Article Text


Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout
  1. J Bryan Sexton1,2,
  2. Kathryn C Adair3,
  3. Michael W Leonard4,5,
  4. Terri Christensen Frankel4,
  5. Joshua Proulx4,
  6. Sam R Watson6,
  7. Brooke Magnus7,
  8. Brittany Bogan8,
  9. Maleek Jamal9,
  10. Rene Schwendimann10,
  11. Allan S Frankel4
  1. 1Department of Psychiatry, Duke University School of Medicine, Durham, North Carolina, USA
  2. 2Duke Patient Safety Center, Duke University Health System, Durham, North Carolina, USA
  3. 3Duke Patient Safety Center, Duke University Medical Center, Durham, North Carolina, USA
  4. 4Safe and Reliable Healthcare, Evergreen, Colorado, USA
  5. 5Duke University School of Medicine, Durham, North Carolina, USA
  6. 6Michigan Health and Hospital Association, Lansing, Michigan, USA
  7. 7Department of Psychology, Marquette University, Milwaukee, Wisconsin, USA
  8. 8MHA Keystone Center, Michigan Health and Hospital Association, Lansing, Michigan, USA
  9. 9Chief Strategy Officer, Safe and Reliable Healthcare, Los Angeles, California, USA
  10. 10Institute of Nursing Science, University of Basel, Basel, Switzerland
  1. Correspondence to Dr Allan S Frankel, Safe and Reliable Healthcare, Evergreen, Colorado 01742, USA; allan{at}


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.

  • safety culture
  • engagement
  • resilience
  • burnout
  • walkrounds
  • feedback
  • score

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from


  • Contributors MWL, TCF, JP and ASF collected and sent the data set used here to JBS. JBS and KCA analysed the data and drafted the manuscript. SRW, BM, RS, BB and MJ consulted on our analyses and/or presentation of our results. All authors edited and provided feedback on the manuscript.

  • Competing interests JBS has an NIH Grant: R01 HD084679-01; MWL, TCF, JP and ASF each works at Safe and Reliable Healthcare, where they administer, analyse and debrief survey data to healthcare organisations. SCORE is available at no cost for research and quality improvement purposes. Safe and Reliable Healthcare offers SCORE and several other surveys through their online platform. The SCORE survey is a synthesis of validated instruments from safety culture and employee engagement research already published in the peer-reviewed literature. We added items and domains that cover psychological safety and quality improvement readiness in ways that were not already published, but the rest of SCORE involved selecting the best available items and domains. All authors stand by the validity of this instrument and the data set used here.

  • Ethics approval Duke university medical center.

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

  • Data sharing statement Reasonable requests to receive access to the data set (accompanied by a data use agreement) should be addressed to the corresponding author.

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles