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Patient Safety Tip
of the Week
June
15, 2021
What’s
Happened to Your Patient Safety Walk Rounds?
We
regret to say that one of the biggest casualties of the COVID-19 pandemic has
been Patient Safety Walk Rounds. Social distancing, masks, and the sheer volume
of workload for all our hospital staffs took their toll on Walk Rounds. But, as the masks come off…it’s time to start Patient Safety
Walk Rounds up again.
In
our February 27, 2018 Patient Safety
Tip of the Week “Update on Patient Safety Walk Rounds” we
reported on a cross-sectional survey, administered to a convenience
sample of 31 hospitals, through the Michigan Health and Hospital Association
MHA Keystone Center as part of their routine safety culture and engagement
assessment (Sexton 2018). That study showed the importance of
feedback in conjunction with Walk Rounds (WR). Work settings reporting more WR
with feedback had substantially
higher safety culture domain scores and significantly higher engagement scores
for four of six domains in the study. The authors suggest that “when WR’s 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.”
Sexton
and colleagues now report on a similar cross-sectional survey at the Duke
University Health System (Sexton 2021). Note that the data in their current study
was taken from a survey done in 2016, well before the COVID-19 pandemic.
Their
Walk Rounds (WR) were modified to elicit more positive emotions, in addition to
building the essential elements of traditional safety WR—trust, psychological
safety, and meaningful connections. This new focus on what is going well was
intended as a shift away from deficiencies and fear, toward successes that
might elicit positive emotions such as pride and hope. They termed this new
form of WR “Positive Leadership WalkRounds” (PosWR). Typical PosWR visits
would occur monthly, last 30 to 60 minutes, and involve 3 to 10 HCWs, a local
leader, and a senior leader. PosWR prompts to elicit
positive interactions were generic and open to modification but included questions
that sought to highlight successes and what was going well.
Their
survey was taken from data collected in the SCORE (Safety, Communication,
Operational Reliability, and Engagement) survey. The SCORE scale includes 7
domains: Work-Life Balance (WLC), Burnout Climate, Emotional Exhaustion,
Improvement Readiness, Local Leadership, Teamwork Climate, and Safety Climate. They
had an overall response rate of 81.5% from over 13,000 potential respondents in
396 work sties. Respondents reflected the gamut of
healthcare workers, though the top three respondent groups were registered
nurses (31.7%), attending physicians (9.7%), and technologists (8.2%).
63.4%
of respondents reported being exposed to PosWR in
their work setting. They divided responses into quartiles based upon level of exposure
to PosWR. Compared to work settings in the fourth ( <
50%) quartile for PosWR exposure, those in the first
( > 88%) quartile revealed a higher percentage of respondents reporting good
patient safety norms (49.6% vs. 69.6%); good readiness to engage in quality
improvement activities (60.6% vs. 76.6%); good leadership accessibility and
feedback behavior (51.9% vs. 67.2%); good teamwork norms (36.8% vs. 52.7%); and
good work-life balance norms (61.9% vs. 68.9%), all being statistically
significant. Compared to the fourth quartile, the first quartile had a lower
percentage of respondents reporting emotional exhaustion in themselves (45.9%
vs. 32.4%), and in their colleagues (60.5% vs. 47.7%). Basically, every domain
of the SCORE safety culture and workforce well-being survey was robustly
associated with exposure to PosWR.
The
results of the 2 studies strongly suggest that conducting Patient Safety Walk Rounds
with a focus on the positive and providing positive feedback to staff help
ensure a culture of safety and lower the risk of healthcare worker burnout.
So,
as you begin to reinstitute your Patient
Safety Walk Rounds now that the COVID-19 pandemic is waning, it’s worth
reiterating some of the observations and recommendations we’ve made in our Patient Safety Tips of the Week for October
7, 2014 “Our
Take on Patient Safety Walk Rounds” and
February 27, 2018 “Update 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. The most recent
Sexton study echoes this: “Staff are consistently pleasantly surprised
when a chief nursing officer shows up on a night shift or weekend to ask about
what is going well in that work setting.”
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 a previous review
by Singer & Tucker (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.
Singer
(Singer 2018) also cautions us not to ignore middle
managers when engaging front-line workers because that 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.
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.
In addition to feedback showing what actions you’ve taken as a result of items identified during Patient
Safety Walk Rounds, positive
feedback to staff is also an
important element of successful Patient Safety Walk Rounds. Sexton et al. also
note that healthcare workers who receive handwritten letters from senior
leaders are remarkably proud, grateful, and hopeful about their future in the
organization.
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.
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. We don’t think you need to do a formal survey such as SCORE in
the Sexton studies, but you can solicit informal feedback from staff on how
they perceive such rounds.
We still
think Patient Safety Walk Rounds are a very important
component of your patient safety efforts. They are probably more important than
ever in the post-COVID-19 era to boost staff morale and combat burnout. But be
sure you do them constructively!
Some
of our previous columns on Patient Safety Walk Rounds:
October 7, 2014 “Our
Take on Patient Safety Walk Rounds”
February 27, 2018 “Update on Patient Safety Walk Rounds”
References:
Sexton
JB, Adair KC, Profit J, et al. Safety Culture and Workforce Well-Being Associations
with Positive Leadership WalkRounds. Jt Comm J Qual Patient Saf 2021; Epub Apr 22, 2021
https://www.sciencedirect.com/science/article/pii/S1553725021000945?via%3Dihub
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 2018;
27: 261-270 Published Online First: 09 October 2017
https://qualitysafety.bmj.com/content/27/4/261
Singer
SJ, Tucker AL. The evolving literature on safety WalkRounds:
emerging themes and practical messages. BMJ
Qual Saf 2014; 23: 789-800
http://qualitysafety.bmj.com/content/23/10/789.full.pdf+html
Singer
SJ. Successfully implementing Safety WalkRounds:
secret sauce more than a magic bullet. BMJ Qual Saf 2018;
27: 251-253 Published Online First: 09 February 2018
https://qualitysafety.bmj.com/content/27/4/251
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