; Fitzpatrick, Maureen MSN, ARNP; Sevdalis, Nick PhD*

doi: 10.1097/SLA.0000000000000451
Original Articles

Objective: To develop a toolkit that covers the clinical, nontechnical, and empathic skills required for effective, safe surgical ward care.

Background: Despite the explosion of interest in patient safety, little attention has been placed on the skill set required for safe and effective surgical ward care. Currently, there is a lack of a systematic approach to improving ward care via assessing and improving residents' ward care skills.

Methods: A comprehensive evidence-based and expert-derived toolkit was developed, including a novel clinical checklist for ward care (Clinical Skills Assessment for Ward Care: C-SAW-C); a novel team assessment scale for wards rounds (Teamwork Skills Assessment for Ward Care: T-SAW-C); and a revised version of a physician-patient interaction scale (Physician-Patient Interaction Global Rating Scale: PP-GIS). Interassessor reliability (κ, intraclass correlation), internal consistency (Cronbach α), and convergent validity (Pearson r correlations) were evaluated statistically in 38 simulated scenarios (during which a patient rapidly deteriorated) involving 185 residents.

Results: Excellent interassessor reliability was obtained for C-SAW-C [median κ = 0.89; median intraclass correlation coefficient (ICC) = 0.94], T-SAW-C (median ICC = 0.99), and the revised PP-GIs (κ = 1.00; ICC = 0.98 or higher). Internal consistency was also very high for all team skills assessed by T-SAW-C (Cronbach α range 0.87–0.94 across 6 skills) and the revised PP-GIS (Cronbach α = 0.96)—all P's < 0.001. Significant positive correlations were obtained between the 3 assessments (r = 0.73–0.92, P < 0.001) thus showing evidence for convergent validity.

Conclusions: We developed a toolkit that captures comprehensively the skills that are required for safe and effective ward care, including the high-risk situation where a patient decompensates. The toolkit offers a systematic evaluation of the quality and safety of surgical ward care and can be used to train and debrief residents' skills and performance.

Supplemental Digital Content is Available in the Text.We report the development and psychometric evaluation of a toolkit that assesses the clinical and team skills required for safe ward care and the quality of the interaction with the patient. Using the toolkit enables evaluation of ward care quality and enhancing physician skills required for effective, patient-centric ward care.

*Department of Surgery and Cancer, Imperial College London, UK; and

Department of Anesthesiology, UM-JMH Center for Patient Safety, Miller School of Medicine, University of Miami, FL.

Reprints: Louise Hull, MSc, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Wright Fleming Building, Norfolk Place, London W2 1PG, UK. E-mail:

Disclosure: L.H., S.A., and N.S. are affiliated with the Imperial Center for Patient Safety and Service Quality (, which is funded by the National Institute for Health Research, UK; However, the authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

© 2014 by Lippincott Williams & Wilkins.