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• Letter to the Editor
  Anthony Camuglia
  Published on: 10 April 2018

• Published on: 10 April 2018

  Letter to the Editor

  • Anthony Camuglia, Consultant Interventional Cardiologist FRACP FCSANZ Princess Alexandra Hospital, University of Queensland, Australia

  To the editor,

  Sexton et al describe an observed association between leadership WalkRounds (WR) with feedback and improved levels of safety culture within healthcare settings.1 This work builds on previous data from this group evaluating WR in building a safety culture.2 These encouraging findings spur the need for understanding the robustness of evidence that the WR concept is built on in order to evaluate if continuation and expansion of the WR concept should be promulgated.

  The research data that WR are based on are largely observational sets or pre and post studies without control groups or objective outcome measures.3 This is fertile ground for bias and confounding that will undermine the probity of the findings. Sources of bias relate to institutional incentives around WR programs succeeding and the want held by individuals to be seen to be implementing initiatives that improve quality. In the present study described by Sexton et al, the cross sectional observational nature of the data collection is exposed to confounding with clinicians involved in a WR program potentially working in an environment with a superior safety culture regardless of the presence of regular WR (with or without feedback).1 Self-selection bias will also be at play as it is with any voluntary survey method as will be recall bias with culturally high achieving environments and poorly functioning settings over and under estimating their performance respectively, and perhaps ascribi...

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  To the editor,

  Sexton et al describe an observed association between leadership WalkRounds (WR) with feedback and improved levels of safety culture within healthcare settings.1 This work builds on previous data from this group evaluating WR in building a safety culture.2 These encouraging findings spur the need for understanding the robustness of evidence that the WR concept is built on in order to evaluate if continuation and expansion of the WR concept should be promulgated.

  The research data that WR are based on are largely observational sets or pre and post studies without control groups or objective outcome measures.3 This is fertile ground for bias and confounding that will undermine the probity of the findings. Sources of bias relate to institutional incentives around WR programs succeeding and the want held by individuals to be seen to be implementing initiatives that improve quality. In the present study described by Sexton et al, the cross sectional observational nature of the data collection is exposed to confounding with clinicians involved in a WR program potentially working in an environment with a superior safety culture regardless of the presence of regular WR (with or without feedback).1 Self-selection bias will also be at play as it is with any voluntary survey method as will be recall bias with culturally high achieving environments and poorly functioning settings over and under estimating their performance respectively, and perhaps ascribing this to the presence or absence of WR (with or without feedback). The limited data in this field using a pure WR intervention (outside a bundled intervention) with control groups have reported mixed findings and possibly a detrimental effect of WR in some settings.3,4

  Another potential concern may be that the outcome data point most assessed and focused on in the WR area is safety culture or other relatively subjective outcomes that are used as a surrogate for clinical outcomes relying on linked evidence outside of the WR studies.5 Data linking an intervention to improve safety culture with a corresponding recorded enhancement in clinical outcome measures appear to be lacking. As is the case in much of the quality and safety space, studies that employ an empirical randomised controlled trial (RCT) approach with objective clinical endpoints are absent from the literature.

  Overall, it might be argued that within the quality and safety field RCTs are not only needed but are perhaps mandatory if the area is to move forward meaningfully. It may seem to some that explanations positioning the area as somehow different or unique when compared with other health spheres is likely to be met with growing cynicism and perhaps the time to turn the corner has arrived.

  References:

  1. Sexton JB, Adair KC, Leonard MW, Frankel TC, Proulx J, Watson SR, Magnus B, Bogan B, Jamal M, Schwendimann R, Frankel AS. Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Quality & Safety. 2018 Apr;27(4)261-270.

  2. Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK. Patient safety leadership WalkRounds™. Joint Commission Journal on Quality and Patient Safety. 2003 Jan;29(1):16-26.

  3. Singer SJ, Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical messages. BMJ Quality & Safety. 2014 Oct;23(10):789.

  4. Singer SJ, Rivard PE, Hayes JE, Shokeen P, Gaba D, Rosen A. Improving patient care through leadership engagement with frontline staff: A Department of Veterans Affairs case study. Joint Commission Journal on Quality and Patient Safety. 2013 Aug;39(8):349-60.

  5. DiCuccio MH. The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic Review. Journal of Patient Safety. 2015 Sep;11(3):135-42.

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  Conflict of Interest:
  None declared.

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