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Implementing management innovations to improve safety of healthcare delivery is a critically important, yet often elusive, goal for healthcare organisations. Safety rounds, in which senior executives spend time on the frontlines of care, talking with staff and observing work, aim to improve safety of healthcare delivery by providing a systematic approach for engaging senior executives with the work system challenges faced by front-line staff and ensuring follow-up and accountability for addressing these challenges. They resemble ‘Management by Walking Around’, which originated at Hewlett-Packard1 and ‘gemba walks’, which are considered a key component of the Toyota Production System.2 However, descriptions of these precursor interventions emphasise engagement of senior executives with front-line workers and not follow-up and feedback about ideas generated through observation and discussion. Perhaps unlike in healthcare delivery, 3 follow up and feedback in technology and manufacturing companies can be assumed.
In this issue of BMJ Quality and Safety, Sexton and colleagues found inconsistent provision of feedback and that ‘providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout.’4 Their research represents a welcome advance over typical intervention studies that simply assess whether an intervention is or is not effective, in that the authors identify a key component of the WalkRounds intervention that differentiates more and less effective forms of intervening. Specifically, WalkRounds followed by feedback to staff generated substantially higher safety culture domain scores and significantly higher engagement scores for four of its six domains.
One interpretation characterises feedback as the key to a successful strategy for implementing safety rounds. This ‘magic bullet’ interpretation could lead earnest executives to believe that feedback is sufficient for achieving benefits of safety rounds. Those holding to this interpretation would expect successful results by merely following prescribed steps, including observing work on the frontlines and then providing feedback to staff about any actions taken. Scholars have attributed this type of rote followership for the failure of healthcare and other organisations to successfully implement total quality management after its introduction in the 1990s. .5–7 Likewise, to focus on feedback would be a dangerous inference, as research has shown that implementing superficial safety rounds that do not achieve the objectives of rounds—‘to encourage senior managers to engage with staff to understand their concerns and partner with frontline workers and managers to resolve obstacles’, has the potential to backfire, making safety climate worse not better.3 8 9 Engagement, understanding, partnership and resolution imply a level of resolve deeper than following any prescribed protocol could accomplish, regardless of the fidelity with which it is executed.
Another less Pollyanna-ish yet perhaps ultimately more helpful interpretation is that feedback is simply a marker of well-executed safety rounds. The authors themselves acknowledge that they used feedback as an indicator of high-quality safety rounds because they lacked data on other potential differentiators. Assuming this interpretation, it is worth considering the characteristics that distinguish high-quality safety rounds. Below is a starter set—there may be others—based on my own and others’ research and anecdotal accounts of safety rounds over more than a decade.
First, two key features that go hand in hand are leader attitudes and actions. Senior executives (ie, those who will be conducting safety rounds) must publicly demonstrate clear and authentic support for the objectives of safety rounds. For instance, when someone raises a concern during safety rounds, the senior executive should thank the staff member for their willingness to speak up on behalf of safety and do so within earshot of as many coworkers as possible. Executives conducting safety rounds must clearly and publicly promote communication and shared understanding with front-line personnel about safety risks and priorities. They must also demonstrate their commitment to these objectives by really showing up for rounds, not just going through the motions. Really showing up means being present when there and actively listening to front-line workers with genuine curiosity about their concerns and suggestions, not just ‘listening and leaving’.10 Really showing up for senior executives also means participating in follow-up discussions about how to address obstacles observed, personally assuming responsibility for changes when warranted and holding themselves and others accountable for the programme as a whole. Through attitudes and actions, senior executives demonstrate the importance of hearing from and addressing concerns of front-line experts, which, in addition to surfacing potentially important safety issues, encourages further engagement and participation of staff at all levels.
Second, attitudes and actions of senior executives must be institutionalised through strong project management and problem-solving infrastructure. There is nothing worse for front-line morale—understandably so—than earnestly contributing thoughts and suggestions and then feeling like your recommendations have been ignored. Maintaining momentum of both safety round observations and follow-through activity is a worthwhile goal for managers implementing safety rounds. For example, one rule organisations have found helpful is to complete rounds once scheduled even if it means substituting the senior executive who participates. Scheduling rounds and associated meetings and documenting, tracking, assigning responsibility, acting, following up and providing feedback on meritorious suggestions require substantial organisational capacity, which must be available to sustain front-line workers’ interest and willingness to engage with safety rounds.
Third, rounds should be conducted with awareness of social and contextual factors. For example, one important question that arises when senior managers engage front-line workers is the appropriate role of middle managers. If middle managers feel their role is ignored when senior executives engage front-line workers, safety rounds risk igniting middle managers’ fears and negative repercussions. Rather than circumventing them, safety rounds can productively engage middle managers as hosts, guides and navigators for senior executives on their safety rounds and as leaders in the development and implementation of strategies to address safety obstacles. Another social factor worthy of consideration is natural social networks, that is, informal relationships and reliance structures within organisations that influence information flow and decision making. Awareness of social networks can be leveraged to promote positive messaging about safety rounds and their results. Contextual awareness recognises that safety rounds implemented in the same way may be successful in one organisation and unsuccessful in another for reasons unrelated to the safety rounds themselves. For example, if an organisation employs a different management system, safety rounds could conflict or serve a redundant purpose. Consideration of how safety rounds can complement and add value to ongoing initiatives, rather than adding to already busy workloads, is appropriate. Likewise, if a new initiative was recently introduced, recognising limitations to organisational attention and competing priorities and thus timing of the introduction of safety rounds may be important.
Like any management intervention, the success of an intervention like safety rounds depends on many more factors than simply closing communication loops, important though this may be. The findings of Sexton and colleagues4 demonstrate a strong and almost certainly real association between feedback and the organisational impact of safety rounds. But, rather than constituting a magic bullet, feedback probably combines with organisational attitudes, infrastructure and social and contextual awareness to constitute the ‘secret sauce’ for successfully implementing management interventions like safety rounds.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.