E1 E1 Leading and creating safer health care Leading and creating safer health care

environments: environments:

The CEO & patient safety walkaboutsThe CEO & patient safety walkabouts

Gren Kershaw

Chief Executive – Conwy and Denbighshire Trust

Gerry Marr

Chief Operating Officer – NHS Tayside

Pat O’Connor

Head of Safety Governance and Risk – NHS Tayside

OverviewOverview

Understand the role of Executives in Patient safety

Identifying strengths and create leaders for patient safety

Design a patient safety walkround program for your healthcare system to promote cultural change

Share examples of safety walkround processes and outcomes

We are Here

Why the Health Foundation chose Why the Health Foundation chose to work on improving patient to work on improving patient

safetysafety

There is an identified need for patient safety to improve

There is a strong evidence base for what works

A focus on patient safety involves clinicians, managers, and patients

To Improve health, and the quality of healthcare for the people of the UK

The Health Foundation’sThe Health Foundation’sSafer Patient’s Initiative Safer Patient’s Initiative

UK Program 4 Healthcare Systems involved in 1st wave 1 In each UK Country, Scotland England,

Ireland and Wales Whole system change package Team driven from the board to the front line 20 new hospitals joined Dec 2006

What were the aims and What were the aims and goals?goals?

Create a culture that demonstrates Patient Safety as our highest priority

Reduce adverse events by 50% Build local capacity and capability for

improvement Develop highly reliable processes of care Transform the organisational approach to

Patient Safety & Quality Improvement

OurOur Goal Goal

Plan for system-level (not just project-level) patient safety improvements

Weave patient improvement activity into the fabric

of everyday life for the entire organisation

Work StreamsWork Streams

5 key Areas of patient safety work Leadership Medicines Management Operating theatres Intensive Care General Ward

Detailed plan for spread throughout theorganisation

How did we make things How did we make things happen?happen?

Implementing evidenced based practice Learning from the experts Using small tests of change (PDSA cycles) Using data and measuring change Managing clinical resistance Demonstrating active leadership

As leaders it was essential to…As leaders it was essential to…

Promote patient safety at every opportunity Put Patient Safety first item on every agenda Manage the safety initiative as a project –

making sure things get done! Manage the spread of good practice Introduce “Safety Walkrounds”

LeadershipLeadership

Patient Safety as a Strategic Imperative Clear Goals and Measurement Reduce variability, waste and harm Skill building

The Key Elements of The Key Elements of Breakthrough ImprovementBreakthrough Improvement

Will to do what it takes to change to a new system

Ideas on which to base the design of the new system

Execution of the ideas

Patient safety programPatient safety program

Provide a focus Celebrate success Accelerate Improvements Small test of change to build confidence and

competence in improvement techniques

Patient Safety WalkroundPatient Safety Walkround

AIM Highly structured process to bring lead executives

and front line staff together to have patient safety conversation with a purpose to prevent, detect and mitigate patient harm.

What are WalkRounds?What are WalkRounds? A carefully planned discussion between Frontline Staff and

– A hospital leader (or two)– A Patient Safety Manager/Director/Specialist– A scribe.– Other (Managers, Pharmacists, Students, patients )

lasting about one hour and regularly repeated– As frequently as weekly, but at a minimum monthly,

located wherever frontline staff do their work, fully supported by back office quality analysis, fully integrated into organisational committees, requiring rigorous application to detail in every step.

History of WalkroundsHistory of Walkrounds 1997

– IHI Collaboratives - Hospital teams work on rapid cycle improvement Leadership support tool

1999– WalkRounds concept is born in IHI Idealised Design

meeting– Many hospitals in IHI Collaboratives begin to implement

2000-3 – Piloted in several US Hospitals

2003 – JCAHO Journal publishes first article on WalkRounds

WalkRounds in controlled trial 2004 Safer Patient’s Initiative

How can patient safety How can patient safety walkrounds help?walkrounds help?

The Patient Safety Walkround process seeks to: Increase the awareness of safety issues by

clinicians Make safety a priority for senior executives Educate staff about patient safety concepts such as

non-punitive reporting and Obtain and act on information elicited from staff

about safety problems and issues Close the gap between those who make or prevent

error and those who make decisions to change the systems

ActivityActivity

Discuss with a partner the ways in which you have a similar process in your organisation and how it works or how it could be set up

What it is for ? What it is for ?

Safety quality, efficiency, effectiveness, timeliness, and equity – are equal parts of the conversation.

A comprehensive management tool designed to:– Help Leaders lead better,– Ensure ever safer and more reliable systems,– Help align frontline and leadership perspectives

What its not about What its not about

Parading senior leadership around the hospital. A relaxed conversation with frontline employees. Specifically about employee or patient satisfaction. Designed to solely address safety issues. Risky conversations. A soapbox for voicing opinions..

However, these may periodically be attributes of WalkRounds

Who will participate?Who will participate?

Senior Executives (President, Chief Nurse, Board Members,Chief Medical Officer, Clinical Chairs)

Patient. Safety, Quality, Risk Manager Managers/Administrators/Physician leaders Frontline Staff

– Doctors,Nurses,Pharmacists– Students, unit administrators, cleaners, porters– Whoever is available and involved in clinical care

When and where?When and where?

Weekly– Varying times– Nighttime shifts

Everywhere– Patient care floors– Labs– Radiology– Pharmacy– Non-Clinical areas

The ProcessThe Process

Schedule one year in advance. Base dates and times on staff availability and

executive availability. Take into consideration shifts, lulls in activity and doctor/ team rounds.

Schedule WalkRounds weekly. – Frequency of WalkRounds will vary based on the size of the

organisation, but one round per week is a good “rule of thumb.”

Rounds should occur at any site where employees and clinicians are involved in patient care but you may include non-clinicial services.

Detailed ProcessDetailed Process

Develop an introduction Highlight

– Confidentiality– What happens with the information

Develop closing remarks Thank all for participating– Summarise key issues – Ask that all staff talk to their colleagues about the

WalkRounds– Remind all staff that this is not the only forum for

discussing safety issues; offer contact information

Example Questions Example Questions

How will the next patient be harmed in your area? How does the environment fail you? How was the last patient harmed in this area – what

happened ? What prevents you from keeping your patients safe? What can senior leaders do to help?

Picture Picture

Getting StartedGetting Started Developing an outline

– Get buy-in from senior 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

– Promote the value of WalkRounds to nursing and medical staff

– Reassure middle management that WalkRounds will support them, and will not be an avenue to bypass them.

Getting StartedGetting Started

Planning– Discuss optimum time for rounds with nurse

managers and executivesAvoid shift changeOffer off-shift visits

– Develop a hospital map to keep track of visits– Create a 3-6 month schedule and distribute– Develop questions to ask

Prepare senior executives

Collect and Analyse DataCollect and Analyse Data

Track all individuals who participate: date, time, and location, comments heard.

Classify each hazard/event by its contributing factors.

Record frequency of each hazard/event Record severity of potential or actual impact on

patients and prioritise. Priority informs actions for senior leadership

Assign Action ItemsAssign Action Items

Produce reports WalkRounds comments, and distribute the reports to senior executives, patient safety committees, and the Hospital Board.

Determine action

On a monthly basis review monthly reports of both open and closed action items.

Activity Activity

Discuss in your healthcare system how you could use or improve a patient safety walkround system

Give Feedback to Board, Give Feedback to Board, Leadership, Management, and StaffLeadership, Management, and Staff

Develop a plan for feeding information back to rounds participants, senior leaders, committees, and the Board within your organisation.

Share good practice in addition to the issues that are identified and addressed newsletters, roadshows,presentations

Be rigorous!

Example of WalkRoundsExample of WalkRounds™™ Report to ExecutivesReport to Executives

Update: Challenges with the process

–cancelations/attendees List of prioritised concerns raised during patient

safety WalkRound for senior management attention – Whole systems concerns– Unit concerns– Environmental concerns– Individual service issues

Outline Feedback to FrontlineOutline Feedback to FrontlinePoint of contactThank youDate Participant role or identification. Recognition that this process is helping

the whole organisation to improveKey priorities discussed /Actions agreed

– E.g. Large number of new on staff . Difficult to get enough experienced

RNs on nights and weekends. Not enough equipment

Any further information contact

PicturePicture

Measure Your ProgressMeasure Your Progress

Refer to actions taken as the result of WalkRounds during later visits to each unit.

Measure safety climate changes periodically, using the Safety Attitudes Questionnaire.

Continually track follow-up comments, time to complete action items, frequency scores, and other indicators recorded in the WalkRounds database.

Key LearningsKey Learnings Surprisingly, it is not difficult to elicit

comments from staff Important to have multi-disciplinary

representation Important for leadership participants to be

well-versed in on-going quality/safety initiatives– Can provide feedback at time of

WalkRound

Key LearningsKey Learnings Managing the large amount of information is

the challenge– Prioritisation– Levels of action– Reporting and sharing

In a large institution, coordinated quality and safety groups are essential– To assign accountability– To receive updates on follow-up

Examples of successExamples of success

Lead Nurse spending too much time on Administration

Actions – Local review of unit activity– Introduced new hospital processes for bed

management system– Whole hospital review – National review of Senior Charge Nurse

Role

Example Example

SummarySummary

Make a plan Tell staff what its for Listen to the discussion Agree key priorities Assign action and Follow up Revisit and make sure its happened

Further Information Further Information

pat.oconnor@nhs.net

NHS Tayside

Kingscross

Clepington Road

Dundee

Scotland ,UK

DD3 8EA

Refs and other helpful Refs and other helpful resourcesresources

Frankel A, Graydon-Baker E, Neppl C, Simmonds T, GustafsonM, Gandhi TK:Patient Safety Leadership Walk Rounds. Jt Comm J QualSaf 2003, 29:16-26. Thomas E.J The effect of executive walk rounds on nursesafety climate attitudes: A randomized trial of clinicalunits.BMC Health ServicesResearch 2005, 5:28 doi:10.1186/1472-6963-5-28www.ecri.org/Patient_Information/Patient_Safetywww.aha.orgwww.ihi.orgwww.npsf.orgwww.ahcpr.gov