Morning report: an Australian experience

The initial format of the morning report was a small meeting with PGY1–PGY3 doctors and medical students. It was supervised by the senior advanced physician trainee and conducted between 08:00 and 09:00 in the Department of Medicine. This meeting was attended by an average of 20 people, including medical students and the physician on call. One or two selected cases, based on their educational value, were presented along with investigations. Discussion centred on issues highlighted by the case. After the meeting, other patients admitted overnight were briefly handed over to the day doctors. The meeting was also conducted at weekends, when it was attended by the on-call physician, a PGY1 doctor and the physician trainee on duty.

In May 2001, the first quality improvement questionnaire was conducted. All morning report participants completed the questionnaire.

The key findings were that most PGY1–PGY3 doctors and physician trainees preferred physicians to be present to improve the teaching and learning value of the meeting. A majority of participants (15/22) reported that they learned something new each day. The self-perceived learning value was highest among students, followed by PGY1–PGY3 doctors and then physician trainees. These results were presented to all the staff at morning report and Department of Medicine meetings.

The findings suggested that reports on all patients admitted overnight should be presented, as participants expressed a dislike of lengthy theoretical discussions centred on one or two cases that seemed to have little relevance to patient management.

In response to feedback from the first questionnaire, the morning handover format was modified to include formal teaching, which consisted of presentations by physician trainees or physicians during the second half-hour of the meeting. A formal schedule was constructed.

Meetings initially functioned well in 2002. However, attendance in 2003 gradually dwindled from 20 down to 5–10 participants. Hence, a further, informal survey in September 2003 was conducted at a morning report and a Department of Medicine meeting to assess the status of the meeting.

As a consequence of including formal teaching, case presentations had become abbreviated. Further, the night physician trainee left early (before detailed presentation of cases). As only limited numbers of cases were presented, critical cases and “near misses” (ie, potential adverse events) were sometimes not presented at all.

As concerns regarding privacy had been raised, patient names were withheld in presentations. This led to significant difficulties for day medical staff in relating cases presented at the meeting to patients later seen on the ward.

Scheduled teaching became unsustainable because PGY1–PGY2 doctors, on 3-monthly rotation, required repetition, whereas PGY3 doctors, physician trainees and specialists were present all year. Senior physician trainees and physicians found the meeting a burden and began to start their ward rounds early, effectively removing the PGY1–PGY3 staff from the meeting.

Overall, the second morning report format was thought less effective than the first because of the focus on formal education rather than on patient handover.

The third and current format was implemented in January 2004. It is similar to the original format but with a stronger focus on punctuality, leadership, physician presence and patient-focused discussions. The Director of Medicine coordinates the meetings, and attendance by on-call physicians and representatives from all units is compulsory. An attendance sheet is maintained.

This format has become popular, with an average of eight consultants attending daily along with PGY1–PGY3 doctors and physician trainees.

Case presentations are made from photocopied or electronic notes, eliminating errors of recall. Complete, uninterrupted presentation of each case, including investigations, takes about 5 minutes. All photocopied notes are then handed over to the day staff at the end of the meeting.

A further change has been the implementation in January 2004 of a focus on bed management. A daily review is conducted of medical patients in surgical beds, and overall medical patient numbers are compared with available beds. Patient numbers per ward and the type of patient (ie, medical or surgical) are displayed on a whiteboard. When each patient is reviewed, a discharge plan is formulated. A daily emphasis on discharging has been promoted.

Change in practice has been brought about by:

• actively accepting surgical patients who do not require an operation onto medical wards; and

• actively promoting transfer of medical patients on surgical wards to medical beds the day after admission.

Further formal questionnaire surveys were conducted in March 2004 and 2005.

In 2004, the 26 respondents (a 100% response) comprised six students, seven PGY1–PGY3 doctors, seven physician trainees and six consultants. Most (22/26) attended the meeting daily, and most (92%) were in favour of the existing format. Despite the absence of organised teaching, 14/26 reported learning something new daily, while 10/26 reported learning something new weekly. The self-perceived learning value was highest among PGY1–PGY3 doctors. Aspects regarded favourably by the respondents were physician presence, quality discussion and debate among experts.

The findings of the 2005 questionnaire were similar, suggesting that the current meeting format is appropriate. Since the beginning of 2005, further refinements have included the introduction of digital radiology images that are accessed from the hospital network and projected from a laptop computer onto a screen.