Innovation on inpatient floors: 21st century white boards

Our old white board (patient names erased for privacy)

Imagine walking into your first day of work, being introduced to a new colleague and hearing, “Here’s the person who’s going to help you solve your problem.” I was a new Project Manager in Patient Care Operations at Children’s Hospital Boston. This brief introduction to Carlos, a Patient Service Associate on 9 South, marked the beginning of a year-long journey.

The problem Carlos laid out is common in hospitals, where multiple information systems, people and tools function in a fractionated, inefficient manner, culminating in a finished product that takes a village to maintain. It’s the problem of keeping the unit’s large, white dry-erase board up to date 24/7.

The white board, found on every inpatient unit, is a communication tool used to display patient assignments (beds, attending physician, nurse, etc.), contact information and clinical information.

A patient’s clinical status can change at any point – and so must the board. Caregiver assignments also change multiple times daily. Carlos works on a busy 25-bed medical floor, where there can be 5 to 15 admissions, transfers and discharges daily, and updating the board is only part of his job. In the evenings, nurses must assume this responsibility, taking them away from patient care.

Shockingly, a large portion of the information on the white board has already been entered into one of our many IT system applications (Epic, CHAMPS, BMS) – but since the white board is pen and paper, it isn’t integrated with those systems. Other shortcomings:

  • Updating the board is a highly manual process, and relies upon support staff, who aren’t necessarily available 24/7.
  • Information isn’t always up to date.
  • Information on room turnover — whether the bed is ready for a new patient — cannot be displayed.
  • Consistency is limited — information on the board varies from unit to unit.
  • There’s no historical reporting capability — information is lost when board is erased.
  • The board is visible only if you are on the unit.

Our first attempt to solve this problem was to pilot an electronic white board from our current Bed Management System application. This board was able to integrate with some of our existing IT systems, standardized the display of a HIPAA-compliant naming convention and included information on room turnover and patient safety precautions. It could track when patients went off-floor to other locations or were transferred in or off the unit or discharged.

But the product still couldn’t meet the needs of the staff.  One of the largest concerns was its inability to integrate with our Cerner system to display CHEWS scores (Children’s Hospital Early Warning Signs). Nurses update CHEWS scores, shown as colored dots on the white board above, every four hours to help identify patients who may be deteriorating clinically. Other problems:

  • The assignment process for caregivers varied depending on their credentials.
  • Updates to hospital information systems had to be installed manually on the computer.
  • It still depended on administrative staff for data entry.
  • It was still only visible on the unit.
  • Customization and reporting capabilities were limited.

So we decided to build our own product. Through Children’s Innovation Acceleration Program, we applied for and won a FastTrack Innovation in Technology (FIT) award. FIT provides a dedicated programming team, which worked with us and the staff on 9 South to develop a prototype.

Our new white board, named ALICE (Aggregated Local Information Collected Electronically), debuted as a pilot May 3-8 and next week (May 17-20) on 9 South. It displays information from various existing systems, reducing the need for manual entry. Most importantly, it displays CHEWS scores — the most recent and the highest score recorded at 0, 4, 8, 12, 16 and 20 hours – so staff can glimpse a patient’s current and recent condition without having to go into Power Chart.

A portion of ALICE's display, showing CHEWS scores at right (click to enlarge)

Viewable from any desktop or laptop, not just the monitors on 9 South, ALICE can print a copy of the caregiver assignment sheet, perform a historical look-up of patient care giver assignments and streamline and standardize the caregiver assignment process.

We work in a world-renowned organization noted for its research and clinical innovation — from culturing the polio virus to novel surgical techniques to scientific breakthroughs in cancer. But beyond these conventional definitions of innovation, we have another opportunity to lead. Atul Gawande told the graduating class of the Stanford School of Medicine last year, “Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually…”

Having the best drugs, devices, technology and people solves only part of the health care equation. Coordinating these pieces in streamlined, efficient, measurable processes — with ALICE as just one example — is our next challenge in practicing great medicine.