How Asking Patients a Simple Question Enhances Care at the Bedside: Medical Students as Agents of Quality Improvement

How Asking Patients a Simple Question Enhances Care at the Bedside: Medical Students as Agents of Quality Improvement

 

 

Hope Olivia Ward; Sarah Kibble; Gney Mehta; Marc Franklin; Joshua Kovoor;
Aled Jones, BN (Hons), PhD; Sukhmeet Panesar, BSc (Hons), MBBS;
Andrew Carson-Stevens, MBBCh, MPhil 

Perm J 2013 Fall;17(4):27-31

https://doi.org/10.7812/TPP/13-028

Abstract

Medical students have traditionally played a passive role in the delivery of health care. The Institute for Healthcare Improvement Open School members and leaders initiated the Ask One Question project in December 2011. Through a commitment to the project, students are learning to assume a unique position in health care settings, as both learners and caregivers. They are improving care at the bedside by asking a simple question: "How can I improve your stay today?" Using the Model for Improvement to adapt the Ask One Question concept for local use, medical students at Cardiff University (United Kingdom) asked 120 patients. A content analysis of those responses identified 89 issues across 4 broad areas for improvement, including communication issues (uncertainty about their care management and desire for more time with their health care professional); practical issues (assistance with tasks made difficult because of ill health); wider organizational and National Health Services requests; and medical needs (requiring medical or nursing intervention). A medical student, a clinical colleague, or the hospital organization could act on those issues. Actions ranged from attending to simple tasks (eg, finding spectacles) or basic care needs (eg, giving a drink) to suggestions requiring wider institutional change. On a simple but effective level, Ask One Question reflects good manners and is a demonstrable competency of patient-centered practice. It is a vehicle for enabling students to seek improvements in health care and initiate relevant actions to improve the patient experience at the bedside.

Introduction

Patients all too often feel ignored and report that their health care has been fragmented and not holistic.1 The quality of patient care has raised considerable political and public concern in the UK,2 fueling efforts to achieve a patient-centered culture within the National Health Services (NHS). The recent Francis Inquiry in the UK revealed that patients and their caregivers were failed at many levels and, among many recommendations, called for better health care leadership and patient-centered care.3,4 These are qualities that can be exhibited by medical students, who are an untapped resource for improving health care quality.5

Medical students have more flexibility and time to spend with patients than employed staff. However, medical students in the UK typically interact with patients for learning purposes only—for example, they obtain medical histories, perform physical examinations, and observe encounters between patients and more senior health care staff—and often assume a passive role in health care delivery and its improvement.6 Moreover, the effects of the "hidden curriculum," defined as "a set of influences that function at the level of organizational structure and culture," can shape the moral and ethical attitudes of medical students during their professional training.7 As a result, students in the early stage of their courses are reportedly more empathic and patient-centered than those in the later stages of their training.6,8,9

The Institute for Healthcare Improvement (IHI) Open School is an interdisciplinary community that has a mission to advance health care improvement and patient safety competencies in the next generation of health professionals.10 It encourages the set-up of chapters where students, supported by faculty, engage with each other about issues related to quality improvement in health care. The Ask One Question project was initiated by IHI Open School members and leaders in December 2011, challenging students to ask patients, "What can I do to improve your stay?" Pilot work undertaken by early adopters of the project in Denmark, Wales, and the US suggests the majority of patients responded to this question with basic care requests, for example hydration, nutrition, and comfort.11,12

This article describes work undertaken by medical students at the IHI Open School chapter at the School of Medicine at Cardiff University in Wales, UK, who sought to adapt and develop the Ask One Question concept and identify opportunities for medical students to make active contributions to health care delivery and its improvement.

Methods

The concept of Ask One Question is simple—ask all patients, "What can I do to improve your stay?" Using the Model for Improvement,13 a series of small tests of change were undertaken between October 1, 2012 and December 1, 2012, to adapt the concept in terms of content (ie, identify the most appropriate question) and execution (ie, identify how and in what situations students can ask the question). Five clinical medical students (HW, SK, GM, MF, JK) from Cardiff University participated in the project.

Students approached inpatients for different clinical specialties including general medicine, trauma and orthopedics, and general surgery. Students typically seek guidance from senior clinical staff to identify suitable patients for them to work with before obtaining histories and performing physical examinations. Patients participated if they agreed to be involved in student learning. At baseline for the first test of change, students asked the question ("What can I do to improve your stay?") at the end of their interaction with the patient. Each student collected the following data: the patient's gender, specialty of his/her responsible clinician, time of day (morning, afternoon, evening), the patient's response, and the actions they undertook for the patient. No confidential or patient-identifying data were recorded, in line with local clinical governance arrangements. Table 1 summarizes key moments from the iterative trial and learning Plan-Do-Study-Act cycles. Team reflection (by all coauthors) informed this process.

With support from faculty advisors (AJ, ACS), approval to undertake this work was sought and granted from the Dean of Medical Education and hospital executives at a local health board, as well as from managers on wards where the project was undertaken. Students with limited clinical experience reported difficulty determining when it was appropriate to act on patients' wishes. For this reason, all students participating in the Ask One Question project were encouraged to liaise with the appropriate nursing or medical staff to assess whether an intervention was appropriate.

Outcome measures for the project were the number of patients assisted, responses by patients, and actions undertaken by students. ACS and SSP undertook a content analysis of responses by independently coding them and developing a coding framework based on a random sample of the free text in the "patient response" and "action by student" fields. The coding framework was applied to all reports with strong agreement between the 2 reviewers (observed kappa statistic = 0.92, 95% confidence interval = 0.87-0.97). Discrepancies in coding were resolved through wider team discussion with HW and SK.

How Asking Patients a Simple Question Enhances Care at the Bedside: Medical Students as Agents of Quality Improvement

Results

Over the course of this short pilot project, a total of 120 patients (72 men and 48 women) were assisted: 82 requested the students' help for a total of 89 issues; 38 patients made no requests. The issues identified fell into 4 broad categories:

  • communication issues (n = 40): a spectrum of communication problems resulting in uncertainty in terms of discharge date and details about care management and prescribed medicines, as well as requests for more time with health care professionals (physicians and nurses) and family
  • practical issues (n = 32): minor requests for assistance with a task made difficult because of ill health
  • wider organizational and NHS requests (n = 10): concerns and ideas relevant for feedback to the wider organization
  • medical needs (n = 7): symptomatic relief or management that required medical or nursing intervention.

An overview of patients by gender and clinical specialty are summarized in Table 2. The issues highlighted by patients are further broken down by category and subcategory, with examples, in Table 3.

Students or other staff fulfilled 61 of the 82 requests from patients. Of those requests, 27 were fulfilled by medical students acting independently, 15 by medical students acting with advice or assistance from professional health care staff, and 19 by other staff members without student involvement. Twenty-one requests were not able to be immediately fulfilled at the bedside (Table 4). We estimate the time taken to fulfill each task ranges from seconds to minutes (certainly no longer than 5 minutes), depending on the complexity of the request.

How Asking Patients a Simple Question Enhances Care at the Bedside: Medical Students as Agents of Quality Improvement

How Asking Patients a Simple Question Enhances Care at the Bedside: Medical Students as Agents of Quality Improvement

How Asking Patients a Simple Question Enhances Care at the Bedside: Medical Students as Agents of Quality Improvement

Discussion

Key Findings

Through asking and reporting responses to a simple question—"What can I do to improve your stay?"—we demonstrated that medical students can make small improvements in patients' experiences of hospital-based care. The contribution made by participating students contrasts with the traditionally passive role of medical students in the clinical environment, which is largely focused on students' meeting prescribed learning objectives rather than making contributions to patient care.

We have also demonstrated that to ask one question is appropriate at the end of a clinical encounter such as history taking or physical examination. Learning generated by successive small tests of change indicated patients were more likely to request assistance if the student first explained the purpose of Ask One Question. Hesitation and uncertainty about accepting the initial offer of assistance is a possible indicator that patients do not normally receive such offers from medical students.

Communication issues concerning physicians and nurses, such as the patient not understanding their medical conditions or plans for discharge, were most commonly discussed. The remainder of patient requests largely involved seeking assistance with practical and medical issues. In cases where the student did not feel competent to manage requests directly, it was possible to relay the information to junior physicians (residents) or nurses and to ensure a discussion took place to address the necessary issues. Issues that were beyond the immediate responsibility of the clinical team, eg, noisy bins and doors and lack of Wi-Fi, were reported back to the Director of Patient Experience at the health board. This feedback is currently being used in conjunction with patient satisfaction surveys and other sources to direct future interventions by the health board.

Practicalities and Opportunities for Improvement

This project highlighted that the Ask One Question approach varied with the severity of the patient's illness and the patient's previous relationship with the student (eg, several previous encounters or none). Although Ask One Question provided a means for identifying immediate opportunities to improve the patients' experiences at the bedside, it also gave rise to an opportunity to have a more in-depth conversation with them about their clinical care experiences and opportunities to improve on this.

For the preliminary testing of this concept, student participants were largely directed to patients for learning purposes by their senior clinical colleagues. Unfortunately this sample did not include patients who were acutely ill or those with communication barriers. Further work is currently underway between stroke survivors and IHI Open School chapter members in Cardiff to identify generic opportunities to improve the care experience of those enduring communication difficulties.

Relationship with the Literature

Ask One Question brings medical students and patients together as partners to achieve patient-centered care at the bedside. In recent years, the Picker Institute has pioneered the concept of patient-centered care that is associated with improved health status, defined as "understanding and respecting patients' values, preferences and expressed needs."14,15

The demands on health care professionals inherent within busy health care systems can sometimes be a barrier for providing care with empathy.16 Medical students are in the privileged position of being able to spend more time with patients, and the students' emotional skill set must be nurtured.17 Ask One Question has the potential to encourage rapport with patients and shift emphasis from administering care to a patient to building a relationship with a person. The emphasis on "persons" rather than "patients" is firmly in keeping with the professional duties and values of modern physicians, who should aim to respect patients as individuals.18 Including Ask One Question as part of early professionalism training at health care schools could assist students to focus on delivering patient-centered care beginning early in their careers.

Medical students traditionally take on a passive role in the hospital, with an emphasis on learning rather than getting involved in patient care. It is recognized that in the later years of professional preparation contact with patients is essential for recognizing patterns of presenting complaints, acknowledging the clinical relevance of basic sciences, and improving professional and communication skills.19 In traditional curricula, senior physicians have used patients solely as "teaching material"20; however patients also have a role as teachers themselves. Many patients are experts in their own condition and have personal narratives about their health care experiences.19 If patients are used as teachers of medical students in their own right, it stands that students should develop patient-centered attitudes as a benefit of the relationship. Ask One Question extends the relationship with the patient by offering a two-way relationship, where the student not only learns from patients but also offers to help alleviate issues that trouble them at the bedside. By collating and aggregating individual answers, students can assist hospitals to gain invaluable information about opportunities to improve the patient experience.

Ask One Question serves as a commitment to the improvement philosophy that everyone in health care has two jobs when they go to work every day—to do their work and to improve it.21 In 2009, the Check a Box. Save a Life. campaign motivated thousands of students to raise awareness and lead efforts to implement the World Health Organization Surgical Safety Checklist at their places of work and study.5 Medical students are an undervalued resource in health care organizations, and when educational providers such as the IHI Open School provide medical students with the skills and knowledge to lead improvement, they can lead change in health care.10,22,23

Implications for Practice, Policy, and Education and Further Work Needed

Asking patients "What can I do to improve your stay?" is good manners and requires no additional professional training or funding. Educators might wish to consider this a demonstrable competency of professional etiquette with patients during examinations. Although assessment drives learning in modern practice, medical schools should advocate the integration of this practice into students' professional encounters with patients and seek methods to evaluate whether this is being done reliably with every patient.

The top five actions that all medical students can routinely consider to assist patients at their bedside are to: 1) ensure patients have water; 2) ensure table and its contents are within reach; 3) ensure they are warm; 4) open curtains after closing them; and 5) adjust the bed safely, as needed. As Ask One Question continues to spread across the globe, it will be interesting to pool the learning and empirically expand this list of actions that all health care students can use to improve the patient experience at the bedside.

Ask One Question can be a vehicle for identifying existing excellence in care as well as for identifying opportunities to improve care. Further work should consider how health care schools could reinforce the professional benefits from Ask One Question and how health care organizations can systematize this practice among their workforce, regardless of discipline or position, at every patient encounter, every time.

Conclusion

Medical students bring a fresh pair of eyes to the health care system where qualified professionals might accept problems as the norm. Ask One Question is a vehicle for enabling students to seek improvements and initiate relevant actions to improve the patient experience of health care at the bedside. Ask One Question is an opportunity for educators to champion and ensure demonstrable competencies of patient-centered practice are present among tomorrow's health care professionals.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

The authors thank Vignesh Rajasundaram for assisting in data collection.

Leslie Parker, ELS, provided editorial assistance.

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