RESEARCH ARTICLE

Using Patient Whiteboards to Engage Families inHarm Prevention and Care Planning: A QualityImprovement StudyKatherine Nowacki, MPH,a,b Tondeleyo Gonzalez, MA, BSN, RN,a Jennifer Mehnert, MSN, RN,a Amy Jacquemard,a Amy Tyler, MD, MSCSa,c

A B S T R A C T OBJECTIVES: Whiteboards are a valuable tool used to facilitate communication between familiesand the care team, but they were underused in our institution. Our aim was to increase families’knowledge of their child’s plan of care, safety plan, and medical care team names by increasing theuse of patient whiteboards with inpatient populations at a freestanding quaternary care children’shospital.

METHODS: With this quality improvement study, we redesigned the whiteboard template toaddress the following 4 main barriers to use: (1) not having enough space to explain concepts tofamilies, (2) having too much information to complete, (3) unclear roles of who completes thewhiteboard, and (4) forgetting to update the whiteboard. We focused the content of the new templateon critical information the family needed to know, assigned roles to make it easy to know who filledout which section, and used plain language.

RESULTS: The use of each whiteboard section on the old templates (n 5 92) versus new templates(n 5 424) were compared. Use increased for all sections (plan of care [48.9% to 71.6%; P 5 .008],safety plan [4.3% to 22.8%; P # .001], medical team [85.8% to 87.6%; P 5 .068], nurse’s name[94.5% to 98.8%; P 5 .031]). After the template redesign, 85.8% of families knew the plan of care,32.3% knew the safety plan, 61.5% knew the medical team’s name, and 92.8% knew the nurse’sname.

CONCLUSIONS: After the implementation of a new whiteboard template, we significantly increasedthe use of patient whiteboards and demonstrated improvement in families’ knowledge of the plan ofcare with inpatient populations at a freestanding quaternary care children’s hospital.

aChildren’s HospitalColorado, Aurora,

Colorado; andbDepartments of Qualityand Patient Safety and

cPediatrics, University ofColorado School ofMedicine, Aurora,

Colorado

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2017-0174Copyright © 2018 by the American Academy of Pediatrics

Address correspondence to Katherine Nowacki, MPH, Department of Quality and Patient Safety, Children’s Hospital Colorado, 13123 East16th Ave, Mail Box 400, Anschutz Medical Campus, Aurora, CO 80045. E-mail: katherine.nowacki@childrenscolorado.org

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Ms Nowacki conceptualized and designed the project, participated in data collection, completed the data analysis, and drafted the initialmanuscript; Ms Gonzalez and Ms Mehnert implemented the project, provided project design feedback, and participated in datacollection; Ms Jacquemard sponsored the project, implemented the project, and provided project design feedback; Dr Tyler implementedthe project, provided project design feedback, assisted in data analysis, and drafted the initial manuscript; and all authors criticallyreviewed and revised the manuscript and approved the final manuscript as submitted.

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The Joint Commission and Agency forHealthcare Research and Quality stressesthe importance of effective communicationin improving both patient safety and patientexperience.1,2 Whiteboards are 1 methodused to help facilitate communicationbetween families and the care team.3–6

Singh et al7 found that using whiteboardsfacilitated communication by providing aconvenient, effective, and durable route forinformation and concerns to be sharedbetween patients and staff.

In 2008, whiteboards were hung at ourpediatric hospital as a recommendation toengage patients and families; however, theywere underused.8 In addition, there was alack of continuity in the design betweenunits and no standard workflow forcompletion.

Inconsistent use of patient whiteboards maybe a missed opportunity to engage familiesas partners in care planning and harmprevention. Although previous research hasrevealed the connection between patientwhiteboard use and the families’ knowledgeof the plan of care, using whiteboards toengage families in safety planning toprevent harm has not been studied.3–6

We conducted a quality improvement studyto improve whiteboard use in the inpatientsetting hospital-wide. Our primary aim wasto increase completion rates for eachsection of the whiteboard by 10 percentagepoints in 12 months. Our secondary aim wasto increase families’ knowledge of the planof care, safety plan, and medical careteam names by 10 percentage points in12 months, which aligned with our hospital’sstrategy to support a “Speak Up” patientsafety culture.9 Our balancing measure wasto maintain the care team’s satisfactionwith whiteboard use $90%.

METHODSContext

Our hospital is a freestanding, teaching,quaternary care pediatric hospital with479 licensed beds and 15 070 inpatientadmissions in 2016. Four units, including2 medical units, an oncology unit, and PICU,were selected to participate in the firstphase of the study. These selected unitsrepresented diverse patient populations,

had variation in whiteboard usage, andhad engaged champions. After the study,interventions were spread hospital-wide toall inpatient, emergency, and urgent carelocations within our network of care. Ourinpatient psychiatric units were excluded.Only English-speaking families wereincluded in the study.

The medical care team is defined as follows:providers (physicians, physician assistants,nurse practitioners), nurses, certified nurseassistants, and other nonclinical teammembers. The whiteboard improvementteam included a hospitalist physicianchampion, nurse managers, the directorof patient family experience, unitrepresentatives, parent partners, healthliteracy experts, and patient safetyrepresentatives. Families are defined as theprimary guardians for the patient.

Interventions

We used Lean Six Sigma methodology tounderstand the current state, design ourinterventions, and track progress over

time.10 Measurable goals and a timeframewere established. Twenty-two baselineobservations were notable for the followingwhiteboard completion rates: nurse namewas filled out 86%, medical team names55%, plan of care 55%, and safety plan 0%of the time. Before developing interventions,we used a voice of the customer (VOC)survey to determine what our end userssaw as barriers to whiteboard use.Fourteen parent partners from our FamilyAdvisory Council and 150 team members(88 nurses, 22 attending physicians,19 clinical assistants, 13 residentphysicians, 6 advance practice providers,1 social worker, and 1 inpatient servicespecialist) were surveyed. Open-endedresponses were categorized into themes.A Pareto chart was used to display thefrequency of each theme (Fig 1).

The VOC survey revealed the following4 main barriers: (1) not having enoughspace to write and explain concepts tofamilies, (2) having too much informationto complete, (3) unclear roles of who

FIGURE 1 A Pareto chart was used to display the frequency of barriers identified to whiteboarduse from end users in our VOC survey of the medical care team and families(88 nurses, 22 attending physicians, 19 clinical assistants, 14 parent partners fromthe Family Advisory Council, 13 resident physicians, 4 nurse practitioners, 2 advancepractice providers, 1 social worker, and 1 inpatient service specialist).

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completes the whiteboard, and (4)forgetting to update the whiteboard. On thebasis of our VOC survey, the team agreedthat a new whiteboard design was neededto address the 4 barriers identified.

To address barriers 1 (not enough availablespace) and 2 (too much information tocomplete), we simplified the whiteboardtemplate to include critical informationfor families. A primary driver of spacelimitation and information overload was achecklist on the old whiteboard templatethat was designed for nurses to use duringbedside shift report. Used on the checklistwere hospital-acquired condition acronyms(eg, “CLABSI” for central line associatedblood stream infections), which were notwell-defined for families, and the sectionwas underused. This checklist was replacedwith “Today’s Safety Plan,” with the aim ofengaging families as partners in patientsafety by tailoring the harm preventionstrategy to the patient by using plainlanguage (ie, words that families canunderstand at the fifth grade readinglevel).11 “Today’s Safety Plan” was designedto be flexible and to align with each unit’spatient safety goals. For example, nursescould write “daily bath” under “Today’sSafety Plan” for a patient with a central lineto remind the family that a bath wasrequired to help prevent infection, or for apatient with bronchiolitis, the nurse couldwrite “keep side rails of bed up” to reducethe risk of a fall. We added a large “Notes”section for families where they wereencouraged by the care team to share whatwas most important to them, or teammembers could draw clinical drawings toexplain upcoming procedures.

To address barriers 3 (unclear teammember roles) and 4 (forgot to update thewhiteboard), we first had to understandthe current workflow for updating thewhiteboard. We used a process map tooutline when and how the whiteboard wasused and by whom. This revealed that theprocess was extremely nursing dependentand time consuming. To address this, theteam developed a process that incorporatedthe entire care team, including the medicalproviders, clinical assistants, and nurses.The template was built with clear

expectations regarding who wasresponsible for filling out each section ofthe whiteboard. Different colored sectionswere assigned to different roles. Thewhiteboard section outlined in blue wouldbe filled out by medical providers (plan ofcare), the section in red would be filled outby nurses (safety plan), and the sectionin yellow would be filled out by clinicalassistants (medical team names).

The final design of the new templateincluded the following 4 sections: medicalcare team names, plan of care, safety plan,and notes. Experts from our health literacyprogram ensured that we used plainlanguage for enhanced comprehension withour families. The final template insert sizeswere 23 in (height) by 15 in (width) in aportrait configuration and were printed inEnglish with Spanish translations (Fig 2).

Study of the Interventions

We used plan-do-study-act (PDSA) cyclesto make iterative changes to our newtemplate design on a small scale beforeimplementation (Supplemental Information;Supplemental Table 1). The study teampiloted changes to the new templatedesign in 2 PDSA cycles over 30 weeks(Supplemental Fig 6). Family and care teamfeedback were incorporated into thewhiteboard design with each PDSA cycle.

With our first PDSA cycle, we tested the newwhiteboard template in 5 patient roomson each of the 4 units. Thirty-eight in-personfamily interviews were collected over9 weeks. This cycle was used to makeadditional changes to the template design(Supplemental Information). Preliminaryresults were shared with our study sponsors,key stakeholders, and improvement team.

With our second PDSA cycle, we tested thenew template on additional units, includinga surgical unit, the emergency department,the neonatal and cardiac ICUs, and 2 urgentcare locations. We expanded the numberof departments in our second PDSA cycle toensure the design could work in differentenvironments. We collected 313 in-personfamily interviews over an additional14 weeks. This cycle was used to makeadditional changes to the template design(Supplemental Information).

We presented our findings to our studysponsors and unit leadership, and adecision was made to spread the newwhiteboard design to all units and networkof care. After this spread, we continued totrack our measures and collected another188 in-person family interviews over anadditional 8 weeks.

Measures

We collected data in the following 3 ways:conducted audits of the whiteboardcompletion (primary outcome), conductedqualitative interviews with families(secondary outcome), and conductedqualitative interviews with the care team(balancing measure). Data were collectedweekly and ranged from 7 to 30 auditsper week collected by unit representatives.Our testing phase was completed over14 weeks and postimplementation datawere collected for 8 weeks. In total,516 audits were collected on whiteboarduse, including 424 audits on the newtemplate design and 92 audits on the oldtemplate design. During the testing andpostimplementation phases, 428 interviewsfrom families and 115 interviews from thecare team were collected. Families werechosen by using convenience sampling, andauditors were instructed not to audit thesame family twice. Auditors worked withfamilies to conduct interviews at aconvenient time for the family and did notinterview during the night shift orweekends. Interviews occurred at any pointduring the patient’s admission.

Our primary outcome measures were thepercentage of completion of the following3 whiteboard sections: plan of care, safetyplan, and medical care team names. Thenotes section was excluded from the auditbecause we did not have a reliable methodfor auditing notes. The medical care teamsection was subdivided into the medicalteam (ie, providers) and nurse names.Whiteboard completion was tracked by thesame auditors conducting the in-personinterviews with families. At the time of thefamily interview, auditors recorded whichwhiteboard sections were filled out. Oursecondary outcome measures, collectedfrom a brief in-person interview, werefamilies’ knowledge of the plan of care,

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safety plan, and medical care team names.For our balancing measure, team memberswere interviewed regarding satisfaction tocompleting the whiteboard template duringthe study. Auditors would interview the careteam after they spoke with families.

Analysis

Completion rates of the old and newwhiteboard templates were collected inadequate numbers for comparison, butthese data were sporadically collectedduring the PDSA cycles rather thancontinuous intervals throughout the study.This lack of data over time limited ourability to effectively analyze these data on acontrol chart. Therefore, a Fisher’s exacttest in Minitab 17 was used to compare

whiteboard use rates of the old template tothe use rates of the new template.12 Dataon our secondary outcomes were collectedcontinuously during the testing andpostimplementation phases of our studyto see if the new template changes fromthe PDSA cycles were impacting families’knowledge. We used statistical processcontrol charts to monitor our progress overtime and distinguish special cause variationfor our secondary outcomes of families’knowledge of the plan of care, safety plan,and medical team.13 Data from the testingand postimplementation phase wereincluded in our p-chart. Where specialcause was noted, control limits wererecalculated. Finally, qualitative answersfrom family and care team interviews were

categorized into themes, and bar chartswere used to display the frequency of eachtheme.

Ethical Considerations

The study was approved for nonhumansubject research and qualified asquality improvement by our hospital’sOrganizational Research Risk and QualityImprovement Review Panel.

RESULTS

For our primary outcome of whiteboard use,completion rates for measured sections ofthe whiteboard were higher with the newtemplate than the old template. The plan ofcare was filled out on average 48.9% of thetime on the old template compared with

FIGURE 2 Old and new whiteboard templates that were hung in a patient room on an inpatient unit at our hospital. A, Old template. B,New template.

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71.6% of the time on the new template (P 5.008). The safety plan was filled out 4.3% ofthe time on the old template and 22.8% ofthe time on the new template (P # .001).The nurse name was filled out 94.5% of thetime on the old template and 98.8% of thetime on the new template (P 5 .031). Themedical team name or doctor in chargecompletion rates did not improve. Themedical team name or doctor in charge wasfilled out 85.8% of the time on the oldtemplate and 87.6% on the new templateof the time (P 5 .068) (Figs 3 and 4).

After the implementation of the newtemplate, there was special cause infamilies’ knowledge of the plan of care. Themean shifted from 72.2% to 85.8%. The othermeasures did not change with the newtemplate (the family knew the safety plan32.3% of the time, the medical team nameor doctor in charge 61.5% of the time, andthe nurse’s name 92.8% of the time).

Most of the 295 comments collected fromfamilies during the in-person interviewswere positive (87%; n 5 258) (Fig 5). Manyfamilies mentioned in their feedback thatthey liked the extra space to write in thenotes section. Families reported using thenotes space to remember medicationschedules, write a list of questions forthe medical team, or list importantinformation they needed to remember like

the spelling of a diagnosis, procedure, ormedication.

Results collected from 115 care teaminterviews revealed that 90% (n 5 104)of care team members could fill out thewhiteboard during their shift, 92% (n 5105) said the whiteboard was easy to fillout, 88% (n 5 102) said they had enoughspace to write, 89% (n 5 103) said theyunderstood their role in filling out thewhiteboard, and 1.7% (n 5 2) said theyexperienced unintended consequences forfilling out the whiteboard (SupplementalInformation). The unintended consequenceswere related to the families’ disappointmentto changes in the plan of care.

DISCUSSION

Effective communication is key to patientsafety and experience, and patientwhiteboards are ubiquitous communicationtools across inpatient settings.1,2 To beeffective communication tools, whiteboardsmust be used by the end users. Therefore,we aimed to redesign the whiteboardtemplate to increase use by end users. Byincreasing whiteboard use, we aimed todemonstrate an increase in families’knowledge of the plan of care, safety plan,and medical care team names.

The whiteboard redesign was guided by ourend users and targeted common process

failures. The template redesign created amore sustainable process for completion ofthe whiteboard by distributing roles acrossthe entire care team. Assigning dedicatedboxed sections for content owners helpedto reduce the assumption that the nursewas the sole user of the whiteboardand identified the other team members(eg, providers and clinical assistants)responsible for contributing information.

If families do not understand healthinformation, they cannot take necessaryactions for their child’s health or makeappropriate health decisions.14 We focusedthe content of the whiteboard template tocritical information that families needed toknow and used plain language. Making thewhiteboard easier to understand wascritical in increasing its use. The oldtemplate used the words “attending” and“providers” to mean a doctor. Many familiesdid not know what an “attending” was,and the word “provider” often meant ahealth insurance carrier. In our new design,we changed “attending” and “providers” to“Medical Team/Doctor in Charge” whichgave families a clearer understandingof who oversaw their child’s care forthe day.

In our study, we increased whiteboard useand improved families’ knowledge of theplan of care. No improvement was identifiedin the percent of families that knew thesafety plan, nurse name, and medical careteam names. Although this may indicatethat whiteboards were not effective incommunicating this information, it morelikely reflects the inadequate baselinedata that existed before the implementationof the new templates. Baseline data onfamilies’ knowledge was collected duringthe testing phase of the new templaterather than before starting our study.However, it was possible that whiteboardsmay not be effective for communicatingmedical care team names to familiesbecause of the large size of our medicalteams (attending, advance practice provider,fellow, senior resident, intern, and medicalstudent). Authors of previous studies haveshown that patients in teaching hospitalsmay be overwhelmed by the size andstructure of large medical teams.15–17

FIGURE 3 Comparison of completion rates for whiteboard sections between the old and newtemplates. P value was determined by Fisher’s exact test, a 2-sample proportions test,for summarized data in Minitab 17.

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FIGURE 4 P-charts reveal the percent of in-person interviews with families who knew the plan of care, safety plan, and medical team names whilewe tested the new templates (July 31, 2016–October 31, 2016) and implementation of the new template in 4 units (November 6,2016–January 8, 2017). A, P-chart of family knew care plan. B, P-chart of family knew safety plan. C, P-chart of family knew medical teamand/or doctor in charge. D, P-chart of family knew nurse. LCL, lower control limit; UCL, upper control limit.

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Our data reveal that families’ knowledge ofnurse name declined in the implementationof the new template. This may be due tothe nurse no longer being the sole userof the whiteboard and disrupting theprocess for writing on the whiteboard.

Our study had important limitations. First,we had a small number of baseline datapoints for our primary outcome, and thesedata were collected over the PDSA cycleslimiting our ability to analyze change overtime. Second, we collected data on oursecondary outcome after we began tests ofchange. This may have limited our abilityto identify significant change in theseoutcomes compared with the baseline.When the new whiteboard template designwas final, we did not randomize patients toreceive the new verses old whiteboardtemplate, limiting our ability to compareknowledge of the plan of care, safety plan,and medical team between the new and oldtemplates. Third, family interviews in thepresence of the whiteboard may have

influenced their answers. Fourth, care teaminterviews were done after the auditorsinterviewed families, and recall bias couldhave influenced the care team members’responses. Finally, only English-speakingfamilies were included and cannot begeneralized to all families.

CONCLUSIONS

After the implementation of a newwhiteboard template, we significantlyincreased whiteboard use anddemonstrated improvement in families’knowledge of the plan of care in theinpatient setting. Hospitals that want toincrease the use of patient whiteboards canlearn from our study. Our hospital has usedwhiteboards since 2008; however, with ourintervention we were able to increase bothwhiteboard use and families’ knowledge ofthe plan of care, pointing to the importanceof an appropriately designed template tomeet the family’s needs. With our study,we add to published literature bydemonstrating that the whiteboard can be

used to communicate the safety plan tofamilies. Partnering with families on safetyby using words and phrases that the familyunderstands builds trust and helps create ashared care plan.18 Our next steps will be tocompare different communication methodsin a randomized study to understand whatmethods work best to improve families’knowledge. In addition to whiteboards,factors used to encourage families to speakup and ask questions could includemultidisciplinary team and family-centeredrounding, leader rounding, discharge paperwork, and targeted culture work.19

Acknowledgments

We thank our executive sponsors DanielHyman, MD, MMM, Chief Medical and PatientSafety Officer, and Suzy Jaeger, Senior VicePresident and Chief Patient Access andExperience Officer, as well as the teammembers and parents that contributed tothis project. We also thank Amy Bodette,Audra Theis, Beth Hicks, Brandy Dale,Brenda Hyle, Bryce Clark, Deb Christmann,Deb Quackenbush, Dorothy Mathiesen,Elizabeth Diaz, Holly Nelson, Janel Olea,Jasmin Goebel, Jessica Schwartz, KatieSchuman, Kaylee Wickstrom, Kelli Dauleh,Kelly Reichert, Kristy Frederick, LindsayKuplack, Lindsey Shaw, Lynette Nerad,Lynn Dalton, Maria Hopfgarten, MaxineArment, Michele Mitchell, Mikelle Taufmann,Narni Avante, Sandi Enzmann, ShelbyChapman, Sondra Valdez, Tia Brayman,and Traci Ertle.

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DOI: 10.1542/hpeds.2017-0174 originally published online May 17, 2018; 2018;8;345Hospital Pediatrics 

Amy TylerKatherine Nowacki, Tondeleyo Gonzalez, Jennifer Mehnert, Amy Jacquemard and

Planning: A Quality Improvement StudyUsing Patient Whiteboards to Engage Families in Harm Prevention and Care

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Planning: A Quality Improvement StudyUsing Patient Whiteboards to Engage Families in Harm Prevention and Care

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