Are Patient Safety Leadership WalkRounds™

Worth It?NNESHRM

November 18, 2013

Katie Blackburn, MSErin Graydon Baker, MS,

RRT, CPPS

Topics Covered• 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– 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• 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 ProcessPhase 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 ProcessSuccesses

•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 ProcessPhase 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• 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

Number of Issues Category24 IS5 Education/Training5 Facilities (structural)5 Pharmacy4 Communication between units/areas/pods4 Equipment functionality/maintenance4 Involvement/Availability/Responsiveness3 Security2 Communication between MDs/RNs2 Equipment availability/organization2 Incomplete/Inconsistent Documentation1 Clinical engineering1 Communication between MDs1 eMAR/Barcoding1 Human error1 MD Coverage1 Policies/Procedures/Protocols1 Radiology1 Specimen Management1 Supply availability/organization1 Supply functionality1 Unnecessary Procedures

71 Total

Data

YTD 2013 (n=15 visits)Average # of high priority issues per visit

4.8

Range 2-9Issues Resolved 52Pending Issues 19Average Time to Resolution

50 days

Examples of Issues• 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

• 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 BakerEGraydonBa@mmc.org

Katie Blackburnblackk3@mmc.org