38 Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007

Implementing leadership rounds to improve patient safety

by Susan Richardson, Shannon Watson, and Tracy Wrong

he provision of safe patient care has become the highest priority forpatients, families, health providers and all associated stakeholders.Recent research findings on the prevalence of adverse events, cou-pled with frequent media coverage of sentinel events, have focusedthe health care industry to develop safer systems. Health care lead-ers have a critical mandate to fulfill, which includes the creation of a

culture that supports safe patient care.Most hospitals, including the Children’s Hospital of Eastern Ontario

(CHEO), use a comprehensive approach for reporting and responding toincidents and critical events. Incident reporting policies and documentationtools are used to ensure that appropriate staff are informed of events in atimely fashion and that high-level trending and analysis of events are avail-able weeks or months later. The ultimate goal for this approach is to identi-fy and understand contributing factors that cause events and to implementchanges that reduce the likelihood of reoccurrence. Practices such as these,while essential, are reactive, addressing risk after an adverse event hasoccurred.

Leadership is identified as one of the critical factors in the successfulimplementation of patient safety initiatives. At the same time, staff mayview leaders as being “out of touch” with the difficulties of their work.Regardless of whether or not staff and management perceptions arealigned, opportunities exist to educate both groups regarding patient safe-ty concepts.

The notion of both groups working together to identify safety improve-ments presented such an opportunity, and led to a pilot project imple-menting Patient Safety Leadership Rounds at CHEO. These rounds havebeen identified as a method for connecting hospital executives and staff inthe pursuit of risk reduction and enhanced safety practices, and usually con-sist of hospital executives visiting units to ask staff about their safety con-cerns, and ensuring follow-up to improve patient safety.1-5 Rounds providean opportunity for the development of a proactive clinical risk identificationsystem that draws equally on staff and management.

The goals of this project were to identify patient safety concerns from thestaff perspective, while at the same time, bringing leaders and staff togeth-er in a manner likely to improve institutional safety culture. The ultimategoal was to enhance systems to support safe patient care.

The literature regarding Patient Safety Leadership Rounds is at a descrip-tive stage of development, with variation in terms of what constitutes“rounds.” Thus there exists considerable opportunity to identify key ele-ments of this intervention required to impact patient safety, as well as howthese elements can most effectively be implemented and sustained.

ContextPatient safety, historically of concern for clinicians, is now on the agenda

of governments, researchers and health care executives. There is an over-whelming call for collaborative action based on the human and financialimpact of Adverse Events (AEs). The Canadian adverse events study provid-ed a national estimate of AEs among patients in acute care hospitals, which

Susan Richardson, CHE, BScOT,MBA, EXTRA Fellow, is a VicePresident of professional services atthe Children’s Hospital of EasternOntario. Susan oversees the imple-mentation of clinical informatics andinformation technology as well as sev-eral patient services.

Shannon Watson, MHSc, is theProject Coordinator for PatientServices at the Children’s Hospital ofEastern Ontario. Shannon’s roleincludes planning and special projects.

Tracy Wrong, CHE, MHA, is Directorof Quality Management at Children’sHospital of Eastern Ontario. Tracyoversees a portfolio that includes decision support, accreditation andclinical risk and patient safety. Thequality group supports clinical andadministrative initiatives at both theteam and corporate levels.

T

ORIGINAL ARTICLE

Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007 39

IMPLEMENTING LEADERSHIP ROUNDS TO IMPROVE PATIENT SAFETY

by extrapolation, indicated that 9,250-23,750 deaths fromAEs could have been prevented.6 At this time, the rate of AEsfor hospitalized Canadian children remains unknown.Several U.S. studies have shown that children experience asubstantial number of potentially preventable patient safetyproblems.7-8

The theoretical framework for understanding AEs looks atboth people and system issues.9 Cognitive psychology hascontributed significantly to the understanding of humanbehaviour and types of errors.10 For this project, a systemsapproach was utilized, as it focuses on the conditions thatcan contribute to or mitigate AEs. White and Ketring empha-size the importance of focusing on systems and their flaws,and encourage the involvement of all staff in identifying fac-tors contributing to “accidents waiting to happen.”11

As noted by the Institute for Healthcare Improvement,only senior leaders are in a position to foster the culture andcommitment needed to address the underlying systemiccauses of AEs.12 This includes establishing patient safety asa strategic priority, developing an infrastructure to supportthis priority and designing specific tools and techniques forengaging staff in the process of creating safer systems forpatients.

Implementation of change/resultsThe design of this intervention was based on the litera-

ture, as well as feedback from internal hospital staff and keystakeholders. CHEO staff identified that the implementationof change to create safer systems was the litmus test for suc-cess. The current literature primarily focuses on the logisticsof conducting the rounds, collecting the information andtracking actions. Less attention is given to determining pri-orities for action or to ensuring accountability.

Dr. Allan Frankel conceptualized WalkRounds™ “as a toolto connect senior leadership to patient safety and to incul-cate safety ideas into the healthcare system.”1 In his role asDirector of Patient Safety, he led the team in conductingPatient Safety Leadership WalkRounds™ at Brigham andWomen’s Hospital (BWH) in Boston.2 A Senior ExecutiveAdopt-a-Work Unit program was implemented at JohnsHopkins Hospital.3 The authors suggest having consistencyin the participating senior executive, including middle man-agers in the process and conducting pre- and post-culturalsurveys. Executive WalkRounds™ (EWRs) were evaluated aspart of a three-month randomized trial at MemorialHermann Hospital in Houston.4 Safety climate was the pri-mary outcome measure. The results of this study demon-strated that nurses in the units who participated in the EWRshad higher safety climate scores than the control group.There was no significant difference in the scores for nursesfrom the intervention units who did not attend the EWRs andfor those in the control group. Hence, active engagement inthe intervention, not just hearing about it, affected nurses’safety-related attitudes. In Canada, rounds have been imple-mented in several hospitals, including the originalWalkRounds™ framework which was implemented atSunnybrook and Women’s College Health Science Centre.5

The intervention in the project reported here included

four interrelated steps: (1) conducting the rounds; (2) priori-tizing identified issues and determining accountability foraction; (3) implementing safety improvements; and (4)measuring the impact of the rounds. Building on the successfactors identified in the literature to enhance adoption andsustainability, rounds were anchored within the hospital’sQuality Management Department, communication and con-sultation with staff was ongoing, decision-makers wereinvolved at all stages of the project and the feedback wasused in the design of the rounds. There was a consistentmessage from staff: ensure that action is taken to addressconcerns – obtaining their perspective followed by inactionis a recipe for failure.

The Hospital Survey on Patient Safety Culture (HSOPS)was chosen to provide a baseline measure of safety cultureon the four pilot units prior to implementation of therounds.13 This is based on the premise in the literature thatrounds may enhance patient safety culture in the organiza-tion.3-4 The survey response rate was 52%. Strengths per-ceived by staff were intra-unit teamwork, supervisor supportand reporting of near-misses. Areas for improvement includ-ed teamwork across units, handoffs and transitions as wellas adequate staff to handle the workload.

Rounds were piloted in the Emergency, Infant MedicalInpatient Unit, Paediatric Intensive Care Unit and the MentalHealth Adolescent Inpatient Unit. These units were selectedas they are high-risk areas that represent a cross section ofunits at the hospital. Each pilot unit was visited approxi-mately once a month between June-December 2006 by theMedical and Operations Directors and the Vice-Presidentresponsible for the area. The Manager of Clinical Risk andPatient Safety (or delegate) attended all rounds, and theChief of Staff and CEO were invited to attend if possible. Theleaders chosen to participate had the authority to effectchange. All staff working on the pilot unit had the potentialto participate during the rounds. The timing and format (e.g.,“sit down” or “walk” rounds) were determined by the unit’sQuality Management team. The Vice-President responsiblefor the area asked staff three questions adapted from the lit-erature.1,4 Questions were as follows: Tell us about your con-cerns from a patient safety perspective; what suggestions doyou have to address these safety concerns; and describe anypersonal practices that you have to ensure safe patient care.

During the course of the pilot, 19 rounds were completed(135 staff). Participants included physicians, nurses, childlife specialists, social workers and therapists. There were 181patient safety issues identified, although some were dupli-cates. Each comment was tracked, regardless, as partici-pants’ identity was not noted. Prioritizing safety concerns forfollow-up occurred in a dedicated session usually one weekafter the patient safety rounds. This group, called the SafetyTopics Action Team (STAT), included individuals who hadconducted rounds plus other key leaders involved in theunit, including Operations and Medical Directors, PatientSafety Champion, Managers, VPs and the Director, Quality.STAT members received a detailed list of safety concernsidentified through rounds, a progress report of previouslyprioritized items and a worksheet for determining priorities

40 Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007

Richardson, Watson, and Wrong

and “just do it” items. Consensus was used to determinefinal priority items, and accountability for action wasassigned based on appropriateness for role. A total of 14 ses-sions were held, with 78 staff concerns prioritized for action.

Patient safety issues were categorized using the VincentFactors framework.14 Vincent’s framework categorizes factorsthat influence clinical practice, and in turn, facilitates identi-fication of potential interventions and error reduction strate-gies. These factors are institutional context, organizationaland management factors, work environment, team factors,individual (staff) factors, task factors and patient characteris-tics.

Interestingly, almost half of the issues identified fell intothe categories of organizational/management and work envi-ronment. Managers were able to quickly implement improve-ments to address many of these concerns, including the fol-lowing:• The practice of procedural sedation was highlighted in

Emergency, with inadequate physician coverage noted asthe key concern. Quickly, players came together from var-ious departments (Emergency, Anaesthesia, Surgery) andfound a solution.

• In the Infant Inpatient Medical Unit, a desire to addressprivacy of patients led to first names only being postedon the main communication whiteboard. However, priva-cy had to be weighed against patient safety to address areal potential for patient mix-up. Patient first and lastnames are now displayed on the board to eliminate con-fusion.

• A crash cart that was difficult to move because of stick-ing wheels was repaired immediately.

Some issues required more extensive redesign and, evenif issues were not completely resolved, it was often possibleto initiate action that could be communicated to the staffinvolved. A concern for the Paeditric Intensive Care Unit wasthe lack of space and quiet workspace in the medicationpreparation area. Staff know that a new unit is planned but isseveral years away from construction. Knowing that the staffunderstand the flow and needs of the unit best, theOperations Director asked a small workgroup to assess theissues associated with this problem and propose the bestpossible solution. Further time will be required to assess thesolution and make it happen.

There was an on-line survey after the pilot was completed,designed to identify staff suggestions for improving therounds and to determine their perception of the outcomesand support for adoption. The survey was completed by 83staff (24% response rate). The majority of respondentsagree/strongly agreed that: staff concerns were heard/under-stood; staff were aware of safety topics prioritized; manage-ment addressed issues raised; and rounds fostered opencommunication between staff and management andenhanced patient safety culture. The respondents stronglysupported adoption of the rounds, with 93% indicating thatthe rounds should continue. In terms of improvement, somestaff indicated that action/follow-up could have been com-municated more extensively. Overall, the rounds were well

received and staff found leadership open and receptive.Value was seen in the rounding process, prioritization ofitems and action plans that were put in place.

Participants in the STAT sessions identified that perhapsthe frequency of the rounds could be changed. The leaderscharged with actioning the items generally agreed that therounds occurred too frequently to allow for significant actionbetween meetings. Participants in the STAT session over-whelmingly (95%) perceived the STAT as an essential com-ponent of patient safety leadership rounds.

Implication for decision-makersThis project expands on existing literature identifying the

key elements of Patient Safety Leadership Rounds requiredto impact patient safety. The processes for conductingrounds, roles of key individuals and the critical success fac-tors that have been identified are transferable to differenthealth care settings. Where leaders and staff want to align toimprove the safety of care, the concept of rounds has appli-cability. Specific risk areas and safety practices identified inthis project may also be applicable to other paediatric andadult acute care hospitals.

Several factors contributed to the organization’s receptiv-ity to the Patient Safety Leadership Rounds, including recog-nition that patient safety is now on the national agenda.Furthermore, hospitals recognize that patient safety planshave become an accreditation requirement of the CanadianCouncil on Health Services Accreditation. These combinedfactors have propelled patient safety to become a strategicpriority for health care organizations, with CHEO being noexception.

The support of key people leading and supporting PatientSafety Leadership Rounds cannot be overstated. Beyondexecutive support, it can be said that pre-existing awarenessof the intervention and the high level of interest by managersand interdisciplinary staff also proved to be instrumental. Itis well recognized that patient safety improvements requirethe alignment of management and clinicians in order to cre-ate an environment that welcomes change. The inclusion ofthese leaders in the process was a critical success factor.Inclusion of both medical and operations “middle manage-ment” on rounds was also a critical factor as they are oftenresponsible to follow through on the changes.

Specific, dedicated resources were critical to the successof the rounds. Specifically, the Director of QualityManagement provided considerable leadership and projectmanagement at each step in the pilot. In addition, the timeof the Manager of Clinical Risk and Patient Safety wasrealigned to support the project. Several improvements alsorequired capital and operating funds.

While several factors contributed to the acceptance of therounds and rendered them meaningful, some barriers werenonetheless identified. Communicating with staff and ensur-ing that they were available to participate in the roundsproved a challenge. Staff involvement in patient care activi-ties, different work shifts and the involvement of trainees inthe unit made it more difficult to solicit appropriate partici-pants for rounds, and impacted accessibility.

Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2007 41

IMPLEMENTING LEADERSHIP ROUNDS TO IMPROVE PATIENT SAFETY

It became clear during rounds that education regardinghuman factors and cognitive psychology concepts isrequired for participants so that everyone has a commonframework for components that contribute to safer systems.

At the outset, when determining awareness and interest,more attention and involvement must be given to supportareas such as infection control, biomedical engineering,facilities maintenance and material management as there isa significant “domino effect” and the cooperation of staff inthese areas is essential.

Occasionally, staff seemed reluctant to fully disclose whatthey considered the necessary steps or measures to improvepatient safety. Staff had a tendency to be on their “bestbehaviour” and to describe steps taken to ensure safetyrather than reflect on possible areas for improvement.

Another barrier was the professional “ownership” forpatient safety. A few staff were somewhat cautious about anew approach, preferring to use their existing mechanismsfor addressing issues.

The frequency of rounds needs to allow adequate time forchanges to occur. It is important to pay attention to the timeand infrastructure required to support the intervention andpromote successful change. While staff were motivated forchange, they also recognized that along with change comesadded demand for time and resources. These competingdemands for staff time, attention and energy should beacknowledged as a real concern and barrier to implementa-tion. By acknowledging this concern, staff became moreinvolved in finding solutions rather than simply focusing onthe potential for increased workload.

Overwhelmingly, the most significant barrier is theredesign of complex processes that are deeply embeddedcrossing professional and functional unit boundaries. In thatsame vein, inter-unit cooperation and determining who hasauthority for implementing change were also identified aschallenges.

Overall, the rounds have enabled clinical staff to see firsthand the benefit of a process that is solely focused onaddressing their patient safety concerns. In addition to theimmediate benefits realized by the hospital in achieving ahigher level of patient safety, it may be of interest to organi-zations with a particular focus on patient safety to includePatient Safety Leadership Rounds as another means ofachieving tangible and timely results.

Future activitiesA key challenge lies in implementing change, not “just”

identifying staff concerns. The longer-term change initiativesarising from this pilot are being monitored to ensure suc-cessful completion. The validation that implemented safetypractices are indeed achieving their intended results isanother essential step for this project. Consequently, someof the safety practices will be audited to ensure sustainabil-ity and effectiveness. While organizational culture changesover the long-term, the Hospital Survey on Patient SafetyCulture will be repeated within the year to determinewhether there have been any changes in the survey resultsnow that the rounds pilot has been completed.

Given the positive feedback from this pilot, it has beenrecommended that the rounds be enshrined as a key com-ponent of CHEO’s Patient Safety Program. It is anticipatedthat rounds could be focused on key themes or priority areas(i.e., safe medication practices) so that questions could varyover time.

Finally, strong linkages between Patient Safety LeadershipRounds and the patient safety education agenda should beestablished. Recognizing that awareness and educationremain key contributors to improving patient safety, it wouldseem fitting to strengthen the flow of information betweenthese two components.

AcknowledgmentsThe authors would like to acknowledge the support and

assistance of Ms. Carol Cooke, Dr. Ian Graham and Dr. KavehShojania.

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