Leader Rounding for High Reliability and Improved Patient Safety
Background: Critical to providing safe, effective patient care is ensuring that communication is open and transparent among all members of the health care team. However, current evidence shows that poor communication is commonplace, contributing to medical errors and poor patient outcomes. Implementing leader rounding may improve communication and reliability. The purpose of this initiative was to create an evidence-based process for the implementation of leader rounding for high reliability at the Veterans Affairs Bedford Healthcare System in Massachusetts.
Observations: We conducted a review of medical literature from 2015 to 2022 that found little research specifically related to leader rounding for high reliability. We created a formal and interactive process to improve patient safety by increasing communication among senior leadership, interdisciplinary teams, and frontline staff.
Conclusions: Open, transparent, and bidirectional communication among all staff is critical to improving patient safety and promoting a culture of safety in health care. This initiative may be of value to other health care organizations that are working to improve patient safety. Future efforts will focus on developing a robust evaluation program to explore the impact of leader rounding for high reliability on safety outcomes.
Tracking
Developing a tracking tool also is important for an effective leader rounding process. This tool is used to document issues and concerns identified during the rounding process, assign accountability, track the status of items, and close the loop when completed. One of the most commonly reported hurdles to staff sharing information to promote a culture of safety is the lack of feedback on what actions were taken to address the concern or issue raised with leadership. Closed-loop communication is critical for keeping staff continually engaged in efforts to promote a culture of safety.20 We have found that a tracking tool helps to ensure that closed-loop communication takes place.
Various platforms can be used for tracking items and providing follow-up, including paper worksheets, spreadsheets, databases, or third party software (eg, SharePoint, TruthPoint Rounds, GetWell Rounds). The tracking tool should have a standardized approach for prioritizing issues.
The stoplight classification system uses color coding (Figure 3).21 Green represents a safe space where there are no or low safety risks and are easily addressed at the local level by the area manager with or without assistance from the leadership team rounding, such as staffing.22,23 The unit manager has control of the situation and a plan is actively being implemented. Yellow signifies that areas are at risk, but with increased vigilance, issues do not escalate to a crisis state.22,23 Yellow-coded issues require further investigation by the leadership team. The senior leader on the team designates a process as well as a person responsible for closing the loop with the area manager regarding the status of problem resolution. For example, if the unit manager mentioned previously needing help to find staff, the area manager would suggest or take steps to help the unit manager. The area manager is then responsible for updating the frontline staff. Red-coded issues are urgent, identifying a state of crisis or high risk. Red issues need to be immediately addressed but cannot be resolved during rounds. Senior leaders must evaluate and make decisions to mitigate the threat. A member of the leadership team is tasked with following up with the area manager, typically within 24 hours. A staffing crisis that requires executive leadership help with identifying additional resources would be coded red.
The area manager is responsible for closing the loop with frontline staff. As frontline staff became more comfortable with the process, we observed an upward trend in the number of reported issues. We are now starting to see a downward trend in concerns shared during rounding as managers and frontline staff feel empowered to address issues at the lowest level.
Measuring Impact
Measuring the impact is a critical step to determine the overall effectiveness of leader rounding for high reliability. It can be as simple as requesting candid feedback from frontline staff, supervisors, managers, and service chiefs. For example, 4 months into the implementation process, the VABHS administered a brief staff survey on the overall process, perceived benefits, and challenges experienced (Appendix 2). Potential measures include the counts of leaders rounding, total rounds, rounds cancelled, and staff members actively participating in rounds. Outcomes that can be measured include issues identified, addressed, elevated, and remaining open; number of extended workdays due to rounds; staff staying overtime; and delays in patient care activities.23 Other measures to consider are the effects of rounding on staff as well as patient/family satisfaction, increase in the number of errors and near-miss events reported per month in a health care organizations’ patient safety reporting system, and increased engagement of staff members in continuous process improvement activities. Since the inception of leader rounding for high reliability, the VABHS has seen a slight increase in the number of events entered in the patient safety reporting system. Other factors that may have contributed to this change, including encouragement of reporting at safety forums, and tiered safety huddles.
