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The evolving literature on safety WalkRounds: emerging themes and practical messages
  1. Sara J Singer1,2,
  2. Anita L Tucker3
  1. 1Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
  2. 2Department of Medicine, Harvard Medical School, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts, USA
  3. 3Brandeis International Business School, Waltham, Massachusetts, USA
  1. Correspondence to Dr Sara J Singer, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Kresge 3, Room 317, Boston, MA 02115, USA; ssinger{at}hsph.harvard.edu

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The road to walking around

The evidence is clear: a strong culture of safety is necessary to deliver reliably safe care.1 Safety culture encompasses a group's shared values, assumptions, attitudes and patterns of behaviour regarding safety.2 ,3 In healthcare organisations with weak safety culture, employees perceive the low priority assigned to safety, and patient safety suffers as a result.4 Researchers measure safety culture using surveys that include items eliciting perceptions of policies, procedures and practices that reflect the extent to which the organisation prioritises safety relative to competing goals.4

Numerous studies find that higher safety climate correlates with better performance on a variety of outcomes.1 ,5–17 Research also shows that senior managers play a critical role in creating, changing and sustaining safety culture.2 ,4 Senior managers’ words and deeds receive outsize attention and greatly influence how frontline workers and middle managers perceive what their organisation values and rewards.

We know less, though, about specific actions senior managers can take to effectively demonstrate their commitment to safety.18 Senior managers seeking to create a stronger culture of safety need to know what steps can overcome consistent differences between frontline workers’ and managers’ perceptions of safety climate. Frontline workers typically have more negative views of safety climate compared with senior managers.19–21

One approach for strengthening safety culture is for managers to spend time on the frontlines of care, talking with staff and observing work. The Lean literature refers to these types of programmes as Gemba walks.22 These walks aim to have senior managers observe concrete problems confronted by frontline staff in real time and foster stronger relationships with frontline staff.23 ,24 Gemba walks thus resemble ‘Management by Walking Around,’ popularised by Peters and Waterman's description of Hewlett–Packard's use of the programme in the 1980s.25

A similar approach appeared in healthcare as early as 1990,26 but did not receive widespread attention until the publication of Frankel and colleagues’ work on Patient Safety Leadership WalkRounds. This programme sought to raise senior managers’ commitment to patient safety.23 ,24 ,27 Based on its success, safety rounds of this type have been advocated by leading healthcare organisations, including the Institute for Healthcare Improvement,28 Agency for Healthcare Research and Quality, and Health Research and Educational Trust in the USA; and the National Health System29 and the Scottish Patient Safety Programme in the UK.

We will use the generic term ‘safety rounds’ to refer to all programmes. Safety rounds aim to improve care by providing a systematic approach for engaging senior managers with the work-system challenges faced by frontline staff and ensuring follow-up and accountability for addressing these challenges. Safety rounds encourage senior managers to observe clinical operations, engage with staff to understand their concerns and partner with frontline workers and managers to resolve obstacles. Safety rounds offer opportunities to fix specific problems identified but also to improve safety culture more generally by building trust, understanding and accountability for safety up and down the organisational hierarchy.24

As of 2014, safety rounds have been implemented by thousands of hospitals worldwide.i Drawing on a handful of publications about safety rounds programmes, reviews of interventions with potential to improve safety culture and patient safety3 ,30 ,31 describe safety rounds as one of the most evidence-based safety interventions used in practice. An emerging literature about safety rounds programmes, including papers recently published in this journal,32 ,33 presents an opportunity to review in more detail what has been learned so far about this promising programme and how interested managers can successfully implement safety rounds in their own organisations.

The expanding literature on safety rounds

In preparing this editorial cum review, we searched PubMed using the terms ‘walkround’, ‘walk round’, ‘walkaround’, ‘walkabout’, ‘Gemba’, ‘safety rounds [and] senior management’ and ‘leadership round’. We identified 93 articles published since Frankel and colleagues’ 2003 publication that first drew attention to the implementation of safety rounds in healthcare.24 After eliminating articles that simply mentioned safety rounds and adding some more articles identified through searches of references, we found 43 studies of safety rounds. The authors each reviewed these papers to identify common themes. We then assigned each paper to themes for which the paper was relevant, noting the paper's findings. (Table 1 presents a complete list of these articles and their key findings).

Table 1

Literature on safety rounds

Technique for improving safety culture

The vast majority of papers report qualitative results from a self-selected implementation of safety rounds in a single or small number of hospitals. Three-quarters of the papers that we review (33 out of 43) report that safety rounds have a positive impact on their organisations. These papers typically state that safety rounds had a beneficial impact on senior managers’ beliefs and problem-solving activities. For example, safety rounds are credited with heightening awareness of and insight about safety issues among senior managers.24 ,34–38 These issues include ones previously unknown, overlooked or presumed resolved by senior managers.39 The novel information increases senior managers’ support for patient safety improvement efforts.24 Consequently, safety rounds enable hospitals to identify and eliminate safety hazards27 ,36–38 40–43 and improve hospital efficiency.39 ,44 ,45 They also allow senior managers to demonstrate that safety is a priority.18 ,37 ,40 ,46 Finally, frontline workers who participate in safety rounds feel more willing to be open about patient safety issues38 and more recognised, and they experience improved morale.35–37 These papers demonstrate ‘proof of concept’ by using case studies of successful implementations of safety rounds to show that (1) it is feasible for senior managers to maintain a rigorous implementation of safety rounds; (2) safety rounds enable senior managers to identify meaningful safety concerns and (3) if hospitals address these concerns, staff satisfaction with safety climate can increase.

Means of addressing safety problems not otherwise identified

A number of papers describe the types of issues identified through safety rounds programmes. Infrastructure problems (eg, equipment, supplies, work environment and facility concerns such as insufficient lighting or trip hazards) are among the most frequent issues identified through safety rounds.35 ,38 ,39 ,44 ,47–52 ,71

Investigators note that infrastructure issues identified through safety rounds pose safety risks and diminish staff efficiency, but can usually be easily fixed.44 Furthermore, safety rounds are an important component of an organisation's portfolio of safety initiatives because the types of issues they uncover are often not highlighted through other safety systems, such as incident reports.38 ,47 ,53 The issues are also not identified through national initiatives,44 which tend to focus on implementing evidence-based practices, such as reducing catheter-related blood stream infections. Therefore, safety rounds provide value by uncovering significant and actionable items that might otherwise remain unresolved.38 ,44 ,47 ,48 ,50 ,53

Cautionary notes

Limitations of safety rounds as a tool for improving safety culture

A potential limitation of safety rounds is that issues commonly implicated in medical errors and near-miss incidents are less frequently raised through safety rounds than are infrastructure-related issues.3 ,32 Examples of issues that contribute to errors and incidents, but are less frequently mentioned in safety rounds include complex or potentially contentious communication,27 ,35 ,40 ,44 ,47 ,49 ,50 especially interdisciplinary communication challenges,27 ,41 ,44 ,54 care delivery issues, such as difficulty accessing electronic information in support of clinical decision making,49 and opportunities for staff education.50 Thus, a risk of embarking on a programme of safety rounds is that the programme might expose mostly minor issues, while other significant problems remain latent. Furthermore, senior managers may be tempted to disregard the majority of issues identified in favour of a small subset most directly related to medical errors.32 Senior managers may also hesitate to address infrastructure issues when they involve significant financial resources. When senior managers do not address issues raised by frontline staff, safety rounds can cause frustration among frontline workers, worsen perceptions of safety climate and potentially negatively impact their attention to patient safety,32 ,55 as we discuss in more detail below.

Methodological limitations of prior research on the efficacy of safety rounds

Most of the studies that report positive results have methodological limitations, such as reporting on a single organisation's implementation of the programme, lack of control groups,36 ,40 ,45 lack of objective performance measures to verify the improvement and self-selection for programme implementation. In particular, self-selection limits generalisability of the findings because organisations that voluntarily embark on a programme of safety rounds might differ from other organisations in ways that effect implementation success. Furthermore, to validate their decision to implement the programme, the organisations might be predisposed to view the outcomes from the safety rounds programme in a positive light. Or, organisations with less positive experiences of safety rounds may choose not to invest the effort in reporting their results, given the difficulty of getting null results published. Finally, most papers reflect the perspective of the hospital personnel responsible for implementing safety rounds. Including a broader set of perspectives might provide more nuanced results. For example, three studies that use in-depth interviews to explore the impact of safety rounds on frontline staff find that safety rounds negatively impact individuals who participate in the rounds.32 ,56 ,57

A subset of 14 papers empirically examines the effect of safety rounds using survey measures of safety climate or safety or quality performance. Eight of these report positive outcomes stemming from safety rounds, such as higher perceptions of safety climate,23 ,38 ,58–60 detection of more adverse events,42 greater patient safety risk reduction,58 higher job satisfaction37 and lower burnout,33 which is linked to safety culture in a paper recently published in this journal.61

However, some studies, including the three with the most rigorous research methods, suggest less sanguine results. Two experimental controlled studies, one in the US Veterans Health Administration55 and the other in the private sector,62 find that safety climate and perceived improvement in performance decline in randomly selected intervention units compared to control units and hospitals. The third experimental study, in which safety rounds were implemented as part of a general improvement programme, shows some improvement in organisational climate relative to control hospitals, but no improvement or a relative decline in multiple other measures.46 ,63 A fourth, uncontrolled study similarly finds that safety climate remains unchanged after a six-month programme that includes safety rounds.64 Another study uses cross-sectional data from 21 paediatric emergency departments (ED) and finds that conducting monthly safety rounds is not associated with higher safety climate scores.65

Keys to successful implementation

The mixed results of safety rounds suggest that implementation differences may drive their success. Indeed, several papers identify possible determinants of successful implementation, including factors related to the breadth of exposure of staff to safety rounds, characteristics of hospital leaders, willingness of frontline workers to speak up, adequacy of the infrastructure for implementing and sustaining the programme, and the specific type of safety rounds programme being implemented.

Intensity of exposure to safety rounds

Several studies find that higher levels of exposure—a higher proportion of staff who have participated in safety rounds, substantial engagement with senior managers during a safety round visit, and the receipt of feedback about actions taken as a result—correlate with better outcomes. In a study of 49 hospitals, Schwendimann and colleagues find that staff-rated safety climate is higher in units where at least 60% of staff report participating in safety rounds.58 However, only 7.4% of hospital units in their study achieve exposure at this threshold. Consistent with this finding, in Thomas and colleagues’ study, which measures the impact of safety rounds on individual nurses, safety climate only increases for those nurses who participate in a safety round visit.60 Similarly, while Frankel and colleagues observe improvement in safety climate perceptions, improvement occurs only in the two of seven hospitals that sustained the safety rounds programme.23

This evidence of a dose-response relationship suggests that safety rounds should involve as many staff as possible. The optimistic notion that positive frontline staff perceptions of safety climate can be spread via positive word-of-mouth from peers who participate in safety rounds does not appear to be supported. Thus, to have a beneficial effect, managers must commit to the time-consuming work of visiting with as many frontline staff as possible, which, in practice probably means visiting a given unit more than, say, once a year. However, several papers comment on the difficulty of sustaining a schedule of frequent safety rounds,23 ,36 even if rounds are conducted by department managers and frontline staff rather than executives.45

Senior managers’ understanding and engagement with safety rounds

Successful implementation requires ‘significant organisational will’.23 ,27 Leaders must engage actively in the safety rounds programme and assume accountability for ensuring resolution of issues and reporting back to frontline workers.18 ,41 ,62 ,66 When conducting rounds, leaders need to listen attentively to gain deeper understanding of the issues that their organisations face.18 ,27 ,55 Less successful implementation stems from the inability of leaders to connect with frontline staff during rounds46 or divergence of leaders’ motives for implementing the programme from the original intent of safety rounds. For example, studies from the USA, UK and Germany report that some managers use safety rounds as a form of surveillance and control rather than inquiry and support.55–57 Some senior managers regard safety rounds as an end in themselves, without engaging in action to resolve staff concerns32 ,62—they want to demonstrate to frontline staff that they care about their concerns without committing to address those concerns. Other studies report instances of managers believing they understand patient safety issues better than frontline staff32 ,55 and controlling and restricting conversations during safety rounds to avoid topics they do not want to discuss.32 Organisations also spend too much time focusing on prioritising problems at the expense of taking action.62 When safety rounds are characterised in these ways, frontline workers become frustrated with them,32 ,55 feel the programme produces fallible insights55 ,57 and respond with scepticism and cynicism.56 ,62

Willingness of frontline workers to speak up

Safety rounds are more successful when frontline staff members openly discuss safety issues in their work areas.39 ,41 This is more likely to occur when the hospital has a just culture.67 ,68 Frontline staff are also more likely to participate when they perceive the programme is adding value,48 as evidenced through constructive actions taken to resolve the problems that challenge them.39 ,62 A few studies suggest the importance of physician involvement in making safety rounds successful67 or a lack thereof being potentially problematic.55

Ability to execute and follow-up on safety rounds

Supportive infrastructure also seems key, including strong project management,23 ,39 scheduling capability,39 ,45 availability of tailored scripts to enable a productive discussion with frontline staff during safety rounds,45 maintaining an effective database to monitor action-taking and formal processes to ensure follow-up.27 ,48 ,66 Middle managers provide critical support for safety rounds39 ,55 as well as implementation practices that include application of analytical tools for understanding the problem, small tests of change, and communication, feedback and celebration of results.43 ,45 ,48 ,66–68

Variations of safety rounds that require further study

Adopt-a-unit

Several studies describe safety rounds programmes whose structural design diverges in potentially useful ways. The most widely used of these may be the senior executive adopt-a-work unit programmes, which is a component of the Comprehensive Unit-Based Safety Program. In the adopt-a-unit programme, managers support a unit on a continuing basis rather than rotating among units.41 Relatedly, several studies report on a department or unit-level implementation of safety rounds rather than a hospital-wide implementation. We found safety rounds papers for radiology,43 intensive care unit,52 ED65 and anaesthesia53 applications. In a notable departure from the ‘quick fix’ type of issues typically identified through safety rounds, a paper reporting on radiology safety rounds conducted by radiology leaders highlights 10 substantial process changes that come from the programme.43 Solving these problems required several iterations of problem-solving cycles to redesign the department's processes. It may be that focusing on a single unit enables deeper problem solving than safety rounds programmes that rotate among different units in the hospital.

Safety rounds as part of more comprehensive or narrowly focused programmes

A second variant is the use of safety rounds as part of comprehensive surveillance programmes47 or as a feature of multifaceted programmes to improve the reliability of clinical care processes.34 These studies find that safety rounds provide a unique source of information that complements other safety initiatives, and that relying solely on safety rounds would hamper safety-related information and performance. Another variation involves rounding for communicating information about specific issues, such as a new strategic plan, rather than inquiring generally about safety concerns.69 This study finds that rounding by senior managers is an effective method for disseminating information to frontline staff.

Other staff can ‘walk around’

Finally, some studies investigate rounding by frontline staff49 ,70 or department managers45 rather than senior managers. In one case, providers use photographs to elicit deeper discussion among other staff members about what was observed on safety rounds.70 Though clearly serving a purpose other than increasing senior managers’ knowledge and engagement with frontline staff, these studies suggest that safety rounds can be successfully used to identify safety hazards on the frontlines, even if they are not led by senior managers.

Safety rounds can improve safety culture, but must be implemented with care

The existing literature suggests that safety rounds can effectively improve culture, address specific safety problems and increase managers’ understanding of safety risks as well as their commitment to addressing them. Successful programmes have been deployed in a wide variety of hospital types, departments, clinical disciplines and geographic locations.

However, poor implementation of safety rounds produces no improvement and can even worsen safety culture. Research shows that when organisations implement safety rounds for the purpose of surveillance or in a superficial manner, it can hurt safety culture by exposing the senior managers’ lack of respect for the frontline staff's input and their lack of commitment to addressing safety concerns. Effective implementation requires senior leadership's commitment to implementing safety rounds as a way of gathering useful information about their organisations’ safety risks, widespread participation of frontline staff in the safety rounds, inclusion of middle managers and follow-up on the issues that are raised. Given that openly questioning and actively listening to frontline workers appears unnatural for many senior managers,32 ,55 ,57 training71 and coaching may be productive strategies for improving the performance of safety rounds.

Future research

Much remains to be discovered about safety rounds. Few studies have gathered objective safety measures. A notable exception is the study by Donnelly et al,43 which finds that the mean number of days between safety events doubled after the implementation of radiology safety rounds. Furthermore, to our knowledge, no studies collected data on the financial costs and benefits of such programmes. Hospital executives have limited time to devote to improvement activities.39 Whether there are other interventions that can improve safety culture more efficiently remains to be seen. Further research could also more closely examine the impact of varied safety rounds experiences on senior managers’ understanding of safety risks. It may be that managers benefit from observing a wide variety of locations and clinical disciplines or, alternatively, that they benefit more from focused safety rounds that create a deeper connection with and understanding of that specialty. Research could compare whether the managers’ background, particularly their status as clinicians or non-clinicians, moderates the impact of variety in safety rounds experience.

Conclusion

It is evident that hospital executives want tangible ways they can make their hospitals safer places for patients. The idea of senior managers walking around and talking to staff has obvious appeal and appears like a simple enough intervention: go talk to staff where they work, listen to what the staff have to say and fix a few problems they point out. However, this simplistic view is misleading. Safety rounds can lead to improved culture, but only when they are implemented authentically and with full commitment and ability to resolve frontline staff's concerns. Half-hearted, insincere or ineffective safety rounds can backfire, eroding rather than improving safety culture and wasting time at all levels of the organisation. Organisations interested in implementing safety rounds are well advised to develop process improvement capabilities first71, or to begin in one or two units, rather than tackling the entire organisation. Senior managers not inclined to invest the time and effort to solicit, really listen and address frontline staff's concerns, may want to focus on other means to improve their organisation's culture. Despite the term ‘walk rounds’, implementing safety rounds is no walk in the park; but then again, improving organisational culture never is.

References

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Footnotes

  • Contributors Both authors made substantial contributions to the conception and design of the work and the analysis and interpretation of our findings. The authors also contributed to drafting the paper and revising it critically for important intellectual content. The authors have given final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Competing interests SJS acknowledges writing three of the papers reviewed in this editorial. ALT acknowledges writing two of the papers reviewed in this editorial.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • i http://www.pascalmetrics.com/leadership/dr-allan-frankel/

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