Our October 7, 2014 Patient Safety Tip of the Week “Our Take on Patient Safety Walk Rounds” discussed positive features of Patient Safety Walk Rounds but also warned that such rounds done poorly can actually be detrimental, especially if the rounds are perceived as being perfunctory and feedback is not provided. We ended by stating that measurement of the impact of these rounds can be difficult.
A new study attempts to provide such measurement (Sexton 2017). Sexton and colleagues did a cross-sectional survey of healthcare workers in multiple settings in the Michigan Keystone collaborative to determine the impact of Walk Rounds (WR) on domains such as safety culture, employee engagement, burnout and work-life balance. Focus was on the importance of feedback.
Over 16,000 surveys were returned, for a response rate of 70.4%. Of those responding, 32.7% reported that they had participated in WR, and 24.3% reported that they participated in WR with feedback. Work settings reporting more WR with feedback had substantially higher safety culture domain scores and significantly higher engagement scores for four of its six domains.
The authors suggest that “when WRs are conducted, acted on, and the results are fed back to those involved, the work setting is a better place to deliver and receive care as assessed across a broad range of metrics, including teamwork, safety, leadership, growth opportunities, participation in decision-making and the emotional exhaustion component of burnout.”
The researchers found that both personal burnout and burnout climate were lowest in work settings that had the highest rates of WR with feedback. Workforce engagement was also clearly higher in work settings with highest rates of WR with feedback and the highest scores in participation in decision-making and growth opportunities. The authors tie this to the concept of “small wins”, in which “a pattern of small wins is a series of concrete outcomes of moderate importance, which attracts allies and deters opponents”.
The study, of course, does not prove causality. It remains conceivable that a strong culture of safety might lead to the positive results found rather than the Walk Rounds being the cause of the better culture of safety.
Sara Singer, whose work we highlighted in our October 7, 2014 Patient Safety Tip of the Week “Our Take on Patient Safety Walk Rounds”, commented in the accompanying editorial (Singer 2018). She again cautioned on the importance of doing Walk Rounds correctly and the risk of their backfiring if done improperly. She offered 3 important keys to successful Walk Rounds:
She makes careful reference to the role of middle managers, noting that ignoring the role of middle managers when engaging front-line workers can risk “igniting” middle managers’ fears and negative repercussions. Rather, she recommends engaging middle managers as hosts, guides, and navigators during WR. She also notes the importance of recognizing informal social networks as potential vehicles to promote positive messages.
It’s worth reiterating some of the observations and recommendations we made in our October 7, 2014 Patient Safety Tip of the Week “Our Take on Patient Safety Walk Rounds”:
How often should you do Walk Rounds? Unfortunately, there are no hard and fast guidelines. We usually recommend that each unit be visited at least every two months, perhaps supplemented by monthly rounds done by other staff.
One bad habit organizations have is only doing Patient Safety Walk Rounds on the day shift. It is extremely important that you do them on all shifts. That takes planning and commitment. Why is it important? Because two-thirds of the staff you want to include in your safety culture work on those other shifts! Not only do you need to convey to them your commitment to improving patient safety but you will also better see and hear about some of the barriers to patient safety on the evening and night shifts.
Who should be there on Patient Safety Walk Rounds? Your core team should include your CEO, COO, CMO, CNO, and head of Quality and Patient Safety. But there are others that should also participate. You’ll want a pharmacist for rounds on almost all units. Bringing your CFO on such rounds is a good way of giving him/her a better understanding of how patient safety issues can impact the bottom line. Your CIO may also gain valuable insights into how staff interact with technology and many of the safety issues resulting from complex IT issues or ones that could use an IT solution. Including representatives from other departments (eg. engineering, housekeeping, SPD, etc.) can also bring unique perspectives. We also recommend that you include your Board members in Patient Safety Walk Rounds. Not every rounds, but mandate that each Board member attend at least one walk rounds session annually. Not only will that help educate them about patient safety but you’ll be pleasantly surprised by the insights they bring to your rounds, either by their perspective as a “consumer” or patient or the perspective of whatever industry they happen to come from. For example, a banker might cringe looking at patients in line in your antiquated patient registration system and have good ideas for improving efficiency and patient flow. Note also that the previous Singer & Tucker review (Singer & Tucker 2014) mentioned the importance of including physicians in such rounds. We wholeheartedly agree. Almost every study done on culture of safety shows disparities between the impressions of frontline staff and physicians (and administrators). However, equally important is not having the physician presence stifle open discussion of issues with staff. We’ve all too often seen situations in which behavior of a physician is the critical safety issue and staff are unwilling to speak about it in front of another physician, even the CMO. Lastly, some include a patient or patient family member. A Board member might fulfill that role but Board members may have an “insider” bias. Having an “outsider” pair of eyes and ears may be important.
Should all those individuals be on every Walk Rounds? Definitely not. Having too many upper management people on rounds can be very intimidating to staff. So split them up. Have 2-3 team members do walk rounds on one unit and others do them on another unit or another shift. You really want to be able to interact with your frontline staff and make them feel comfortable in speaking up.
What units should get Walk Rounds? Answer: all of them. But some may need particular attention, particularly those that are “melting pots” like the Radiology suite. In our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite” we discussed the multitude of safety issues seen in Radiology suites that have little to do with radiology per se. And don’t forget to include non-clinical units. You’d be surprised how often your Walk Rounds with your housekeeping department provides insights into patient safety issues.
Remember, you are not just doing walk rounds for show. The most important thing you can do is identify issues and follow up. One member of each team should keep a formal issues log that includes action items and dates for expected actions. Timely feedback to frontline staff on actions taken for each item is extremely important. And beware of simply telling staff “that’s been referred to Committee X” because that often conveys the message “nothing is going to be done”. You will encounter some items that cannot be fixed simply or expediently. In such cases you need to be honest with your staff and tell them, for example, that a current budgetary or technical restraint won’t allow a quick fix (eg. “that is in the software version update to be installed in 3 months”). But at least they will know that it is still on your list. Singer & Tucker also stress that frontline staff become frustrated when senior management spends too much time prioritizing issues rather than taking actions. We recommend that you use the same process for follow up that you use to ensure actions taken when you do a Root Cause Analysis. That means you keep a list of actions not yet completed or other “open” items and discuss these at each of your regular Quality Improvement/Patient Safety Committee meetings until you have closed the loop.
Body language on Walk Rounds is extremely important. Not theirs, yours!!! The old adage that 90% of communication is nonverbal holds true. If your body language conveys disinterest or “let’s just get this over” it won’t matter what you are saying with your staff. They will recognize that such rounds are perfunctory. But don’t ignore the body language of your workers either. You may notice one worker “squirm” a bit when something is being said. In such cases, it is worthwhile to have someone later meet that worker in a very non-threatening setting and say “I noticed you seemed uncomfortable when so-and-so was saying…”. You may be surprised at what you hear.
We agree with Singer & Tucker that “surveillance” on walk rounds can be counterproductive but that applies mainly to surveillance of people. That doesn’t mean you shouldn’t look for some unsafe conditions when doing your safety rounds. For example, if your facility handles behavioral health patients (even if it is only in your ER) you should be looking for things like “loopable” items in the bathrooms in your radiology suite that might be used for suicide. Or you might check floor stock to make sure you don’t have vials of concentrated heparin that might mistakenly be given to patients during a heparin “flush”. Or some of the battery charging/recharging issues we raised in our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”. And we always recommend vigilance to alarm safety issues during Walk Rounds (see our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management”) or issues with filled and unfilled oxygen cylinders being intermingled. Looking for all those things can be done in a less conspicuous and non-threatening manner.
The most important thing on Walk Rounds is encouraging staff to speak up about potential safety issues. To do this you need a comfortable, nonpunitive culture in which staff understand that they will be praised, not vilified, for their openness. For example, we all know that workarounds are usually potentially dangerous, yet they are ubiquitous. Workarounds are almost always a sign of an underlying root cause that needs to be fixed, so identifying workarounds is important. When you ask staff about workarounds you need to let them know you are looking to fix whatever problem makes them do a workaround and that you are not going to punish them for doing a workaround.
Walk Rounds are also a good way to get a feel for safety culture on each unit. We feel you get a much better understanding of “local (unit)” culture on such rounds than you get on the many formal safety culture assessment tools used by many organizations.
Be considerate of your workers’ time constraints. The last thing you want is for them to be thinking “Oh no! Here we go again! I’ll never get my work done today!”. There are no hard and fast rules for the time duration of individual walk rounds. But planning with the middle managers ahead of time can help ensure that workers are freed up to engage and participate without fear that their workload is accumulating in the background.
Lastly, how do you measure the impact of your Walk Rounds? That, of course, is difficult because it’s hard to separate out the results from Walk Rounds from all the other patient safety activities your organization is doing. And surveys such as that in the Sexton study can be expensive to administer and analyze. We think the most important measure is looking at the issues log you accumulated through WR and being able to report the percentage of safety issues identified and resolved. You can also elicit informal feedback from staff on how they perceive such rounds.
We think Patient Safety Walk Rounds are a very important component of your patient safety efforts. But be sure you do them constructively!
Sexton JB, Adair KC, Leonard MW, et al Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf 2017; Published Online First: 09 October 2017
Singer SJ. Successfully implementing Safety WalkRounds: secret sauce more than a magic bullet. BMJ Qual Saf 2018; Published Online First: 09 February 2018
Singer SJ, Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical messages. BMJ Qual Saf 2014; 23: 789-800