Are Patient Safety Leadership
WalkRounds™ Worth It?
NNESHRM
November 18, 2013
Katie Blackburn, MS
Erin Graydon Baker, MS, RRT, CPPS
Topics Covered
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WalkRounds Concept
Experience at Brigham and Women’s Hospital
Maine Medical Center Process
Successes and Pitfalls
Your Stories
WalkRounds Concept
• 2001 conversation at the Institute of
Healthcare Improvement with Dr. Allan
Frankel
– Increasing the in-basket of patient safety
information
– Changing the culture of safety by increasing
transparency
– Engaging senior leadership with front line staff
around patient safety issues
Experience at Brigham and
Women’s Hospital
• Would hospital leadership be willing to openly discuss
operational failure, safety and harm with front line staff?
• Would frank and open discussion occur in a public setting?
• Could the information elicited be collected and aggregated in
a useful manner?
• Would the information collected affect actions or resource
allocation?
A. Frankel, et al., Patient Safety Leadership WalkRounds at Partners Healthcare, JC
Journal on Quality and Patient Safety, Aug. 2005
Preparation for Implementation
• Two hour presentation to hospital executives
– Promote leadership involvement
– Discuss high reliability concepts
– Ensure blame –free reporting
• Framework and timeline for process
– Confirm expectations of senior leadership involvement
– Suggest follow up and reporting structure
• Comments
• Action items
BWH Implementation Process
• Hospital Executive sponsorship in January 2001
• Participants
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CEO, CNO, CMO, COO (one per round)
Patient Safety Manager
Scribe
Pharmacist
Physician leader, unit manager
• Scheduling
– Weekly
– All locations
BWH Implementation Process
• Facilitation
– Send sample questions in advance
– Begin with introductions and premise of the rounds
– Hear comments with empathy; elicit examples of patients
who have been harmed or nearly harmed by our systems
– Walk around or not
– Synthesize rounds with those actions that the team will
take back
– Ask participants to share the rounds experience with their
colleagues
– Thank the participants and invite them to reach out
anytime
Data Gathering
• Comments versus adverse events
• Gather all comments for trending; aggregate
– Contributing factor
– Level of risk ( harm v potential harm)
– Location
• Use Access or other relational database; Excel
or Word format for tracking is not helpful!
– Assign actions to appropriate leadership
Follow up and Feedback
• Most critical element to the success of
WalkRounds
• Outline a reporting structure with
expectations for follow up
– Quality Council; Care Improvement Council
• Provide bi-directional feedback to staff and
leadership
– Direct email to participants; Newsletters
Continuous Improvement
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Add CIO or designee as a regular participant
Add Board members to WalkRounds
Add patients to WalkRounds
Review safety reports and past WalkRounds
action items as a starting point for discussion
• Take photos when appropriate
• Survey staff periodically for suggestions for
improving rounds
Related Methodology
• Comprehensive Unit –Based Safety Program
(CUSP)
• Leveraging Frontline Expertise ( LFLE)
• Management by Walking Around ( MBWA)
SJ Singer, et.al., Improving Patient Care Through Leadership Engagement with Front
Line staff.., JC Journal on Quality and Patient Safety, Aug, 2012
What Makes it Worth It?
• Changing Culture
– PHS CEO still participates in BWH WalkRounds
– Staff satisfaction with WalkRounds
– Balance of too many senior leaders participating
• Examples
– MRI safety zoning completion
– Software for assigning care team
– Biomedical equipment changes- default settings
Maine Medical Center Process
Phase I
• WalkRounds at MMC commenced in 2005
• Expectation for leadership participation to include unit
nursing leadership, key ancillary departments, and chiefs
• Visits occurred every other week to an inpatient unit and
were coordinated six weeks in advance
• Visit summary created and issues were e-mailed to
individuals to address
• Data stored in an Excel file
• No imperative to ensure items were addressed or to track
progress
Maine Medical Center Process
Successes
• Many issues were addressed
• WalkRounds persisted in this fashion for 7 years
• Visits to ancillary units occurred
Pitfalls
• Scheduling challenges
• Interval between visits to a unit
• C level participation waned
• Items not tracked to resolution
• Analysis of issues not easily accomplished
• Value to staff
Maine Medical Center Process
Phase II
• 2011 service line structure established with expectation of
leadership participation and oversight of issues
• Schedule set for the entire year-visits remain every other week
• Visits to outpatient locations incorporated
• Post visit huddle to discuss high priority issues and assign for
resolution
• High priority issues are entered in a data base and tracked through
to resolution
• Low priority issues are not tracked
• Minutes are taken and distributed to executives, anyone
attending/participating in the visit and the Patient Safety Team
• Bi-directional updates on issues provided to staff and leadership
Phase II Successes
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Size of visits
Engagement of service line leadership
Analysis of issues possible
Inform QI projects
Feedback = staff engagement
Phase II Pitfalls
• Not always knowing the context and capturing the issue
correctly
• Determining what units to visit-too many to accomplish in a
timely fashion
• Epic has been a topic of much discussion-may divert from
some of the other safety concerns
• Sometimes a challenge to get some of the issues addressed
• Sometimes a challenge to close the loop with staff
• C level participation is sparse
• Size of visits
Data
Number of Issues
YTD 2013 (n=15 visits)
Average # of high priority
issues per visit
4.8
Range
2-9
Issues Resolved
52
Pending Issues
19
Average Time to Resolution
50 days
Category
24
IS
5
Education/Training
5
Facilities (structural)
5
Pharmacy
4
Communication between units/areas/pods
4
Equipment functionality/maintenance
4
Involvement/Availability/Responsiveness
3
Security
2
Communication between MDs/RNs
2
Equipment availability/organization
2
Incomplete/Inconsistent Documentation
1
Clinical engineering
1
Communication between MDs
1
eMAR/Barcoding
1
Human error
1
MD Coverage
1
Policies/Procedures/Protocols
1
Radiology
1
Specimen Management
1
Supply availability/organization
1
Supply functionality
1
Unnecessary Procedures
71
Total
Examples of Issues
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IS-Epic
– Login
– Orders
Education and Training
– Patient education needs
– Use of Epic
Facilities
– Installation of overhead mirrors
– Timing of automatic doors locking in SCUs
– Shower room that leaks out into hall
Pharmacy
– Education about who to contact for service
– Pyxis availability during certain hours
– Pyxis overrides in emergent situations
Communication
– Time spent on phone tracking down provider
Equipment
– Bed rails
Improvement Opportunities
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Connecting with night and weekend shifts
Frequency of visits and visits to more units
Track low priority items
Create reports for service line use
Newsletter
Board member/patient participation
Survey staff periodically for suggestions for improving
rounds
Your Stories
• Experience with Other models?
• Thoughts about how to improve?
Thank You!
Erin Graydon Baker
EGraydonBa@mmc.org
Katie Blackburn
blackk3@mmc.org