A column by Maureen Flynn

This month we focus on a resource document ‘Quality and Safety Walk-rounds Toolkit’ developed to support staff and health service providers to focus on quality and safety.

Quality and safety walk-rounds
Quality and safety walk-rounds (also know as leadership walk-rounds) provide structured process to bring senior managers and front line staff together to have conversations with a purpose to prevent, detect and mitigate patient/staff harm. The aims in introducing walk-rounds are multiple, to:

• Demonstrate senior managers’ commitment to quality and safety for patients, staff and the public
• Increase staff engagement and develop a culture of open communication
• Identify, acknowledge and share good practice
• Support a proactive approach to minimising risk, timely reporting and feedback
• Strengthen commitment and accountability for quality and safety.

Quality and safety walk-rounds are different in purpose and approach to assessments or advance walk-rounds for hygiene or other inspections. It is about an open conversation around one important issue – how can staff and managers work together in creating a culture focused on ‘quality and safety’.

Who: They provide a formal process for members of the executive/senior management team/members of the board (for example CEO, CFO) to talk with staff and patients about safety issues in their unit or team and show their support of staff for reporting errors/near misses.

Where: Walk-rounds can be conducted in any setting such as wards, departments, operating theatres, clinics, general practice and community settings, but are not limited to these. They are also useful in services such as pathology and portering or other areas that may affect patient care or the safety of the organisation such as information communication technology (ICT) and finance.

It is useful for the walk-rounds to start with a tour of the unit/team and meeting with patients (where possible). A meeting area as close to the patient/service area (as possible) such as an office or seminar room can be used for the discussion. It is best to agree a time limit (eg. one hour).

What: The walk-round is not a surprise it is planned in advance at a suitable time for the unit/staff and management team. The team in the area being visited is asked to describe what is working well or a change that was brought in at local level that might also work in other locations. They may also be asked to think of a recent example of a risk or patient safety incident they have experienced.

How: It can be helpful to ask probing questions and all members of staff are actively encouraged to participate. A number of issues that might be considered are:

• Identifying/acknowledging good practice
• Communication, eg. within teams and with patients
• Teamwork, eg. how the team operates
• Risk management, eg. the experience of the team in reporting incidents or near misses
• Prevention and control of HCAI, eg. standard of cleaning and compliance with hand-washing
• Environment, eg. changes to the physical environment
• Equipment, eg. new safety devices or maintenance and access to equipment
• Process, eg. medication reconciliation, drug errors or delays in prescribing medication, clinical audits, missing or incomplete healthcare records
• CPD, eg. safety education and training specific to the area
• Leadership, eg. key quality improvements plans to address national standards.

At the end of the walk-round, everyone agrees any safety issues identified. The aim is for the safety issues to be dealt with at a local level with the support of the executive/ senior management team. If the ward/area is a ‘productive ward’ site, this is an opportunity to discuss progress with other improvement initiatives and update the ‘visit pyramid’.

The findings of the walk-round can be circulated and discussed at the appropriate line management forum. By exception they may be circulated also to the executive/senior management team. Responsibility is delegated to address issues arising. This will also provide evidence, for assurance. The aim is to complete these actions within an agreed timeframe. This does not prevent all staff from addressing the risks identified and recording these on the unit risk register, where appropriate.

Why: Ultimately, we want to nurture a culture where problems in care are openly discussed and solutions identified, where hierarchies are flattened and all staff feel that they can speak up and contribute to improving the services we provide.

Get involved
If you are not already participating, you can invite senior managers in your organisation to your area for a walk-round. To help plan a visit, the toolkit contains a flow diagram with the steps involved, suggested prompt questions for staff and patients, sample letters and an information leaflet for staff. The documents can be accessed via the Quality and Patient Safety Division home page at http://www.hse.ie/eng/about/Who/qualityandpatientsafety/. We would be really pleased to receive feedback and your experience of using the toolkit and how this might be improved.

Maureen Flynn is the director of nursing (national lead for quality and safety governance development) at the Office of the Nursing and Midwifery Services Director, Quality and Patient Safety Division, HSE

Acknowledgement
With special thanks to the working group, steering group, international reference panel and the colleges and associations for preparing and endorsing our approach, along with the many staff who contributed by sharing their experiences of using walk-rounds. For further information and access to resources email: maureena.flynn@hse.ie or thora.burgess@hse.ie

Quality & Safety - Quality and safety walk-rounds