Daily goals: not just another piece of paper*.

Communication failure is one of the most frequently identified root causes of sentinel events (1), and a leading factor in medical errors (2). Thus, open, collaborative, and accurate communication is paramount to delivering high quality care in a dynamic and complex setting, such as the intensive care unit (ICU). It is no surprise that high performing ICUs possess patient-centered cultures that stress continuous communication, collaborative problem-solving, and care coordination (3). Collaborative communication through multidisciplinary rounding has been associated with decreased mortality among ICU patients (4). Nevertheless, providers and patients’ relatives believe communication in the ICU is challenging and inconsistent (5,6). In 1994, the Society of Critical Care Medicine (SCCM) and the American Association of Critical Care Nurses (AACN) advocated a multidisciplinary approach when practicing critical care medicine. In 2001, SCCM re-emphasized this team approach with nursing, respiratory therapy, and pharmacy participation, and the use of protocols to deliver consistent care (7). The Daily Goals rounding tool, first published in 2003, was developed to address these recommendations (8). The tool incorporates the principles of the aviation industry’s Crew Resource Management, a training program designed to improve interpersonal communication and encourage the use of all possible information sources to mitigate errors and increase efficiency. The Daily Goals tool tackles the main defects of conventional rounding by: i) standardizing communication to reduce encoding and decoding errors and improve information sharing, ii) diminishing perceptions of a hierarchy and fostering diverse and independent input, and iii) encouraging convergent thinking to ensure teams articulate and meet patient-centered goals. The tool can also be used to simplify the system and create redundancy to help ensure patients receive evidence-based therapies. The authors were not prescriptive with the tool components, format, and implementation to encourage units to adapt the tool to fit local context and culture. Since its inception, the Daily Goals tool has been part of multifaceted interventions associated with significant and sustained reductions in healthcare-associated infections across diverse types of ICUs (9,10). Several observational studies have used it and improved outcomes, most commonly length of stay, provider communication, and understanding of plan in adult ICUs, pediatric ICUs and non-ICU settings (11,12). Despite its widespread impacts, little is known about how the tool is used, how it impacts outcomes, and whether it is valued in the clinical setting. It is clear that this work is much more complicated than checking the boxes of a checklist. In this issue of Critical Care Medicine, Centofanti et al. (11) describe that a diverse group of ICU providers found the Daily Goals tool to be a “quick and simple tool with impacts on communication, patient care and education.” The authors observed the Daily Goals tool in use on rounds, analyzed completed tools, and conducted semi-structured interviews with providers to better understand the tool’s use and elicit provider perspectives. Their field observations provide new insights into how the tool is used. For example, it is most often reviewed at the end of a patient’s round, with most team members remaining engaged during the review. Analysis of data on the filled-in forms suggests that nurses use it to draw physician attention to their clinical concerns. Qualitative content analysis of provider interviews reveals that the Daily Goals tool improves communication by facilitating a systematic approach and multidisciplinary input, while serving as a central data repository. Providers believe that the comprehensive nature of the tool decreases the potential for errors and promotes patient recovery through best practices and “bringing rounds back to the patient.” It also teaches physician and nurse trainees to think in a systematic manner, and prompts teaching points during rounds. This study is novel because it studies and reveals how providers use the tool. Ethnography is a valuable but underused methodology in medicine to better understand how contextual factors (e.g., professionalism and team organization) influence intervention performance (13). Without a more complete understanding of how an intervention like the Daily Goals tool fits in clinical practice, its effectiveness and generalizability are likely limited. The authors’ observations and interviews reveal the tool’s main strength: it can be easily modified to suit local unit preferences and practices, thereby facilitating provider buy-in, implementation and sustainability across diverse settings. Modifying tools to fit local context is an important strategy to move providers from merely ‘compliant’ (or non-compliant) to ‘engaged’ because they find value in completing the tool. Efforts to deliver high-quality and reliable care require attention to both technical and adaptive work. Summarizing best evidence and developing policies, protocols, or checklists to ensure patients receive evidence-based practices are examples of technical work. Often, quality improvement efforts primarily focus on the technical work. Yet these same efforts often fail from adaptive challenges, such as clinicians who are reluctant to change their practice, or lack of leadership support (14). Health care has long perceived adaptive work as less essential to improve the quality of care, focusing instead on improving and standardizing technical skills and technological capabilities. Adaptive work is challenging and complicated yet essential. It requires an understanding of the health care delivery system, how providers maneuver in this system, and human behavior if we are to change peoples’ values, attitudes, and behaviors, foster engagement and ownership of the improvement process, and create a collaborative culture within the local unit and larger health care system. Adaptive work lays the cultural and organizational groundwork to facilitate technical work. Addressing the adaptive challenges helps to ensure providers find value in completing the tool so it is ‘not just another piece of paper to fill out’. This effort is worthwhile: units that implement Daily Goals and invest in addressing the adaptive challenges of implementation are rewarded with improved provider engagement, teamwork, performance, and patient outcomes (9,10,15).