Allan Frankel

The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units

BackgroundExecutive walk rounds (EWRs) are a widely used but unstudied activity designed to improve safety culture in hospitals. Therefore, we measured the impact of EWRs on one important part of safety culture – provider attitudes about the safety climate in the institution.MethodsRandomized study of EWRs for 23 clinical units in a tertiary care teaching hospital. All providers except physicians participated. EWRs were conducted at each unit by one of six hospital executives once every four weeks for three visits. Providers were asked about their concerns regarding patient safety and what could be done to improve patient safety. Suggestions were tabulated and when possible, changes were made. Provider attitudes about safety climate measured by the Safety Climate Survey before and after EWRs. We report mean scores, percent positive scores (percentage of providers who responded four or higher on a five point scale (agree slightly or agree strongly), and the odds of EWR participants agreeing with individual survey items when compared to non-participants.ResultsBefore EWRs the mean safety climate scores for nurses were similar in the control units and EWR units (78.97 and 76.78, P = 0.458) as were percent positive scores (64.6% positive and 61.1% positive). After EWRs the mean safety climate scores were not significantly different for all providers nor for nurses in the control units and EWR units (77.93 and 78.33, P = 0.854) and (56.5% positive and 62.7% positive). However, when analyzed by exposure to EWRs, nurses in the control group who did not participate in EWRs (n = 198) had lower safety climate scores than nurses in the intervention group who did participate in an EWR session (n = 85) (74.88 versus 81.01, P = 0.02; 52.5% positive versus 72.9% positive). Compared to nurses who did not participate, nurses in the experimental group who reported participating in EWRs also responded more favorably to a majority of items on the survey.ConclusionEWRs have a positive effect on the safety climate attitudes of nurses who participate in the walk rounds sessions. EWRs are a promising tool to improve safety climate and the broader construct of safety culture.

Patient Safety Leadership WalkRounds.

BACKGROUND In the WalkRounds concept, a core group, which includes the senior executives and/or vice presidents, conducts weekly visits to different areas of the hospital. The group, joined by one or two nurses in the area and other available staff, asks specific questions about adverse events or near misses and about the factors or systems issues that led to these events. ANALYSIS OF EVENTS: Events in the Walkrounds are entered into a database and classified according to the contributing factors. The data are aggregated by contributing factors and priority scores to highlight the root issues. The priority scores are used to determine QI pilots and make best use of limited resources. Executives are surveyed quarterly about actions they have taken as a direct result of WalkRounds and are asked what they have learned from the rounds. RESULTS As of September 2002, 47 Patient Safety Leadership WalkRounds visited a total of 48 different areas of the hospital, with 432 individual comments. DISCUSSION The WalkRounds require not only knowledgeable and invested senior leadership but also a well-organized support structure. Quality and safety personnel are needed to collect data and maintain a database of confidential information, evaluate the data from a systems approach, and delineate systems-based actions to improve care delivery. Comments of frontline clinicians and executives suggested that WalkRounds helps educate leadership and frontline staff in patient safety concepts and will lead to cultural changes, as manifested in more open discussion of adverse events and an improved rate of safety-based changes.

Revealing and Resolving Patient Safety Defects: The Impact of Leadership WalkRounds on Frontline Caregiver Assessments of Patient Safety

OBJECTIVE To evaluate the impact of rigorous WalkRounds on frontline caregiver assessments of safety climate, and to clarify the steps and implementation of rigorous WalkRounds. DATA SOURCES/STUDY SETTING Primary outcome variables were baseline and post WalkRounds safety climate scores from the Safety Attitudes Questionnaire (SAQ). Secondary outcomes were safety issues elicited through WalkRounds. Study period was August 2002 to April 2005; seven hospitals in Massachusetts agreed to participate; and the project was implemented in all patient care areas. STUDY DESIGN Prospective study of the impact of rigorously applied WalkRounds on frontline caregivers assessments of safety climate in their patient care area. WalkRounds were conducted weekly and according to the seven-step WalkRounds Guide. The SAQ was administered at baseline and approximately 18 months post-WalkRounds implementation to all caregivers in patient care areas. RESULTS Two of seven hospitals complied with the rigorous WalkRounds approach; hospital A was an academic teaching center and hospital B a community teaching hospital. Of 21 patient care areas, SAQ surveys were received from 62 percent of respondents at baseline and 60 percent post WalkRounds. At baseline, 10 of 21 care areas (48 percent) had safety climate scores below 60 percent, whereas post-WalkRounds three care areas (14 percent) had safety climate scores below 60 percent without improving by 10 points or more. Safety climate scale scores in hospital A were 62 percent at baseline and 77 percent post-WalkRounds (t=2.67, p=.03), and in hospital B were 46 percent at baseline and 56 percent post WalkRounds (t=2.06, p=.06). Main safety issues by category were equipment/facility (A [26 percent] and B [33 percent]) and communication (A [24 percent] and B [18 percent]). CONCLUSIONS WalkRounds implementation requires significant organizational will; sustainability requires outstanding project management and leadership engagement. In the patient care areas that rigorously implemented WalkRounds, frontline caregiver assessments of patient safety increased. SAQ results such as safety climate scores facilitate the triage of quality improvement efforts, and provide consensus assessments of frontline caregivers that identify themes for improvement.

Using the Communication and Teamwork Skills (CATS) Assessment to Measure Health Care Team Performance

BACKGROUND Patient safety administrators, educators, and researchers are striving to understand how best to monitor and improve team skills and determine what approaches to monitoring best suit their organizations. A behavior-based tool, based on principles of crisis resource management (CRM) in nonmedical industries, was developed to quantitatively assess communication and team skills of health care providers in a variety of real and simulated clinical settings. THE CATS ASSESSMENT The Communication and Teamwork Skills (CATS) Assessment has been developed through rapid-cycle improvement and piloted through observation of videotaped simulated clinical scenarios, realtime surgical procedures, and multidisciplinary rounds. Specific behavior markers are clustered into four categories-coordination, cooperation, situational awareness, and communication. Teams are scored in terms of the occurrence and quality of the behaviors. The CATS Assessment results enable clinicians to view a spectrum of scores-from the overall score for the categories to specific behaviors. CONCLUSION The CATS Assessment tool requires statistical validation and further study to determine if it reliably quantifies health care team performance. The patient safety community is invited to use and improve behavior-based observation measures to better evaluate their training programs, continue to research and improve observation methodology, and provide quantifiable, objective feedback to their clinicians and organizations.

Patient Safety Leadership WalkRounds™ at Partners HealthCare: Learning from Implementation

BACKGROUND Brigham and Womens Hospital (BWH) began Patient Safety Leadership WalkRounds in January 2001; its experience, along with that of three other Partner Healthcare hospitals, is reported. COLLECTING DATA ON WALKROUNDS: Data were obtained from interviews with patient safety personnel, WalkRounds scribes, and senior leaders. FINDINGS A total of 233 one-hour WalkRounds during 28 months yielded 1,433 comments--30% related to equipment, 13% to communications, 7% to pharmacy, and 6% to workforce. Actions occurred quickly in small hospitals. Formal processes for managing larger issues were necessary in large organizations. Implementation feasibility featured more prominently than severity in determining actions. DISCUSSION The study generated essential guidelines for success--for example, the supporting resources must include the maintenance of effective information databases that identify actions taken, and the discussions during WalkRounds are influenced by who in leadership is participating, their ability to quietly listen, and whether they have clinical or nonclinical backgrounds. CONCLUSIONS WalkRounds appears to be an effective tool for engaging leadership, identifying safety issues, and supporting a culture of safety.

Teamwork and Communication in the Operating Room: Relationship to Discrete Outcomes and Research Challenges

The literature defining and addressing teamwork and communication is abundant; however, few studies have analyzed the relationship between measures of teamwork and communication and quantifiable outcomes. The objectives of this review are: (1) to identify studies addressing teamwork and communication in the operating room in relation to discrete measures of outcome, (2) to create a classification of studies of the relationship between teamwork and communication and outcomes, (3) to assess the implications of these studies, (4) to explore the methodological challenges of teamwork and communication studies in the perioperative setting, and (5) to suggest future research directions.studies in the perioperative setting, and (5) to suggest future research directions.

A closer look at associations between hospital leadership walkrounds and patient safety climate and risk reduction: a cross-sectional study.

Leadership walkrounds (WRs) are widely used in health care organizations to improve patient safety. This retrospective, cross-sectional study evaluated the association between WRs and caregiver assessments of patient safety climate and patient safety risk reduction across 49 hospitals in a nonprofit health care system. Linear regression analyses using units’ participation in WRs were conducted. Survey results from 706 hospital units revealed that units with ≥60% of caregivers reporting exposure to at least 1 WR had a significantly higher safety climate, greater patient safety risk reduction, and a higher proportion of feedback on actions taken as a result of WRs compared with those units with <60% of caregivers reporting exposure to WRs. WR participation at the unit level reflects a frequency effect as a function of units with none/low, medium, and high leadership WR exposure.

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

OBJECTIVE To create and test a reproducible method for measuring emotional climate, surgical team skills, and threats to patient outcome by conducting an observational study to assess the impact of a surgical team skills and communication improvement intervention on these measurements. DESIGN Observational study. SETTING Operating rooms in a high-volume thoracic surgery center from September 5, 2007, through June 30, 2008. PARTICIPANTS Thoracic surgery operating room teams. INTERVENTIONS Two 90-minute team skills training sessions focused on findings from a standardized safety culture survey administered to all participants and highlighting positive and problematic aspects of team skills, communication, and leadership. The sessions created an interactive forum to educate team members on the importance of communication and to role-play optimal interactive and communication strategies. MAIN OUTCOME MEASURES Calculated indices of emotional climate, team skills, and threat to patient outcome. RESULTS The calculated communication and team skills score improved from the preintervention to postintervention periods, but the improvement extinguished during the 3 months after the intervention (P < .001). The calculated threat-to-outcome score improved following the team training intervention and remained statistically improved 3 months later (P < .001). CONCLUSIONS Using a new method for measuring emotional climate, teamwork, and threats to patient outcome, we were able to determine that a teamwork training intervention can improve a calculated score of team skills and communication and decrease a calculated score of threats to patient outcome. However, the effect is only durable for threats to patient outcome.

Patient Safety: Anesthesia in Remote Locations

The safety of anesthesia delivered in the operating room is enhanced by the standardization and reliability built into that environment, which has prescriptive and detailed protocols for almost every procedure performed. Experienced anesthesiologists come to rely on these operating room characteristics to support the delivery of safe care. Anesthesiologists giving anesthesia outside the operating room often find themselves in settings that lack this rigor and that therefore challenge safety. This article describes the basic concepts in safety, with an emphasis on teamwork and communication, and then discusses how their application ensures safe care in remote locations.

Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout

Background There is a poorly understood relationship between Leadership WalkRounds (WR) and domains such as safety culture, employee engagement, burnout and work-life balance. Methods This cross-sectional survey study evaluated associations between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture, employee engagement, burnout and work-life balance, across 829 work settings. Results 16 797 of 23 853 administered surveys were returned (70.4%). 5497 (32.7% of total) reported that they had participated in WR, and 4074 (24.3%) reported that they participated in WR with feedback. Work settings reporting more WR with feedback had substantially higher safety culture domain scores (first vs fourth quartile Cohen’s d range: 0.34–0.84; % increase range: 15–27) and significantly higher engagement scores for four of its six domains (first vs fourth quartile Cohen’s d range: 0.02–0.76; % increase range: 0.48–0.70). Conclusion This WR study of patient safety and organisational outcomes tested relationships with a comprehensive set of safety culture and engagement metrics in the largest sample of hospitals and respondents to date. Beyond measuring simply whether WRs occur, we examine WR with feedback, as WR being done well. We 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. Whether WR with feedback is a manifestation of better norms, or a cause of these norms, is unknown, but the link is demonstrably potent.