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Implementation
Implementation of a considerative of a checklist
checklist to improve productivity
and team working on medical
129
ward rounds
Received 2 November 2010
Roselle Herring Revised 14 November 2010
Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK Accepted 16 December 2010

Gordon Caldwell
Worthing Hospital. Western Sussex NHS Trust, Worthing, UK, and
Steve Jackson
University Hospitals of Leicester, Leicester Royal Infirmary, Leicester, UK

Abstract
Purpose – In the changing environment of the National Health Service (NHS) medical ward rounds
have become increasingly complex. With complexity comes the inevitable risk that things will go
wrong. Serious failures in care can have important consequences for individual patients, their families,
cause distress to health care staff and undermine public confidence in the NHS. The paper’s aim is to
introduce the concept of a medical ward round considerative checklist to improve ward round
processes, effectiveness, reliability and efficiency, aid team working and foster better communication.
Design/methodology/approach – The checklist includes aspects of ward round preparation, the
consultation, progress assessment, discharge planning and handover. It is a “considerative checklist”
as it not simply checking if an essential component has been done but rather that it has been
considered, discussed, action identified and communicated effectively and involves an “at the point of
care check and correct” process.
Findings – The introduction of the checklist has provided a systemic approach to medical ward
rounds, provided reassurance that quality care is given, aided active participation from all health care
professionals and reignited team work. It has streamlined handover, improved patient and professional
communication, improved medical documentation and provided an audit tool for ongoing improvement.
Research limitations/implications – The diversity of general medicine makes standard measures
of quality of care such as length of stay, morbidity and mortality outcomes hard to measure; however,
qualitative data can be obtained.
Originality/value – The authors have developed a systemic ward round approach which ensures
attention to quality and safety at the point of care, encourages team working and improvements can be
documented.
Keywords Medical care, Team working, Patients, National Health Service
Paper type Research paper

Introduction
Medical ward rounds are very complex clinical activities. A ward round is a series of Clinical Governance: An International
meetings between a team of highly trained health care professionals and individuals Journal
Vol. 16 No. 2, 2011
with illnesses – patients. Together the team and those individuals make important pp. 129-136
decisions that will affect the patient’s current and future health and may affect all of q Emerald Group Publishing Limited
1477-7274
the patient’s remaining life. DOI 10.1108/14777271111124482
CGIJ Health care professionals reach a diagnosis or define clinical problems as carefully
16,2 as possible and decisions are made about investigations and treatments. Decisions are
made on the basis of the clinical information about the patient, including history,
examination, and clinical progress over time, response to treatments and results of
investigations. The health care professionals utilise the general evidence about
appropriate treatments available including Evidence Based Medicine, Clinical
130 Guidelines and the team’s own clinical expertise. The team negotiates the particular
treatment for the individual patient taking into account the patient’s clinical context
and the patient’s opinions and beliefs, desires and priorities. This requires a high level
of thinking, judgement of risk and careful decision making. These decisions are also
made in the context of that society’s local and national health economy, ethics and law.
To add to the complexity, medical ward rounds are attended by an ever changing
team of heath care professionals. This is primarily because of the reduction in junior
doctors’ working hours, the introduction of acute medical wards and speciality wards
and the rise in speciality nurses and supporting professionals.
Clinical experience and clinical audit have raised a number of concerning issues
around the ward round process.
.
Clinical information was hard to find because notes were not being filed properly
in the hospital notes.
.
Chest x-rays, electrocardiograms and blood tests were not consistently being
reviewed.
. Fluid balance charts, glucose chart, weight chart and drug charts were
infrequently reviewed and often poorly completed.
.
Intravenous access was often not removed when no longer needed, with the
associated risk of cannulae site infection.
.
Deep vein thrombosis prophylaxis treatment was not being prescribed or
reviewed on a systemic basis.
.
There was a number of inappropriate cardiac arrest calls in patients who should
have been receiving end of life care.
.
Discharge planning was often unclear and weekend plans were not written.
.
Poor communication with nurses about diagnosis, management and discharge
planning.

The Department of Health has stipulated in its Standards for Better Health that we
should ensure health care provided is both safe and of acceptable quality and that there
should be a framework for continuous improvement (Department of Health, 2006). In
the changing environment of the NHS medical ward rounds have become increasingly
complex and the current ward round process may not aspire to these standards. With
complexity comes the inevitable risk that things will go wrong. Serious failures in care
can have important consequences for individual patients, their families, cause distress
to the committed health care staff and undermine public confidence in the services the
NHS provides (Department of Health, 2000).
In complex activities outside and within medical practice checklists can be helpful
in reducing errors (Gawande, 2009). The aviation industry successfully uses checklists
for its complex tasks. Tests pilots make their lists simple, and short enough to fit on an
index card, with step-by step checks for takeoff, flight, landing, and taxiing (Degani Implementation
and Weiner, 1993). Within the NHS checklists can also serve as important tools for of a checklist
decreasing medical error and improve overall standards of patient care.
Implementation of the World Health Organisation Surgical Safety checklist has been
shown to reduce surgical mortality and morbidity (Haynes et al., 2009). The use of the
ventilator acquired pneumonia care bundles in the intensive care setting (Evans, 2005)
and surviving sepsis bundles have been invaluable (Dellinger et al., 2004). We 131
introduce the use of a medical ward round considerative checklist. We have developed
the term “considerative checklist” as it not simply checking if an essential component
has been done but rather that it has been considered, discussed, action identified and
communicated effectively.

Design
The considerative checklist was developed by collectively identifying essential
components for medical ward rounds. These included aspects of ward round
preparation, the consultation, progress assessment, discharge planning and handover.
It was expected that if we worked as a team we could ensure all essential components
of the checklist would be addressed. The Caldwell Considerative Checklist Process
(CCCP) is shown in Figure 1.
The checklist consists of 32 items, 20 which are essential components for
consideration during a ward round. The essential components of the checklist are
shaded or yellow. The remaining components are white, in that they may need to be
considered. When identifying essential components clinical thinking was consistently
highlighted as being of considerable importance. It is therefore the top domain. Clinical
thinking includes revisiting the diagnosis. Is the diagnosis correct? Could it be
anything else? Is the patient making the expected progress?
It is a considerative checklist, therefore the outcome for each component is that it
has been considered, discussed, action identified and communicated effectively. For
example, the outcome of deep vein thrombosis prophylaxis may be that it is not
suitable, contraindicated, a reduced heparin dose recommended in view of renal failure,
ordinary medical dose prescribed, TED stockings only or that heparin should be
discontinued.
It has been developed for use on “post take” and routine ward rounds in an ordinary
district general hospital but could be customised to any specific situation. Its simplicity
lies in the fact that it is only one A4 side and can be easily undertaken during the ward
round. The process involves appointing a checklist coordinator at the beginning of the
ward round; this can be a doctor, medical student or senior nursing staff. The
coordinator observes closely and notes any important aspects not considered in the
patient review. At the end of the consultation the consultant or team leader turns to the
coordinator and asks if all aspects have been covered. The checklist coordinator must
be able to report any omissions and they must be addressed before moving to the next
patient. It is important to respect the checklist coordinator and not alienate them or
become irritated by their report, especially when time constraints exist.
The health care team should be encouraged to complete investigation requests,
specialty referrals and discharge summaries during the patient review. This expedites
patient discharge, improves clinical information provided on request forms, prevents
delay in requests and eliminates the need for a post ward round job handover.
CGIJ
16,2

132

Figure 1.
The Caldwell
Considerative Checklist
Process (CCCP)

Encouraging physicians to use the checklist

Incorporating a checklist into the routine practice is not always a smooth process.
Implementation can initially lengthen the duration of a medical ward round and
physicians have their own style and may initially be resistant to a new ward round
structure. However, the checklist components do not need to be followed in their
entirety. We would encourage medical teams to practise using the checklist and adapt
in accordance to their personal practice and speciality needs. Care of the elderly
physicians may wish greater emphasis on patient rehabilitation whereas a cardiologist
may wish to include inspection of the coronary angiogram site.
The checklist is easy to follow and requires little preparatory education. To drive
and maintain the initiatives it is important to develop a team approach. The
commitment and support from the medical consultant, ward sister sends a valuable Implementation
message to other healthcare professionals. of a checklist
Limitations to evaluation
The surgical speciality lends itself to standard measures of quality of care such as
length of stay, morbidity and mortality outcomes. The diversity of general medicine
makes such outcomes hard to measure. There are too many confounding variables 133
leading to debate about cause and effect.
What we can deduce is that the introduction of the checklist has provided:
.
A systemic approach to medical ward rounds.
.
Reassurance that quality care is given.
.
Aided active participation from all health care professionals and reignited team
work.
.
Streamlined handover.
.
Improved patient and professional communication.
.
Improved medical documentation.
.
Provided an audit tool for ongoing improvement.

The checklist allows teams to follow a high quality process; good outcomes rarely
come from poor quality process. Research has shown that 70 per cent of adverse
incidents are preventable. However, although errors can be minimised they will never
be completely eliminated (Department of Health, 2000). Measures therefore need to be
in place to minimise events. A systems approach is required to tolerate the inevitable
human errors and contain their damaging consequences. The considerative checklist
systemic approach encourages teamwork limiting individual human error, it provides
an audit trail as errors frequently repeat themselves and provides a process to correct
problems at the point of care. We can use the reduction in adverse events as a measure
of success for the considerative checklist process but it may be difficult to identify
specific factors that can be targeted to improve patient care.

Strengthen the considerative checklist evaluation

We can strengthen evaluation by mapping the checklist to General Medical Council –
Duties of a Doctor (General Medical Council, 2008), National Patient Safety Agency
(National Patient Safety Agency, 2007, 2009), and National Institute of Clinical
Excellence(National Institute for Health and Clinical Guidance, 2010). This is
demonstrated in Figure 2.
Peer opinions are also extremely valuable for evaluation. Semi structured
interviews with doctors, nurses and students who have worked with us have provided
some qualitative data.
Comments provided by two of our junior doctors:
I found that the checklist really helped me highlight areas that I should be paying more
attention to on the ward round (Dr C, Core Medical Trainee).
The main lesson I learnt is how easy it is to leave important things undone without a
systematic approach to the rounds (Dr U, Locum Core Medical Trainee).
CGIJ
16,2

134

Figure 2.
Mapping the
Considerative Checklist
 Implementation
of a checklist

135

Figure 2.

Part of the problem in evaluating the checklist lies in the lack of clear guidelines on
how to conduct a medical ward round. Historically, doctors have learnt ward round
conduct from clinical experience. Our Trust is also using the checklist for
apprenticeship learning. The ward round checklist can act as a self-feedback,
teaching tool for undergraduates and postgraduates. It helps identify individual
omissions and provides a resource to learn and improve. Overseas doctors have found
the checklist useful, since they may initially have problems adjusting to new medical
and cultural systems. As a team we can recount the changes in our own professional
behaviour.
We believe we have developed a systemic ward round approach which ensures
attention to quality and safety at the point of care, encourages team working and
improvements can be documented.
We encourage colleagues to use and adapt the checklist to their speciality and
personal requirements and would very much appreciate any comments, criticisms and
feedback from their experience.

References
Degani, S. and Weiner, E. (1993), “Checklists: concepts, design and use”, Human Factors:
The Journal of the Human Factors and Ergonomics Society, Vol. 35 No. 2, pp. 345-59.
Dellinger, R.P., Carlet, J.M., Masur, H., Gerlach, H. and Calandra, T. et al., (2004), “Surviving
Sepsis Campaign guidelines for the management of severe sepsis and septic shock”,
Critical Care Medicine, Vol. 32, pp. 858-73.
Department of Health (2000), An Organisation with a Memory, DOH, London.
CGIJ Department of Health (2006), Standards for Better Health, DOH, London, April.
16,2 Evans, B. (2005), “Best practice protocols: VAP prevention”, Nursing Management., Vol. 36
No. 12, pp. 10-16.
Gawande, A. (2009), The Checklist Manifesto: How to Get Things Right, Profile Books, London.
General Medical Council (2008), Good Medical Practice: Duties of a Doctor, General Medical
Council, London.
136 Haynes, A.B., Weiser, T.G., Berry, W.R., Lipsitz, S.R., Breizat, A-H.S., Dellinger, E.P., Herbosa, T.,
Joseph, S., Kibatala, P.L., Lapitan, M.C.M., Merry, A.F., Moorthy, K., Reznick, R.K.,
Taylor, B. and Gawande, A.A. (2009), “A surgical safety checklist to reduce morbidity and
mortality in a global population”, New England Journal of Medicine, Vol. 6 No. 5, pp. 491-9.
National Institute for Health and Clinical Guidance (2010), “Venous thrombosis reducing the
risk”, CG92, January.
National Patient Safety Agency (2007), Safer Care for the Acutely Ill Patient: Learning from
Serious Incidents, National Patient Safety Agency, London.
National Patient Safety Agency (2009), Safety in Doses – Improving the Use of Medicines in the
National Heath Service, National Patient Safety Agency, London.

Further reading
BMA, Resuscitation Council (UK) and the RCN (2007), “A joint statement from the BMA,
Resuscitation Council (UK) and the RCN, October 2007”, Decisions Relating to CPR.
Department of Health (2004), Achieving Timely Simple Discharge from Hospital: A Toolkit for the
Multidisciplinary Team, Department of Health, London, August.
National Patient Safety Agency (2008), Clean Hands Save Lives, National Patient Safety Agency,
London.
Swafford, S. (1997), “Invasive devices increase the risk of infection”, British Medical Journal,
Vol. 314 No. 7093, p. 1501.

About the authors

Roselle Herring is Specialist Registrar Diabetes and Endocrinology, at the Royal Surrey County
Hospital NHS Foundation Trust, Guildford, UK. Roselle Herring is the corresponding author and
can be contacted at: [email protected]
Gordon Caldwell is Consultant Physician at Worthing Hospital, Western Sussex NHS Trust,
Worthing, UK.
Steve Jackson is Consultant Physician at the University Hospitals of Leicester, Leicester
Royal Infirmary, Leicester, UK.

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