Implementing a daily goals sheet: data from Hospital Medicine 2017

A daily goals sheet is a simple bedside communication tool that states what the team intends to achieve for a patient during the next 24 hours. It can include diagnostic tasks, treatment milestones, mobility, nutrition, discharge barriers, escalation plans and ownership of each action. The concept gained practical attention at the Society of Hospital Medicine’s 2017 meeting, held from 1–4 May at Mandalay Bay Resort and Casino in Las Vegas.

For Australian hospitalists, the value of the meeting’s material lies less in copying an American form and more in adapting the underlying method. A goals sheet can support a busy medical ward round, make multidisciplinary priorities visible and give patients and families a clearer account of the plan. The conference archive provides the wider educational setting in which these ideas were presented, including research, patient-care practice, innovation and continuing professional development.

What the daily goals sheet is designed to solve

Hospital care often fails at the point where information moves between people. A consultant may set a plan during the morning round, a registrar may interpret it differently, and a nurse may be left unsure whether a scan, medication change or discharge task is urgent. A daily goals sheet creates a shared version of the plan that can be checked by everyone involved.

The document should be brief enough to use during a ward round, yet specific enough to guide action. “Continue treatment” is too vague; “reduce oxygen to room air if saturation remains within the prescribed range” gives the team a measurable target. The best forms also identify who owns the task and when it should be reviewed.

In Australian hospitals, this approach can fit naturally with bedside handover, multidisciplinary team meetings and electronic medical record workflows. It should complement the formal progress note rather than replace it. The clinical record explains reasoning and decisions; the goals sheet makes the immediate priorities easy to find.

Lessons that emerged from the 2017 meeting

The 2017 meeting placed strong emphasis on practical hospital medicine: safer systems, efficient teamwork, evidence-based decisions and reliable patient communication. Those themes support a daily goals process because the sheet is a small intervention aimed at a larger problem—variation in how teams plan, communicate and follow through.

A useful interpretation of the meeting’s data is that implementation matters as much as design. A polished template will not improve care if it is completed late, hidden in the record or ignored during handover. Teams need an agreed time for updating it, a clear location and a shared expectation that the plan will be reviewed with the patient whenever appropriate.

The method also reflects a broader shift towards defining daily progress in observable terms. Rather than waiting for the discharge summary to explain what happened, clinicians can identify the next safe step each morning. That might be weaning intravenous therapy, confirming a consultant review, arranging allied health assessment or determining whether a patient can return to a regional community.

Building a form clinicians will actually use

A practical sheet usually begins with the patient’s name, location, date and responsible team. It can then divide the plan into a small number of domains: diagnosis, treatment, investigations, mobility, nutrition, prevention of harm, communication and discharge. Each section should contain only the information needed for the day.

The wording should favour action verbs and time limits. “Review renal function after diuresis” is stronger than “monitor kidneys”. “Physiotherapy assessment before 1400” creates a clear expectation. If a result is pending, the sheet should state who will check it and what decision depends on that result.

Avoid turning the form into a second comprehensive chart. Excessive fields encourage copying and make important changes difficult to spot. A compact paper sheet may work in a ward where electronic access is inconsistent, while a digital version may be better where several services need simultaneous access. Either format needs version control so that an outdated plan is not mistaken for the current one.

Testing the process on an Australian ward

A sensible pilot might begin with one general medical unit in a metropolitan public hospital, such as a ward in Melbourne, Sydney or Brisbane. The team could use the sheet for four weeks, involving the consultant, registrar, junior doctors, nurses, pharmacist, physiotherapist and discharge coordinator. A nurse unit manager can help ensure that the process fits existing bedside handover rather than adding a competing routine.

The pilot should measure both reliability and usefulness. Useful measures include the percentage of eligible patients with a current sheet, the proportion of sheets containing a named owner, the frequency of documented discharge barriers and the time taken to complete the form. Teams can also track missed investigations, delayed medication changes, unplanned overnight escalation and patient understanding of the day’s plan.

Qualitative feedback is equally important. Ask whether the sheet reduced repeated calls, improved weekend preparation or made family discussions easier. On a regional or rural service, the form may be especially valuable when visiting specialists, telehealth clinicians and local staff share responsibility. The design must still work when staffing is lean and the team is covering several sites.

Connecting goals with patient safety

Daily goals should include safety-netting, not just routine tasks. A patient with sepsis may need a target for blood pressure, urine output or antibiotic review. Someone at risk of delirium may need a sleep plan, mobilisation and a medication review. A patient awaiting discharge may need confirmation of transport, carer capacity, equipment or follow-up.

Escalation criteria belong on the sheet when they are relevant. The plan can state what change should prompt senior review and who should be contacted. This is particularly useful overnight, when the clinician receiving a call may not have attended the morning round. Clear parameters support clinical judgement without pretending that every decision can be reduced to a tick box.

Other conference learning can strengthen this safety focus. For example, a concise clinical updates guide can help teams decide which evidence-based changes deserve a place in local protocols. The daily goals sheet should then translate those protocols into patient-specific actions, rather than becoming a catalogue of general recommendations.

Making patients and families part of the plan

A goals sheet is most effective when it is understandable to the patient. Technical language such as “optimise volume status” may be appropriate in a clinical note but is not a useful explanation at the bedside. “Reduce swelling and check whether you can walk safely to the bathroom” communicates the purpose more clearly.

The clinician can review two or three priorities during the ward round and invite the patient or family to identify practical barriers. In Australia, this may involve an Aboriginal liaison officer, interpreter, carer or community health professional. Cultural safety requires more than translating words; the team should check who needs to be involved in decisions and whether the proposed plan is realistic after discharge.

The sheet can also record the expected next step, such as “home with daughter tomorrow if walking assessment is satisfactory”. This helps distinguish a clinical goal from a promise. If the plan changes, the reason should be explained and the new target recorded. That habit may reduce confusion when several services discuss discharge at different times.

Using technology without losing clinical judgement

Electronic forms can make goals visible across the care team, but they introduce their own risks. Copy-forward text may leave yesterday’s targets in place. A required field may be completed with meaningless words. Alerts may be overlooked if the system produces too many of them. Digital implementation should therefore begin with a small number of high-value fields and a clear review process.

Point-of-care tools can support the plan when used appropriately. A hospitalist considering fluid status, lung pathology or procedural guidance may find the ultrasound checklist useful as a reminder of preparation, image acquisition and documentation. The scan itself should lead to a defined action, such as reviewing diuretic therapy or requesting further imaging, rather than appearing as an isolated task.

Technology must also suit local infrastructure. Some Australian wards have mature electronic medical records, while others rely on mixed paper and digital systems. Rural hospitals may have slower connectivity or visiting clinicians who use different platforms. A printable fallback and a clear policy for updating the authoritative version can prevent the tool from becoming another source of fragmented information.

Measures that show whether it is working

Evaluation should combine process, clinical and experience measures. Process measures show whether the form is being used: completion rates, update frequency, named accountability and documentation of discharge planning. Clinical measures may include length of stay, delayed discharges, medication omissions, falls, rapid-response calls and unplanned transfers, interpreted carefully because many factors affect them.

Patient and staff experience measures can reveal benefits that routine data miss. Patients can report whether they knew the plan for the day. Nurses can indicate whether priorities were clearer during handover. Junior doctors can describe whether the form helped them organise reviews and follow-up. Short interviews often explain why compliance is poor or why a particular section is valuable.

A dashboard should avoid presenting the sheet as a cure-all. Improvement is more credible when teams compare baseline data with a defined pilot period and review unintended effects, such as extra documentation time or duplicated notes. The aim is dependable communication, not a perfect percentage. Local leaders can use the results to refine the form and decide whether wider rollout is justified.

Practical recommendations for implementation

A daily goals initiative is most likely to last when it is attached to an existing clinical rhythm. The morning round, bedside handover and afternoon safety check offer natural points for updating and reviewing the plan. The following principles keep the intervention focused:

• Start with one ward, one patient group and a short pilot period.
• Limit the form to daily priorities, measurable targets and named owners.
• Include discharge barriers, escalation triggers and patient-centred goals.
• Train the whole multidisciplinary team, not only doctors.
• Audit completion, accuracy and usefulness rather than completion alone.
• Provide a paper or offline option for rural, regional and mixed-system settings.
• Review the form with patients and families using plain, respectful language.

The data and educational themes associated with Hospital Medicine 2017 support a practical message: communication tools work when they are designed around real clinical behaviour. A daily goals sheet should reduce ambiguity, fit existing workflows and make the next safe step visible to everyone.

For an Australian service, the strongest starting point is a simple ward-based pilot with a named clinical owner, weekly feedback and measures that matter to patients and staff. Used consistently, the sheet becomes a dependable bridge between the ward round, bedside care, handover and discharge planning.