Popularity of safety walks surges
But going walk-about may not always pay off
If you ask someone familiar with Lean management systems to name one of the things that makes those systems different from more traditional healthcare management, he or she may very well mention that leadership makes it a point to head to the front lines regularly. If there is a problem, they want to see it through the eyes of the person experiencing it. This notion has led to an increasing popularity of senior management safety walks, which take the suits from the C-suite down to the trenches where nurses and physicians do the real work of patient care. The idea is that if they see what really happens, they will be more adept at making policy decisions that ensure smooth operations and safer systems. It also supposedly helps them solve intractable problems by giving them a different perspective than they usually see from their office — less Pollyanna about safety and more realistic, say nurses and doctors.
This kind of safety rounding has been supported by organizations like the Institute for Healthcare Improvement and the Agency for Healthcare Research and Quality. But does the research on it bear out the theory?
A new study1 in the October issue of the British Medical Journal looked at 43 papers on this practice and found mixed results. The best studies in terms of methodology showed little or no improvement from the practice, while the best outcomes are associated with having a large number of senior leaders exposed to the rounds. Other factors include ensuring the issues discovered were followed up on, that front-line staff felt comfortable speaking up — having an existing culture that didn’t play the blame game — and what kind of program it was, whether single-unit or part of some broader program.
There are good, valid reasons for senior managers to walk around and see what’s going on with front line staff, says study co-author Sara Singer, MBA, PhD, an associate professor in the department of health policy and management at the Harvard School of Public Health and the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston. "Patient safety is important, and we are not where we should be. There is plenty of evidence that having a culture of safety has a lot to do with providing safer care. So if the priority of senior managers is evident to staff that safety matters, then front-line staff will look to that. They really do have the power to effect change, as well as to provide the resources that lead to safer care."
Senior leaders can also demonstrate that they care — for patients and staff — by doing these walk-abouts, says Singer. "It is one of the very few evidence-based practices where they can impact a safety culture. If you are a front-line worker, and your CEO comes down, it has an impact on you. It is a low-cost, simple, and potentially very effective way to engage your staff."
But, she warns, while it can be a great strategy, there are also great pitfalls to be aware of if you decide to create a leadership safety walk program.
First, the evidence on these walks comes not just from healthcare, but from other industries, particularly manufacturing. Some of the evidence that engages healthcare may not be appropriate to healthcare, she says.
Second, as in any case where you are asking front-line staff to speak up, you have to make sure that everyone in the organization feels comfortable doing so, that there is no culture of intimidation, that nurses aren’t cowed by doctors, that there is no bullying of housekeeping by nurses. "Everyone needs to be on the same page, where everyone and anyone can speak up and no one will get a negative reaction for doing so, as long as the communication is done in an acceptable and polite manner," she says.
Third, be aware that there is a "dose response" to walk rounds. "More interaction with more people creates a deeper impact," she says.
Perhaps most importantly, Singer says that what others do may or may not work for your organization. There are many among the 43 trials she looked at that seemed to work for the individual facilities. "My educated guess is that if you create a program you think will work in your organization, it is better than a template program created for everyone. Many variants work because people gave thought to [the] needs of the particular facility and designed the program accordingly."
Having a safety rounding program can enable a hospital to transform its safety culture and give senior management a way to interact with front-line staff that they haven’t had. "It gives them a way to respond in a way they haven’t, too, and to encourage staff to speak up more than they have, as well. But it won’t be any of that unless you go out in a genuine way ready to listen to them, ready to hear from them what is safe and what isn’t, and ready to follow up with resources to correct the problems," she says.
Even if it does all of that and the program works really well, you still may not find out about all the problems your hospital has when the leaders go out on their walking tours. "You have to look at problems from multiple sources," she says. "What you will hear from front-line staff tends to be about infrastructure and equipment, not the failures of communication that the Institute of Medicine would put at the center of safety problems."
It could be that those things that would lend themselves to a chart review just don’t come up, she notes. A question like "what would make patients safer" may not elicit the response "if my colleagues would communicate better." On the floor, when asked that question, the nurse’s thoughts may immediately go to the fact that she wants the med carts stocked more often. Try to think of good questions for leaders to ask while on the rounds that might tease out the kinds of safety issues that you know exist but are less likely to arise with common questions, Singer says.
Safety rounding isn’t the right answer for every hospital, Singer says. If you aren’t in a facility with a culture that will commit wholeheartedly to it, don’t. "Do something else. There is less risk of a backlash. If you ask about problems and then don’t do anything about them, you create a negative spiral around safety culture," she notes. "But if you are committed, this can be the bomb."
For more information on this topic, contact Sara J. Singer, MBA, PhD, Associate Professor, Department of Health Policy and Management, Harvard School of Public Health, Department of Medicine, Harvard Medical School Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA. Telephone: (617) 432-7139.
- Singer SJ, Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical messages. BMJ Qual Saf 2014;23:789-800 doi:10.1136/bmjqs-2014-003416.