E1 Leading and creating safer health care environments: The 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

Overview 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 to work on improving patient safety To Improve health, and the quality of healthcare for the people of the UK 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 The Health Foundation is an independent charity that aims to improve health and the quality of healthcare for the people of the UK i) There is an identified need for patient safety to improve Many reports worldwide including ‘An organisation with a memory’ (Department of Health, 2000) have observed that many breakdowns in patient safety have a familiar ring, displaying strong similarities to incidents that have happened before. ii) There is a strong evidence base for what works The evidence base for preventing similar incidents and creating safer care practices is strong, but there is an implementation gap, with evidence still not informing many commonplace procedures and practices in hospitals. We want you to achieve measurable improvements in the care that you offer, then you can start to develop your role as an exemplar rolling out models for improvement, providing opportunities and access for others to learn from your experiences. iii) A focus on patient safety involves clinicians, managers and patients. Safer organisations exhibit a culture that puts patient safety at the centre of everything they do. We hope that a focus on patient safety will help transform organisational culture, improving patient safety by galvanising support from clinicians, managers and patients. Also, by improving safety, organisations can learn how to improve the quality and performance of services overall.

The Health Foundation’s 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 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

Our 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 Streams 5 key Areas of patient safety work Leadership Medicines Management Operating theatres Intensive Care General Ward Detailed plan for spread throughout the organisation

How did we make things 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… 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”

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

The Key Elements of Breakthrough 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 program Provide a focus Celebrate success Accelerate Improvements Small test of change to build confidence and competence in improvement techniques

Patient 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? 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 Walkrounds 2004 Safer Patient’s Initiative 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 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

Activity 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 ? 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 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? 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? Weekly Everywhere Varying times Nighttime shifts Patient care floors Labs Radiology Pharmacy Non-Clinical areas

The 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 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 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?

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Getting 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 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 Started Planning Discuss optimum time for rounds with nurse managers and executives Avoid shift change Offer 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 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 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 Discuss in your healthcare system how you could use or improve a patient safety walkround system

Give Feedback to Board, Leadership, 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 WalkRounds™ Report 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 Frontline Point of contact Thank you Date Participant role or identification. Recognition that this process is helping the whole organisation to improve Key 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

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Measure 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 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 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 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

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Summary 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 pat.oconnor@nhs.net NHS Tayside Kingscross Clepington Road Dundee Scotland ,UK DD3 8EA

Refs and other helpful resources Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK:Patient Safety Leadership Walk Rounds. Jt Comm J Qual Saf 2003, 29:16-26. Thomas E.J The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units.BMC Health Services Research 2005, 5:28 doi:10.1186/1472-6963-5-28 www.ecri.org/Patient_Information/Patient_Safety www.aha.org www.ihi.org www.npsf.org www.ahcpr.gov