Frontline caregiver assessments of patient safety improved in both hospitals after implementing the WalkRounds project. This study builds upon previous WalkRounds research, which assessed safety climate among nurses present during the intervention (Thomas et al. 2005
), by including all types of caregivers within a patient care area during WalkRounds. In addition, this study conducted WalkRounds weekly for 18 months, rather than monthly for 3 months.
We found that WalkRounds provided a formal structure and ongoing mechanism for caregivers to surface and address patient safety defects. In fact, the paired sample t-test results demonstrated significant improvement in the items that specifically dealt with discussing local patient safety concerns. Discussing and learning from errors, feeling encouraged by colleagues to report concerns, and knowing how to report concerns were themes from the four items that improved the most, and may be a result of senior leaders connecting with frontline workers to reveal and resolve concerns. In particular, improvement in the safety climate item “I am encouraged by my colleagues to report any patient safety concerns I may have,” indicates that WalkRounds bolstered a shared sense of patient safety interconnectedness among the caregivers in a given patient care area.
The types of problems elicited during WalkRounds were influenced by the type of providers who participated. Nurses preferentially discussed operational problems, while physicians tended to focus on clinical decision-making issues. In both cases, the WalkRounds leader's skill in directing conversation and making participants feel safe determined whether the concerns elicited included a discussion of real adverse events.
Anecdotally, issues raised during WalkRounds fell into three categories; those that could be resolved locally, those that required cross-departmental collaboration, and those that required significant resources demanding new budget allocations. It is unlikely that the impact of organizational actions on perceptions of safety is directly related to these categories or to the cost or resource components of the action. Instead, a reasonably frugal action such as changing metal utensils to plastic may have an enormous impact on safety and perceptions of safety.
WalkRounds may empower caregivers with a stronger sense of responsibility for patient safety, coupled with a stable and predictable partnership with upper management to provide resources and remove barriers relevant to improve patient safety. Specific examples in two patient care areas with strong changes in safety climate scores support this suggestion. In one care area, the first WalkRounds elicited a discussion about poorly functioning wheelchairs that led to their replacement. In the second area, a serious adverse event was discussed during WalkRounds that led to a consensus that errors could be discussed in a supportive environment.
Analyses from other industries suggest that improving frontline assessments of safety increases actions that promote safety and minimize risk taking behaviors (Roberts 1990
). The implication for health care organizations is that WalkRounds, by comparison to monies spent on other efforts to improve safety especially in the realm of informatics, is an inexpensive mechanism through which leaders can positively influence and document safety and quality over time. Moreover, WalkRounds in conjunction with a cultural assessment provides a clear picture of patient care areas with low safety climate scores that would benefit the most from WalkRounds. This is important given the limited resources for patient safety interventions. Using a validated cultural assessment tool, such as the SAQ , to diagnose strengths and weaknesses at the patient care area level is a powerful way to harness the wisdom and insights of frontline caregivers while helping direct the attention, resources, and responsiveness of hospital leaders to care areas that need it most. To be better stewards of dwindling resources and availability of leaders, the SAQ could be used to diagnose and triage assistance in the form of WalkRounds to units that need help.
Notable in this study is that only two of the seven hospitals were successful at broad and sustained implementation of WalkRounds. Commitment from leadership, a champion trained in quality or safety, and time and resources to manage the data and feedback are the three components that these two institutions had when compared with the other five hospitals. All three components appear to be necessary for success.
Implications of Recruiting Clinical Areas to Participate versus Using Early Adopters
Similar to the lesson learned by the U.S. armed services after the Vietnam War, there is a significant difference in performance and outcome when using a mandatory draft versus a volunteer army. Most of our collective experience using WalkRounds and the SAQ has been with early adopters who were ahead of their contemporaries in thinking about and addressing patient safety defects. We have found that hospitals recruited to rigorously conduct WalkRounds or administer a cultural assessment survey have a significantly lower level of engagement and sustainment than hospitals who seek our guidance to conduct these interventions as a result of their own progressive thinking.
Albeit anecdotal, early adopters
have consistently garnered higher levels of participation, more rigorous follow-through, and higher SAQ response rates than their recruited
counterparts. For example, our study achieved a 60 percent response rate for the SAQ , whereas it typically garners a response rate of over 80 percent for hospital-wide (Pronovost and Sexton 2005
). In this sense, our results may be an underestimation relative to the results achieved by some hospitals that chose to rigorously implement WalkRounds and refine the process on their own (Pronovost et al. 2005
). In addition, hospital systems, such as Ascension, that were early adopters of safety culture assessment have garnered system-wide SAQ response rates of over 80 percent (across 60 hospitals and 24,000 respondents), and have integrated their results with decisions to choose patient safety interventions that are most appropriate for specific patient care areas (Rose et al. 2006
). Unlike previous WalkRounds research that used an experiment/control group design, we chose a less sophisticated pre–post design, whereby each patient care area served as its own control. Prior work has demonstrated that control groups are easily contaminated by experimental group participants who float between patient care areas (Thomas et al. 2005
). To compensate, we used a longer exposure period for WalkRounds (approximately 2 years) than previous work.
There were potential limitations to this study. First, detecting improvements in safety climate scores were limited by the small number of participating patient care areas, which resulted in statistical power limitations. Nevertheless, the separately conducted paired samples t-tests indicated significant improvement in safety climate scores for hospital A, and approached significance ( p=.06) for hospital B. Second, including only two hospitals limited our ability to generalize more broadly to hospital across the U.S. However, our sample did include an academic teaching and community facility. Third, a pre–post study design limited our ability to conclusively say that the WalkRounds caused the improvement in safety climate. While WalkRounds were the most visible effort during this period, the improvements might have been due to a more general temporal trend toward improved safety climate or other patient safety activities.
In conclusion, WalkRounds are not a patient safety panacea. Rather, they should be considered in the context of organizational readiness as a function of available leadership time, organizational resources, and patient safety-related priorities. The intent of WalkRounds is to implement a patient safety infrastructure that bridges the gap between leaders and frontline caregivers. The end result reported here is a significant improvement in frontline caregiver assessments of patient safety, and a narrowing of the apparent disconnect between RN and nurse managers/charge nurses. The spread and adoption of WalkRounds worldwide (Budrevics and O'Neill 2005
; Verschoor et al. 2007
) suggests that the process meets a need not yet met, which is eliciting caregiver concerns to identify local hazards within a framework that allows for the removal of barriers that impede actionable steps to make improvements. Assessing safety climate with the validated SAQ , affords leadership and frontline caregiver alike, the ability to empirically identify specific care areas that are struggling. In turn, WalkRounds can be implemented to identify and address local concerns, and track progress over time. Taken together, safety climate assessment and WalkRounds allow hospitals to diagnose, target, and treat the patient care areas in need of resources and leadership attention.