Leadership Series: Executive Patient Safety Walkarounds
As we near the ninth anniversary of the Institute of Medicine’s watershed report on medical harm in the U.S. healthcare system, To Err is Human: Building a Safer Health System, boards of trustees and administrators at many institutions remain uncertain and/or uncomfortable with their role in the patient safety arena. The Commonwealth of Pennsylvania encouraged closer trustee engagement under Act 13 by allowing trustee membership on the Act 13-mandated patient safety committee to be formed within each hospital. While this was a positive step, board members often remain distanced from the bedside in this traditional structure where much of the content may remain “reporting” of staff activities. More recently, the Institute for Healthcare Improvement’s 5 Million Lives Campaign has included as one of its “planks” to “Get Boards on Board”1 and strongly encouraged the meaningful, active participation of the board in goal-setting, resource allocation, public transparency, and accountability of medical staff and management for the achievement of safety and quality objectives. Realization of “Get Boards on Board” will require a deeper understanding of the promise and perils of patient safety and quality and the failure to attain them, respectively, in an increasingly scrutinized environment.
How can we begin the in-depth education of our board and administration and begin to bridge the clinical comfort gap? One potential and highly satisfying approach for both trustees/administration and the clinical staff of the hospital is the conduct of Executive (or Leadership) Patient Safety Walkrounds. Walkrounds were brought forward as such a bridge by Allan Frankel and his colleagues, who have demonstrated successful deployment at the Brigham and Women’s Hospital in Boston.2 Conceptually appealing and based on the philosophy that “the currency of leadership is attention,” Executive Patient Safety Walkrounds have been introduced in many hospitals. While Frankel et al. did not include trustees in their initial efforts, the format allows both board members and senior executives to visibly place their imprimatur on the patient safety efforts of the clinical staff and learn quite directly the challenges to success in the domain of patient safety from frontline staff.
Abington Memorial Hospital’s patient safety staff members have been conducting patient safety walkrounds for several years and have witnessed an increasing level of participation and robustness in the exercise. We have found that less structure places both staff and trustees/executives more at ease. We offer walkrounds in the morning, afternoon, and evening, as well as on night shift and following monthly board meetings. The frequency of our walkrounds is generally one or two times per month, and because of their increasing popularity with the board, we now conduct two walkround visits in different areas of the hospital simultaneously. We often provide advance notice to the nurse manager or department director (e.g., pharmacy) as a courtesy and will generally visit two areas in each session. Before the walkround begins, we review with the trustee(s) and executive(s) the objectives of the walkround and provide some common questions or points of focus that they may wish to engage in with the staff (see below for examples of the former and latter). Additionally, we provide them with a simple trifold brochure containing this information.
- Provide senior leaders an opportunity to listen to the issues (this is important to staff as it pertains to the safe care of our patients).
- Provide regular forums with staff to learn about issues related to team practice, communication, and a transparent culture of reporting near misses and errors in order to create improvements.
- Provide a regular opportunity for senior leaders including board members to demonstrate their commitment to Abington Memorial Hospital’s patient safety efforts.
Common Questions/Focus Points for Conversation
- Can you think of any incidents or adverse events that happened in the past few days that have resulted in prolonged hospitalization for a patient?
- Can you think of patients we have harmed as a result of problems with how we deliver care?
- What is the next thing that could happen on your unit that might lead to a patient being harmed?
- Have there been any near misses that have been averted because of existing systems or an individual’s actions?
- What proactive steps should we take to prevent the next adverse event?
- Can you think of a way in which the system or the environment fails you on a consistent basis?
- What specific actions from leadership would make the work you do safer for patients?
- What changes could be made in your unit to promote patient safety more consistently?
- What “keeps you up at night” when it comes to caring for your patients?
- How are we actively promoting a blame-free culture and working on the development of a blame-free reporting policy?
- Are you treated with non-negotiable mutual respect by others on the care team?
- What things do you do on your unit to create situational awareness of the risks in patient care every day?
It is highly apparent and gratifying that our low-tech intervention of walkrounds has energized our trustees by their successful interactions in the clinical context, which they substantially influence along with management by policy decisions and resource allocation. Further, the board genuinely enjoys meeting the staff and engaging them in clinical discussions on quality and safety—topics that were the impetus for their volunteering their energies in the first place. In addition, it is an excellent employee satisfier. Neither management nor board members should shy away from starting this simple yet intimate tool for demonstrating commitment to patient safety and beginning to harvest the vast, largely untapped learning imbued with those at the bedside. We urge you to get started today. As one of our board members recently exclaimed after his first walkround, “This was the most enjoyable and meaningful exercise I’ve had in my five years as board member . . . it’s the reason I joined the board in the first place.”
- Institute for Healthcare Improvement. Get boards on board [online]. [cited 2008 Jun 11]. Available from Internet: http://www.ihi.org/IHI/Programs/Campaign/BoardsonBoard.htm.
- Frankel A, Graydon-Baker E, Neppl C, et al. Patient safety leadership walkrounds. Jt Comm J Qual and Saf 2003 Jan;29(1):16-26.