Improving Daily Patient Goal-Setting and Team Communication: The Liber8 Glass Door Project*

Abstract

OBJECTIVES: 

To develop and implement a tool to improve daily patient goal setting, team collaboration and communication.

DESIGN: 

Quality improvement implementation project.

SETTING: 

Tertiary-level PICU.

PATIENTS: 

Inpatient children less than 18 years old requiring ICU level care.

INTERVENTION: 

A “Glass Door” daily goals communication tool located in the door front of each patient room.

MEASUREMENTS AND MAIN RESULTS: 

We used Pronovost’s 4 E’s model to implement the Glass Door. Primary outcomes were uptake of goal setting, healthcare team discussion rate around goals, rounding efficiency, acceptability and sustainability of the Glass Door. The total implementation duration from engagement to evaluation of sustainability was 24 months. Goal setting increased significantly from 22.9% to 90.7% (p < 0.01) patient-days using the Glass Door compared to a paper-based daily goals checklist (DGC). One-year post implementation, the uptake was sustained at 93.1% (p = 0.04). Rounding time decreased from a median of 11.7 minutes (95% CI, 10.9–12.4 min) to 7.5 minutes (95% CI, 6.9–7.9 min) per patient post-implementation (p < 0.01). Goal discussions on ward rounds increased overall from 40.1% to 58.5% (p < 0.01). Ninety-one percent of team members perceive that the Glass Door improves communication for patient care, and 80% preferred the Glass Door to the DGC for communicating patient goals with other team members. Sixty-six percent of family members found the Glass Door helpful in understanding the daily plan and 83% found it helpful in ensuring thorough discussion among the PICU team.

CONCLUSIONS: 

The Glass Door is a highly visible tool that can improve patient goal setting and collaborative team discussion with good uptake and acceptability among healthcare team members and patient families.

RESEARCH IN CONTEXT

• Team collaboration and goal-directed patient care improves outcomes and reduces medical errors.
• Communication of goals and plans is challenging in the ICU setting.
• There is a need for mechanisms to improve evidence-based goal setting and patient care processes.

AT THE BEDSIDE

• A highly visible “Glass Door” tool on the front of each patient room can improve patient goal setting, collaborative team discussion, and rounding efficiency.
• This communication tool demonstrated good uptake and was sustainable, especially during a pandemic.
• The Glass Door was preferred over paper-based daily goals checklists by healthcare providers, acceptable to family, and improved family engagement.

Goal-directed care optimizes patient management and limits ICU-associated adverse events such as nosocomial infection, over-sedation, and handover errors (^1–3). Effective team communication is a good predictor of shared understanding among team members of patient care goals and improves organizational performance, patient safety, parent satisfaction, and strategic consensus in healthcare settings (^4–6). Collaboration during patient care rounds improves the delivery of goal-directed care and ICU best practices (⁷). However, due to the complexity of the ICU environment and patient needs, communication of goals and plans can be challenging (⁸). This is amplified by the differing perceptions of communication openness among the various interprofessional groups within the ICU (²). Specific interventions have been designed to improve team communication and prompt evidence-based goal setting in the ICU, such as daily goals checklists (DGCs), team training, new progress note formats, write-down/read-back formats, and whiteboards (²). However, such tools are limited by adaptive challenges and failure to change provider practice (⁶). While checklists are important tools to standardize work processes, their adoption has been slowed by a variety of factors including limited use of implementation methods (⁹).

PICULiber8 was an implementation study of a multi-pronged rehabilitation bundle in critically ill children (NCT03573479; manuscript under review). As part of this study, stakeholder engagement revealed the need to improve team collaboration and communication around patient goals. The objective of this manuscript is to describe the development and implementation of the “Glass Door,” a tool to facilitate team-based communication and daily patient-goal setting. The outcomes of interest were implementation based and focused on the uptake of the Glass Door, its impact on patient goal setting, the acceptability and the sustainability of this tool.

METHODS

Design and Setting

This substudy of the PICULiber8 project was conducted with approval by the Hamilton Health Sciences Hamilton Integrated Research Ethics Board (HiREB Project No. 4493, approval date January 2018) in a 12-bed, medical-surgical PICU at McMaster Children’s Hospital (MCH), Hamilton, Ontario, Canada. Procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975. We followed the Standards for Quality Improvement Reporting Excellence 2.0; 11 (¹⁰).

Process

We applied Pronovost’s 4 E (Engagement, Education, Execution, Evaluation) model in the development and implementation of a new PICU daily goal-setting tool (¹¹). The drivers and implementation phases are summarized in Figure 1.

Figure 1.: Implementation process. DGC = daily goals checklist.

Engagement

In November 2018, we audited the use of the existing DGC, a 10-domain, paper-based bedside checklist (Appendix A, https://links.lww.com/PCC/C327). The audit revealed that the DGC was present at the bedside on 41.4% patient-days (29/70), and goals were set in only 22.9% patient-days (16/70). We then conducted focus group interviews of PICU team members (physicians [MD], nurses, and allied health) to assess impressions of the DGC, reasons for low compliance, and if change was necessary. A full summary of the focus group results is included in Appendix B (https://links.lww.com/PCC/C327). Key barriers to the use of the paper DGC were: 1) inconsistencies with communication and application of the DGC, 2) lack of clinician responsibility for DGC completion; and 3) lack of perceived importance of the DGC. Based on this feedback, we concluded that the DGC did not facilitate patient goal-setting and team communication of daily plans as intended, and an improved mechanism was needed.

We established a team of key stakeholders consisting of the PICU nurse educator, a safety and quality improvement nurse, two bedside nurses, respiratory therapist, pharmacist, physiotherapist, PICU fellow, two PICU attendings, and a family member. The team was responsible for reviewing the audit and focus group data and addressing the barriers and facilitators to the DGC. The team defined the objectives of the tool should: a) encourage team collaboration and communication; b) improve patient goal-setting specifically for key evidence-based domains; c) be easily visible, accessible, and feasible to use by all team members including family; and d) be acceptable and sustainable. Based on these objectives, it was determined that the paper DGC should be replaced by a new tool: the “Glass Door.”

Glass Door Development

The team met from December 2018 to March 2019 to design the content, education and execution process for the Glass Door. The Glass Door domains were determined by stakeholder feedback and review of the evidence for improved patient outcomes. These consisted of seven systems that cover the ICU Liberation ABCDEF components, that is, allowing awakening, good sleep and comfort, breathing, delirium, early mobilization and family goals; in addition to cardiovascular, nutrition, and fluid balance goals (Fig. 2) (^9,12). Additional prompts were included for planned investigations or procedures, reviewing current medications and catheters, research studies and discharge disposition. There was a section to specify “Goals or Targets” and a section to indicate if the goal was achieved or in progress (“Current progress”). Written goals were specifically not to include private or personal patient information but rather physiologic or actionable targets (e.g., target pain score < 4; mobility goal: out of bed). Goals were to be determined early in the shift in discussion with interprofessional team members prior to ward rounds, and progress could be updated throughout the day by any of the bedside team (e.g., Respiratory therapist for “B: Breathing,” registered nurse for pain, level of consciousness, and delirium scores). These goals would be reviewed with the entire team using the Glass Door during formal bedside rounds (twice a day) to ensure that they are still appropriate and collectively understood. Family goals could be written by either a family member or a bedside team member. Families could also opt out of the use of the Glass Door. The Glass Door content was reviewed and approved by the privacy office at Hamilton Health Sciences. Glass Door draft decal templates were piloted outside two patient rooms over a 2-month period (September 2019 to October 2019), and feedback was solicited on the content, formatting, readability, and sensibility.

Figure 2.: Glass Door decal. Bal = fluid balance, CAPD = Cornell Assessment of Pediatric Delirium, CVS = cardiovascular, Metab = metabolic, RASS = Richmond Agitation-Sedation Scale, TFI = total fluid intake.

Family members were engaged throughout the implementation process. This included the family representative of the Glass Door team and the MCH Family Advisory Council and Youth Advisory Council. A Parent Information Sheet was drafted with their guidance (Appendix C, https://links.lww.com/PCC/C327). We solicited input from family members of PICU patients during the pilot period.

Education and Execution

The final Glass Door decals were rolled out across all PICU patient rooms in November 2019. Team preparation and education for the roll out was conducted through newsletter announcements 2 weeks prior to the “go-live” date and in person announcements at the daily morning team huddles. Education and training videos created by the Glass Door team were disseminated to PICU staff via email, linked QR codes posted around the PICU, and resident training packages, accessible through YouTube, the PICULiber8 website (www.PICULiber8.com), and the local PICU shared drive (^13,14). In-person, PICU staff training was executed by the PICU nurse educator. PICU attendings received multiple training sessions by the Glass Door Project team members. Glass Door Champions were identified among the PICU fellows to promote and provide support on its daily use.

Evaluation and Analysis Plan

We used mixed methods to evaluate the following implementation outcomes of interest pre-and post-Glass Door introduction: a) uptake—frequency of written goals on the Glass Door; b) performance—frequency of verbal discussion of patient goals on ward rounds; c) efficiency—the duration of daytime ward rounds; d) acceptability, as assessed by self-administered surveys and focus group interviews; and e) sustainability, remeasurement of compliance rates 1-year post-implementation. The Glass Door was designed to be a communication tool and not a documentation standard; hence, we assessed “uptake” rather than compliance. Performance and efficiency audits were conducted by one of two independent observers in the pre-implementation (June 2019 to August 2019) and post-implementation periods (December 2019 to March 2020). To ensure rounds were audited in a standardized way, the auditors were trained to time the duration of rounds and to document if goals were discussed using a data collection form. Bedside rounding team members were blinded to the purpose of the audit. For performance, goal setting was deemed to have occurred if a system-specific patient goal was discussed during bedside rounds. Rounding efficiency was assessed by the duration of bedside rounds for each patient. Continuous data were reported as median (first quartile [Q1]–third quartile [Q3]). Event rates were reported as n (%) of patient-days. Statistical comparisons between pre- and post-implementation periods were evaluated using the chi-square test for proportions (n [%]) and rate differences, skewed continuous or interval data were compared using the Mann-Whitney U test. Acceptability and perceptions of the Glass Door were assessed post implementation using surveys and focus group interviews with key stakeholders (PICU leadership, nursing, physicians, residents, and interprofessional health team members). Interviews were conducted by independent trained personnel (Centre for Evidence Based Implementation, McMaster University, Hamilton, ON, Canada) and thereafter coded and analyzed using QSR International Pty Ltd. NVivo (Version 12; https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home).

RESULTS

The total implementation duration from engagement to completion of evaluation of sustainability of the Glass door was 24 months (November 2018 to November 2020) (Fig. 1).

Uptake and Sustainability

We assessed Glass Door uptake 2 weeks post-implementation on a total of 74 patient-days, representing a total of 518 goal-setting opportunities (Table 1). Uptake for goal-setting increased significantly from 22.9% with the DGC to 90.7% of patient-days using the Glass Door (p < 0.01). Uptake was sustained and improved to 93.1% 1-year post-implementation (p = 0.04). Uptake was very good (over 90%) across all systems-based domains. The family goal-setting was 60.8% following implementation and 69.9% 1-year later.

TABLE 1. - Glass Door Uptake: Frequency of Written Goals

Domain	2 wk Post-Implementation, n (%) Patient Days; Total n = 74	1-yr Post-Implementation, n (%) Patient Days; Total n = 83	p
Total completion rate across all domainsa	470/518 (90.7)	541/581 (93.1)	0.04
A (analgesia, level of arousal goal)	70 (94.6)	82 (98.8)	0.09
B: breathing/respiratory	72 (97.3)	81 (97.6)	0.87
C: cardiovascular/hemodynamic targets	70 (94.6)	81 (97.6)	0.23
D: diet and nutrition	71 (95.9)	82 (98.8)	0.18
E: early mobilization	71 (95.9)	81 (97.6)	0.44
F: fluid balance	71 (95.9)	76 (91.6)	0.05
Family	45 (60.8)	58 (69.9)	0.09

^aTotal number of goals in all domains across all patient days.

Performance

We audited 49 and 50 patient rounding events in the pre- and post-implementation periods, respectively (Table 2). This corresponded with a total of 28 and 32 individual patients in the respective periods. Severity of illness scores were higher in the post-implementation (Pediatric Index of Mortality-3 [PIM-3] score –6.5 [Q1 –6.6 to –5.6]) compared with pre-implementation periods (PIM-3 score –5.6 [Q1–Q3 –6.6 to –2.8]). The frequency of goal discussions increased overall from 40.1% (157/392) to 58.5% (234/400) of all possible goal-setting events (p < 0.01). Goal discussions improved significantly for respiratory, cardiovascular, hematology/infectious disease systems, as well as for mobilization and family goals. Bedside rounding duration decreased from a median of 11.7 minutes (95% CI, 10.9–12.4 min) to 7.5 minutes (95% CI, 6.9–7.9 min) post-implementation (p < 0.01).

TABLE 2. - Goal Setting and Rounding Duration Pre- and Post-Implementation of Glass Door

Characteristic	Pre-Implementation, n (%) Patient Days; Total n = 49	Post-Implementation, n (%) Patient Days; Total n = 50	p
Patient demographics
Age, mo (Q1–Q3)	60 (10–191)	52 (16–88.5)	0.063
Male, n (%)	23 (46.9)	25 (50.0%)	0.66
Pediatric Index of Mortality-3 score, median (Q1–Q3)	–5.6 (–6.6 to –2.8)	–6.5 (–6.6 to –5.6)	0.03
Frequency of goals discussed on rounds:
A (analgesia, level of arousal)	31 (63.3)	27 (54.0)	0.17
B: breathing/respiratory	23 (46.9)	44 (88.0)	< 0.01
C: cardiovascular/hemodynamic targets	8 (16.3)	18 (36.0)	< 0.01
D: diet and nutrition	32 (65.3)	34 (68.0)	0.69
E: early mobilization	12 (24.5)	20 (40.0)	0.01
F: fluid balance	23 (46.9)	28 (56.0)	0.20
Family	15 (30.6)	37 (74.0)	< 0.01
Other: hematology/infectious disease	13 (26.5)	26 (52.0)	< 0.01
Rounding duration, median (95% CI), min	11.7 (10.9–12.4)	7.5 (6.9–7.9)	< 0.01

Acceptability

Healthcare Providers

Sixty-seven of 94 healthcare providers (HCPs) (71.3%) completed the post-implementation survey. Sixty-one of 67 respondents (91%) perceived the Glass Door to be helpful for team discussion, collaboration, and team awareness of patient goals. Forty-one respondents (61.2%) found the Glass Door often or routinely helpful in understanding patient goals of care, and 44 (65.7%) felt it improved communication of patient goals to other team members. Fifty-one of 65 respondents reported having used both tools; 41 (80.4%) preferred the Glass Door, 7 (13.7%) preferred the DGC, and 3 (5.9%) preferred verbal communication for collaborating on patient goals. The main identified barrier to the Glass Door was inconsistencies in application depending on which intensivist was leading rounds. Areas for potential improvement were suggestions to include additional parameters such as patient weight, time of completion, and endotracheal tube position.

Family Members

Twenty-nine families completed the surveys, 19 (66%) of whom found the Glass Door helpful in understanding the daily goals for their child. Twenty-four families (83%) found it helpful in ensuring thorough discussions and goal planning among the PICU team (Fig. 3). Ten (34%) found the content too technical, 8 (27%) did not feel adequately oriented to the board, 6 (21%) thought the location of the Glass Door (on the front door or window of patient room) may limit family use. Five (17%) made suggestions to include other items, for example, vital signs, test results, medications and schedule, a section for parents to write comments or questions.

Figure 3.: Patient family perceptions of Glass Door.

DISCUSSION

The objective of this quality improvement project was to improve patient goal setting for key evidence-based clinical care practices in the PICU. The Glass Door was designed for this purpose with inter-professional and family stakeholder engagement. Uptake of the Glass Door was excellent and led to significant improvement in patient goal setting, communication of clinical targets and efficiency of ward rounds. Uptake of the Glass Door was not only sustained but higher 1-year later. The Glass Door was acceptable to HCP and family members, who found this a helpful tool for team communication for patient management goals.

The evidence for paper-based tools is inconsistent for improving communication (¹⁵). In contrast, this study adds to accumulating evidence that visual tools such as the Glass Door can improve HCPs understanding of patient plans, reduce handover-related communication errors, and leads to improved team communication and collaboration (^16,17). The improved uptake of the Glass Door compared to the paper-based DGC may be due to several factors: it is a clearly visible focal point of discussion in front of each patient room, goals could be referred to and updated in real time according to patient condition, and it engaged the entire team including family. As this tool was created with the specific needs of the unit in mind and with staff collaboration, shared ownership of the tool may contribute to its uptake and sustainability. The use of brightly colored markers on the Glass Door also facilitated engagement with staff and families, bringing an aspect of fun to the tool. The Glass Door was associated with a significant increase in both written as well as verbal discussion of family goals, a clear improvement in family engagement and communication. It was acceptable to families and was more effective in empowering family members to engage in goal setting than the DGC. This is consistent with evidence that open data display of patient data improves family situational awareness, empowerment, error detection, engagement in discussion with their healthcare team (¹⁸).

We observed that the frequency of written goals do not always correspond with goals discussed during rounds. This may be explained by the limitations of our audit process, which occurred only during rounds, while goals are encouraged to be made early during the day prior to rounds and could be amended at any time during the day. Nevertheless, there are some clear systems for which goal discussions during rounds improved. Whether this was prompted by the Glass Door or the acuity of the patients is unclear, as we note that the patients audited in the post-implementation period were sicker. Nevertheless, these suggest there are areas for ongoing improvement and education.

Strengths of this study include the use of an implementation framework, mixed methods analysis, and a collaborative approach involving interprofessional team members and family. The use of an implementation framework shown to be successful in the ICU setting allowed us to understand barriers and potential facilitators, define our objectives for change, and develop solutions specific to the needs of our PICU. Limitations of this study include the following: this tool is not inclusive as it is only in English; we did not track family survey response rates; verbal discussion of goals during rounds may have been missed by the auditor and hence under-reported, especially if goals were made or edited outside of daily rounds. Although the team were blinded to the assessment outcomes of the auditor, it is possible the presence of the auditor may have influenced their behavior. Nevertheless, this would apply to both pre- and post-periods. We assessed uptake by domain per patient-day and total uptake, but we did not measure the degree of uptake (i.e., n [%] of domains) per patient. Statistical Process Control charts may be preferred over the pre-post method we used to assess change; this continuous assessment was not feasible in our study. Given that we demonstrated significant change in goal-setting in a short period of time (< 1 yr), we concluded that it was most likely influenced by the Glass Door. As the objective of this quality improvement study was to develop and implement an improved communication tool, we focused on implementation outcomes rather than clinical outcomes; we acknowledge that this is an important endpoint for future study.

As our multimember, interprofessional teams continue to grow and become more autonomous, especially in the setting of increased patient isolation and restrictive visitor policies prompted by wake of the COVID-19 pandemic, the Glass Door continues to be a key facilitator for team communication and family engagement. Since the completion of this study, an electronic health record (EHR) was introduced in our institution in mid-2022. We were encouraged that this technology would potentially improve decision support for patient management plans and paused the use of the Glass Door. We have since observed that the EHR documentation requirements for each interprofessional team member has in fact siloed the thought process and eliminated the family input. These unintended consequences of EHR on communication have emerged in the ICU literature (^19,20). This depersonalization of patient care has prompted us to recognize the value of the Glass Door in facilitating team collaboration and communication, which we now continue to use; it serves as a “one-stop-shop” platform for communication among the PICU team as well as non-PICU consulting services; it facilitates stewardship (e.g., for antibiotics, sedation, rehabilitation, catheters) and has additional benefits such as reminders for appointments, celebrations, and raising research awareness. The future role of the Glass Door remains unclear with the advancements in information technology and electronic decision support tools; however, such tools are expensive and not yet widely available. In contrast, the Glass Door is low cost ($40 Canadian per decal), simple, and feasible to implement across high as well as low-income settings. Patient privacy considerations should be cleared with local jurisdictions prior to implementation.

CONCLUSIONS

The Glass Door in this single center PICU study improved daily patient goal setting for evidence-based clinical practices, team communication, and rounding efficiency. This highly visible communication tool that serves as a focal point of discussion with cues for evidence-based patient care was acceptable to HCP and families and improved family engagement. This simple, low-cost intervention was sustainable and remained helpful for communication, particularly during the COVID-19 pandemic.

ACKNOWLEDGMENTS

We thank the doctors, nurses, respiratory therapists, allied health, as well as the patients and families at the McMaster Children’s Hospital PICU for their engagement and input in the Glass Door Implementation. We thank the McMaster Children’s Hospital Patient and Family Advisory Committee for their suggestions on the Glass Door design and content. We thank Dr. Samara Zavalkoff and the PICU team at Montreal Children’s Hospital for sharing their experience with their Glass Door implementation process. We also thank our departmental research assistants Kimberly Krasevich and Jasmine Nanji and our data collection assistants Hannah Zimmerman and Grace Lamond.