‘I think we should just listen and get out’: a qualitative exploration of views and experiences of Patient Safety Walkrounds

This explored the views and experiences of patient safety walkarounds from the perspective of both senior managers and frontline clinical staff.

Semi-structured interviews with 11 leaders and 33 frontline staff at two major teaching hospitals with mature walkaround programs was undertaken.

Providing backgrounds, it’s said that walkarounds allow the capturing of intel that isn’t unearthed from other formal mechanisms, like incident reports or chart reviews.

Some other research has shown “modest improvements” in patient safety indices associated with walkarounds. A recent RCT counters this by finding that the implementation of a walkaround program led to marked decreases in staff perceived performance improvements. Moreover, another study found staff disappointment with the walkaround program some questioning whether leaders actually acted on the identified issues.

Results

While the espoused purpose of walkarounds according to leaders was “engaging front-line staff in an open, blame-free conversation and valuing their clinical and practical expertise regarding potential patient safety problems” (p825), senior leaders reported attitudes and behaviours that “contradict the stated goals and principles of walkrounds” (p823).

Indeed, some leaders (p823):

• “tended to regard executive visibility as an end in itself and generally did not engage with staff concerns beyond the walkrounds encounter”
• “believed they understood patient safety issues better than front-line staff and even characterised staff concerns as ‘stupid’”
• “acknowledged that they often controlled the conversations, delimiting what counted as patient safety problems and sometimes even steered the conversations to predetermined topics”

In alignment to the above points, the findings from this study were divided into three themes that highlight the “disjuncture between the principles of walkrounds and senior leaders’ attitudes in practice” (p825):

• nominal respect for front-line concerns
• executive presence without engagement
• controlling the conversation.

These themes will now be covered.

1. Nominal respect for front-line concerns

A key espoused purpose of walkarounds according to leaders was for them to hear directly from frontline staff about patient safety issues. This was echoed by a number of leaders during interviews, with some recognising that frontline staff are experts.

However at odds with this espoused purpose was some comments from leaders which highlighted them “merely paying lip service to front-line staff as experts” to “explicitly disparaging their concerns” (p825).

Indeed, while frontline staff were espoused as experts of their domain in one sense, leaders in other cases discounted frontline staff as experts whom leaders could learn from. In one case a leader remarked that they wouldn’t really learn from staff as they already know what’s going on.

Half of the leaders remarked on their frustration that staff would bring up issues that the leaders regarded as irrelevant to patient safety. Leaders felt that staff too frequently brought up matters of environment and physical infrastructure compared to topics that leaders counted as more aligned to patient safety.

Thankfully not all leaders shared this view – but in the extreme case, there was examples where leaders were “characterising staff concerns as ‘stupid’ and ‘trash” (p825).

These examples came from leaders without clinical backgrounds; indeed, those leaders from clinical backgrounds tended to have more appreciation for the legitimacy of environmental issues faced by staff.

2. Executive presence without engagement

Most leaders spoke of the importance of being visible to staff as a way to demonstrate commitment to patient safety.

Nevertheless, one leader acknowledged “wanting to appear interested for the benefit of the front-line staff rather than actually being interested” (p825).

More broadly, leaders expressed only limited interest in engaging with staff concerns beyond the workaround encounter itself. For instance, one leader remarked that they should just listen to the staff’s concerns “and then get out” (p826).

Interviews with staff revealed that they perceived a lack of ongoing commitment from leaders to address safety concerns beyond initial face-to-face meetings. Many staff were initially excited to meet senior leaders and felt that they had been heard and acknowledged but in some cases, became “disillusioned with the process due to lack of resolution to the issues raised during walkrounds and the absence of follow-up communication” (p826).

3. Controlling the conversation

While walkarounds are supposed to predicated on open, non-hierarchical communication – interviews with leaders highlighted that they often controlled the conversations.

For instance, leaders set the boundaries at the outset or through the walkarounds on what should or shouldn’t be discussed. Moreover, one leader’s definition of professionalism – being productive and positive – was used to rule out discussing certain topics that frustrated staff which the leader perceived as being “‘too negative’ and ‘polluting’” (p826).

Another leader used the word “whining” to describe a walkaround interaction.

A staff unit manager expressed the pressure and stress for staff during some walkarounds, where there was a perceived “intense pressure on front-line staff to conduct themselves in the expected manner during the walkrounds” (p826).

In wrapping up the findings, it’s highlighted that:

• Some leaders only had nominal respect for the concerns of frontline staff and in some cases, explicitly disparaged them
• They viewed their executive visibility on the floor as an end in itself rather than to engage with staff about concerns
• They acknowledged controlling the conversations and thereby delimiting what counts as patient safety problems.

On the last point, some leaders attributed to the difference between how each party viewed what counts as patient safety issues to “poor understanding by front-line staff of patient safety problems” (p827).

While some leaders were dismissive of what they perceived as the small issues, the authors highlight evidence that found leaders addressing the small safety and admin issues “reduces frustrations of front-line staff, improves quality of care and leads to better clinician–managerial relationships” (p827).

Indeed, while many of these “whinges” (as one leader remarked) or issues that are perceived to be small issues and unrelated to patient safety may be irrelevant to the leader, for staff they are frequent sources of frustration and challenge and result in erosion to staff morale. Moreover, fixing these issues may “reduce the occurrence of more serious patient safety problems” (p827).

Thus, “Senior leadership should be encouraged to prioritise both small issues that impact the daily workflow of staff, not just more substantive problems that fall more within their conception of patient safety” (p827).

To conclude, walkarounds “may inadvertently lead to counterproductive attitudes by senior leaders at odds with the recommended principles of walkrounds” (p823).

Link in comments.

Authors: Rotteau, L., Shojania, K. G., & Webster, F. (2014). BMJ quality & safety, 23(10), 823-829.