Informal leadership rounds result in major patient safety improvements

Hospital execs are inundated with informative data and monthly reports, but the leaders who often make the best decisions to improve patient safety are the ones who step away from their desks every so often and walk around the organization to talk with staff and patients.

Leadership rounds are an informal way for CEOS to connect with frontline staff to discuss patient safety issues and ideas for systems improvement, says Catherine Miller, R.N., J.D., risk management and patient safety specialist for the Cooperative of American Physicians Inc.' CAPAssurance Program. And, she says, nearly every major patient safety organization considers rounding to be one of the best way leaders can show their commitment to patient safety. It reinforces to staff that their work matters.

"Staff are the greatest untapped resource in the hospital," says Miller, pictured right, during an exclusive interview with FierceHealthcare. "They are the ones who are ultimately familiar with the work and have the best ideas for fixing things. For CEOs to talk to staff directly and use the rounding to reinforce the organization's mission, it is a way for them to recognize staff for setting the standard….It allows leaders to acknowledge staff on the spot. "

Two of the biggest obstacles to conducting these rounds are time and competing interests, but Miller says it's important to schedule the rounds and commit to them. "Like exercise, it's easy to put it off. There is always something burning and requires immediate attention. If it's not on your schedule and you plan for it, you can come up with excuses not to do it," she says.

But once it appears on the calendar, it's more than simply walking out the door and visiting units. Leaders must plan how to approach these visits. "You need to have a planning meeting for these to be successful," she says. "You can't just get together in a group and head out."

Essential steps for the rounding team

First, Miller says, consider who will join you on these rounds. Some organizations have the director of nursing, director of pharmacy and a frontline staff member. Others also include patient advisors and a scribe to take notes. "You also want to decide whether you want a big team that spreads out visiting different locations or do you just visit one unit together," she says. "A big group can be intimidating for staff. From my experience, people tend to break up when visiting a unit and that's a good thing. Forming rounding pairs--someone with clinical experience and a nonclinical person--that's worked for me."

Also think about how often you want to conduct rounds. Some organizations find monthly rounds work best, as it gives them time to follow up on issues discovered while talking to staff. Others meet twice a month. "You must make sure these issues are summarized, tracked and followed through to completion. You must may immediate attention to patient safety issues that you discover so there is shorter time for resolution," she says.  

Make sure to cover all the details before you set out for your first visit. Define the mission, purpose, frequency, how much time you will spend on the floor, where you'll meet and so on. Miller also suggests that leaders communicate the plan to managers and directors so they understand the purpose of the rounding. 

"You want them to realize you aren't going on a witch hunt that the purpose of these rounds is to spread the value of the organization and identify opportunities for improvement to work collaboratively. Then they in turn can prepare staff so everyone feels at ease," she says.

In the beginning, the conversations with staff may feel awkward, she says. Once staff become used to administrators visiting the unit, these discussions will become more natural. "Eventually, the more you round, the more likely staff will tell you what's bothering them," she says.

Finally, Miller urges leaders to follow up with staff after the conversations to let them know that you are working on the problems that they identified. "Staff can't see what's going on behind the scenes, so it's important to follow up with anyone who brings up a patient safety issue," she says. "Even if it's just to say we are working on it. Let staff know it's being addressed and not being ignored."

Use rounding to create a culture of safety

Miller encourages leaders to use the rounds as an opportunity to introduce the concept of a just culture, one in which the organization encourages people to come forward with a patient safety concern without fear of discipline or punitive actions.

"Leaders shouldn't be reactive when they hear something sensitive or deficient. They need to be reasonable, fair and just in their approach as they seek to understand the issue," she says. The team must also thank and recognize any individual who escalates a patient safety concern as a "patient safety advocate."

If staff is reluctant to share information or fear being identified as a "whistleblower," remind them that the goal of the organization is to create a culture where staff is free to openly discuss errors and make improvements--and that the focus is on performance improvement, not personal failure.

One way to encourage conversations is to create a script before heading out on the rounds. Consider asking questions: What's working well on this unit? What needs improvement? Do you have resources you need to do a good job? What are barriers to provide care? When think about your job, is there anything that keeps you up at night?

"Sometimes you'll get answers like, 'No, I think we are doing great job." Other times, that's a loaded question. You will get a lot of information and need to address those things that are reported.

These conversations will help change the culture of the organization, Miller says. "It is like a breath of fresh air. It helps staff feel so valued when people take interest in what you do. It helps administrators get way from being behind the desk and helps them recommit."

Miller says she's witnessed several organizations use rounding to improve service and safety. For example, if a rounding team is concerned with low patient safety scores and a spike in fall rates, they may notice during their visits that staff don't rush to respond to call lights. "That's a service issue and a clear patient safety issue," she says.

In this situation, leaders should follow up with the manager to investigate the issue and develop an improvement plan with staff input.

"The essential message is, we're all in this together; we're all on the path of continued improvement together," Miller says.

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