WalkRounds Designing an effective patient safety improvement process

1. WalkRoundsDesigning an effective patient safety improvement process Allan Frankel MD Director of Patient Safety Partners HealthCare Faculty Institute for HealthCare Improvement Erin Graydon-Baker, MS, RRT Patient Safety Manager Brigham and Womens Hospital

2. Designing the WalkRounds Process • Essential organizational strategy • Evolution of WalkRounds • What WalkRounds is and is not • Getting started • Information evaluation and feedback • Designing action items with accountability • Data management • Measuring and sustaining the progress

3. ORGANIZATIONAL STRATEGY • Aim • Leadership engagement in safety • Promoting a safety culture • Measure of success for the CEO • Regular use of the WalkRounds information at all levels • Regular participation in the rounding process • Infrastructure • Data management software • Regular presentation of actions and accountability at the board level

4. ORGANIZATIONAL STRATEGY • Pre-eminent Leadership • Evidence based optimal care • Sustainable Safety culture • Enhanced Workforce • Marketplace success

5. ORGANIZATIONAL STRATEGY ORGANIZATIONAL STRUCTURE • Pre-eminent Leadership • Aligned senior and clinical leadership • Engagement between leaders and frontline staff • Flow of Information • Effective reporting relationships and committee structures • Evidence based optimal care • Chronic disease management • Systematic use of protocols and pathways • Real time information for clinical decision making • Sustainable Safety culture • Just Culture • Reliable reporting • Effective Communication and Teamwork • Patient engagement • Enhanced Workforce • Values Grounded Behavioral Based Development • Total Rewards Programs • Revitalizing the Joy of the Care Experience • Systematic Retention, Recruitment, Re-training • Marketplace success • Organizing Targets by New Measures-Standards-Practices • Driving Enterprise Wide Systems Performance • Winning in Evolving Pay-For-Performance Programs • Integrating Outcomes, Process, Structure, and Patient Centered Measures

6. ORGANIZATIONAL STRATEGY ORGANIZATIONAL STRUCTURE • Pre-eminent Leadership • Aligned senior and clinical leadership • Engagement between leaders and frontline staff • Flow of Information • Effective reporting relationships and committee structures

7. ORGANIZATIONAL STRATEGY ORGANIZATIONAL STRUCTURE WORK AND MEASUREMENT • Pre-eminent Leadership • Aligned senior and clinical leadership • Engagement between leaders and frontline staff • Flow of Information • Effective reporting relationships and committee structures • Perform WalkRounds. • Integrate committee structures. • Quality and Safety Department • Project Management • Attention to every detail.

8. ORGANIZATIONAL STRATEGY ORGANIZATIONAL STRUCTURE WORK AND MEASUREMENT • Pre-eminent Leadership • Aligned senior and clinical leadership • Engagement between leaders and frontline staff • Flow of Information • Effective reporting relationships and committee structures • Evidence based optimal care • Chronic disease management • Systematic use of protocols and pathways • Real time information for clinical decision making • Sustainable Safety culture • Just Culture • Reliable reporting • Effective Communication and Teamwork • Patient engagement • Enhanced Workforce • Values Grounded Behavioral Based Development • Total Rewards Programs • Revitalizing the Joy of the Care Experience • Systematic Retention, Recruitment, Re-training • Marketplace success • Organizing Targets by New Measures-Standards-Practices • Driving Enterprise Wide Systems Performance • Winning in Evolving Pay-For-Performance Programs • Integrating Outcomes, Process, Structure, and Patient Centered Measures • WalkRounds

9. ORGANIZATIONAL STRATEGY ORGANIZATIONAL STRUCTURE WORK AND MEASUREMENT • Pre-eminent Leadership • Aligned senior and clinical leadership • Engagement between leaders and frontline staff • Flow of Information • Effective reporting relationships and committee structures • Evidence based optimal care • Chronic disease management • Systematic use of protocols and pathways • Real time information for clinical decision making • Sustainable Safety culture • Just Culture • Reliable reporting • Effective Communication and Teamwork • Patient engagement • Enhanced Workforce • Values Grounded Behavioral Based Development • Total Rewards Programs • Revitalizing the Joy of the Care Experience • Systematic Retention, Recruitment, Re-training • Marketplace success • Organizing Targets by New Measures-Standards-Practices • Driving Enterprise Wide Systems Performance • Winning in Evolving Pay-For-Performance Programs • Integrating Outcomes, Process, Structure, and Patient Centered Measures • WalkRounds

10. History • 1997 • Institute for HealthcareImprovementCollaboratives • Hospital teams work on rapid cycle improvement • Leadership support • Determines success of teams • Determines longevity of teams • 1999 • WalkRounds concept is born in IHI Idealized Design meeting • Primary goal – Leadership engagement in patient safety • Many hospitals in IHI Collaboratives begin to experiment • 2000 • Brigham and Women’s Hospital • Pilot of rigorous WalkRounds discussed, begins January 2001 • Other useful aspects of WalkRounds realized • Cyclical flow of information • Concern-Evaluation-Responsibility-Action-Feedback • Johns Hopkins Hospital • Incorporates concept into ICU • CUSP – Comprehensive Unit-based Safety Program

11. History • 2001 • HRSA (Health Research Services Administration) funds grant to evaluate 10 Massachusetts Hospitals • Investigators • AHA’s HRET (Health Reseach and Educational Trust) • Partners HealthCare • Bryan Sexton’s Attitudinal Survey Instrument bundled with WalkRounds concept • Spread to Kaiser Permanente with a 2 hospital pilot • 2003 • JCAHO Journal publishes first article on WalkRounds concept • Memorial Herman Hospital (Eric Thomas) evaluates WalkRounds in controlled trial • 2005 • August JCAHO Journal Lead Article – WalkRounds Implementation • Kaiser – Mandatory WalkRounds in Kaiser’s 30 hospitals • UK – Safer Patients Initiative • 4 Hospital Trusts adapt WalkRounds to UK environment • Singapore and Hong Kong Hospitals begin WalkRounds

12. What is WalkRounds? • A carefully choreographed discussion between Frontline Staff and • A hospital leader (or two) • A Patient Safety Manager/Director/Specialist • A scribe. • Other (Managers, Pharmacists, Students) • lasting about one hour and regularly repeated • As frequently as weekly, but at a minimum monthly, • located wherever frontline staff do their work……….

13. What is WalkRounds? • Fully supported by back office quality analysis • In which concerns are: • Collected • Analyzed • Tracked • Reported • Integrated with data from • Reporting Systems • Root Cause Analyses • Surveillance Data • Audit Data

14. What is WalkRounds? • Fully integrated into Operations committees • data is presented regularly • responsibility for actions is assigned • collaborative efforts are expected • results and feedback are monitored

15. What is WalkRounds? • Requires • rigorous application to detail in every step • combining top-down and bottom-up coordinated management

16. WalkRounds is NOT • Solely about safety • Parading senior leadership around the hospital • An informal conversation with frontline employees • Specifically about employee or patient satisfaction • Designed to solely address safety issues • Risky conversations • Always scintillatingly interesting • A soapbox for voicing opinions • An opportunity for Leadership to showcase • Usually conversations with patients (so far) • However, these may periodically be attributes of WalkRounds

17. WalkRounds Reporting Systems Root Cause Analyses Reports Analyzed validation Leadership feedback to clinicians/employees Contributing Factors Identified ACTION Discussion with Leadership

18. A Typical WalkRound • Briefing • Rounding • Debriefing • Database • Follow up

19. Getting Started • Set the stage • Buy-in from senior clinicians and executives; align expectations • Time commitment • Expected level of participation on rounds • Level of responsibility with follow up • Resources required • Be clear about the process • Peer review protected • Time commitment • Expectations for those who participate • Map your hospital • Promote the value of WalkRounds to nursing and physician staff • Reassure middle management that WalkRounds will support them, and will not be an avenue to bypass them or to elicit damaging comments about their management abilities.

20. Opening Statement for Rounds • “We are moving as an organization to open communication and a environment that apportions accountability carefully and avoids inappropriate blame. We believe that by doing so we can make your work environment safer for you and your patients. The discussion we are interested in having with you is confidential and purely for patient safety and improvement. We are interested in focusing on the systems you work in each day rather than on blaming specific individuals. The questions we might ask you will tend to be general ones, and you might consider how these questions might apply in your work areas in regards medication errors, communication or teamwork problems, distractions, inefficiencies, problems with protocols etc. We are happy to discuss any issues of concern to you. Our goal is to take what we learn in these conversations and use them to improve your work environment and the overall delivery of care.”

21. Asking the Right Questions? • “How will the next patient be harmed in your area?” • “How does the environment fail you?” • “The last patient who was hurt as a result of how we delivered care – what happened?” • Many other possible questions…….

22. Information Elicited • Systems failures • Near misses and real harm • Potential for harm • Comments • Who said them, where and when • Contributing factors • Frequency • Severity

23. Closing Statement for Rounds • “We appreciate the time and effort you put into taking care of patients and making their experience in our organization remarkable. Our job is take the information you have given us, to analyze it carefully, figure out what actions we might take to fix problems, assign those responsibilities to individuals and hold their feet to the fire until the problems are solved. We promise to let you know how we’re doing and we will come back and elicit your opinion. We will work on the information you have given us. In return we would like you to tell two other people you work with about the concepts we have discussed in this conversation. • As you see or think of other adverse events or are concerned about potential harm to a patient please report it by ________________ (Fill in the mechanism to be used in your particular organization). Near misses and adverse events are windows that we can all use to improve the safety of care we deliver. We can only address the issues if we know and talk about them openly.”

24. Information Evaluation and Feedback • Patient Safety team • Evaluates possible actions • Feasibility • Sends email immediately after rounds to everyone. • “This is what we heard today…..We’ll be working on it.”

25. Providing Feedback • Dear ________, • Thank you for taking the time to participate in the Patient Safety Walk Round held in the OR on Friday, Dec 1. The input we received during this round was wonderful, and it helps us identify what we need to focus on in improving the safety of our patients and reducing possibilities for error here at ___________ Hospital. • This is the list of comments from our visit to the OR. If you have any corrections or additions (now or in the future) to these, please let us know! You can reply directly to this message. • Large number of novices on staff . • Difficult to get enough experienced RNs on nights and weekends. • Older OR halls extremely cramped. No storage available for stretchers, beds, • etc. • If you have any more questions about patient safety or related issues for you or your department, please don't hesitate to contact us. Thanks again for your participation and support. • Jane Doe • Patient Safety Director • John Smith • Patient Safety Assistant • Joan Doe2 • Director of Quality Management • Jack Smith2 • Chief Medical Officer

26. Analyzing the Information • Vincent’s Model of Contributing Factors • Team factors • Individual staff factors • Task factors • Patient factors • Work environment • Organization and management • Institutional Context Vincent et al, BMJ 1998

27. Assigning Action Items • Produce reports of categorized and prioritized WalkRounds comments • Distribute the reports to senior executives, patient safety committees, and the hospital Board. • Determine action items • Using comments, priority scores, and contributing factors. • Convene clinical leaders, administrative directors and executives monthly. • Establish communication with those responsible for actions being taken.

28. Sample Summary to the Executives • Patient Safety Executive WalkRounds™Update: • As requested, the Patient Safety team will provide you with the list of concerns raised during WalkRounds™. One of our challenges with these WalkRounds™ is to communicate the issues and progress towards resolution to both you and the reporters. • Our plan includes:*emailing the reporter with a confirmation of issues*developing a coordinated approach to prioritize the issues in terms of actual or potential harm to patients*communicating the issues to you in a timely manner*facilitating the discussion of the issues *communicating any improvement made to you and the reporter. The list below describes the issues raised during WalkRounds™ in aggregate, lists the responsible VP and assigns a risk priority score derived from the potential risk to patients multiplied by the number of times that the issue was raised. These items represent the overriding concerns of the front line staff:

29. Hospital Operations and WalkRounds • WalkRounds should be a permanent agenda item on a large multidisciplinary operations committee comprised of: • Chairs and Chiefs • Administrators and Quality/Safety Personnel

30. Measuring Your Progress • Measure safety climate changes • using the Safety Attitudes Questionnaire. • track follow-up comments • Track actions taken • Measure time to complete action items • % of action items completed within 3mos, 6 mos

31. Resources • FTE: In the beginning…. • ¼ to ½ Pt. Safety Manager • ¼ to ½ Scribe/Assistant/Database Mgr. • FTE: Once established….(i.e. 9 months) • ¼ or less Pt. Safety Manager • ¼ Scribe/Assistant/Database Mgr.

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36. Examples of Completed Action Items • Provided increased access to patient information from affiliated clinics • Surveyed staff for safety reporting system improvements; revised reporting system • Increased MRI safety with appropriate zoning • Piloting a radio frequency tracking system for biomedical equipment

37. Examples of Completed Action Items • Developed and implemented an algorithm for employing a back up system for paging system outages • Automatic doors installed in the Cardiac Intensive Care Unit • Added bedrail extenders to prevent patients from falling from beds with high air mattresses • Improvements to the new eMAR system

38. Impact of Executive WalkRounds Memorial Herman Hospital % of respondents within a clinical area reporting good safety climate 35

39. Typical Mistakes

40. “ The Main Part of WalkRounds is visiting the Floors” • Leadership visiting a unit …… • isn’t WalkRounds. • is only the first small step. • WalkRounds fail when other components aren’t in place. • Database management • Analysis • Operations • Assigning actions • Feedback

41. “ We Can Start Documenting on Paper or Excel” • KEY COMPONENTS of success: • Microsoft Access database • A person to manage it • The Access database facilitates • Data management • Report generation • Feedback • Measurement

42. “ Feedback is Too Time Consuming” . • Feedback is the way to show frontline providers that you’re serious. • The WalkRounds visit alone is a show without substance. • The Actions taken are the important part. • Feedback ensures knowledge of the Action!

43. Questions?Comment!