clinical contributions Patient Safety Executive Walkarounds

1 29 The Permanente Journal/ Summer 2006/ Volume 10 No. 2 Patient Safety Executive WalkaroundsBy Steven P Feitelberg, MDAbstractThe KP Patient Safety Executive Walkarounds Program in the KP SanDiego Service Area was developed to provide routine opportunities forsenior KP leaders, staff, and clinicians to discuss Patient Safety concernsproactively, working closely with our labor partners to foster a cultureof Safety that supports our staff and physicians. Throughout the KP SanDiego Service Area, the Walkarounds program plays a major part inpromoting responsible identification and reporting of Patient Safety is-sues.

2 Because each staff member has an equal voice in discussing pa-tient Safety concerns, the program enables all employees union andnonunion alike to engage directly in discussions about improving pa-tient Safety . The KPSC leadership has recognized this program as a ma-jor demonstration that the leadership supports Patient Safety and pro-motes reporting of Safety issues in a just culture. clinical contributionssafe as possible for patients . 2 (TheNQF of which KP is a member isa private, not-for-profit membershiporganization created to developand implement a national strategyfor measuring and reporting on thequality of health care.)

3 The medi-cal profession has realized that im-proving Patient Safety must beamong the highest priorities ofhealth care leaders and , only by direct andregular contact with real care deliv-ery can leaders understand the prob-lems of staff and clinicians in deliv-ering safe care. To facilitate this levelof involvement, the KP San DiegoService Area launched the PatientSafety Executive Walkarounds Pro-gram. This program gives top KPleaders the tools to show KP staffand clinicians that the KP leadershipis committed to Patient Safety and toIntroductionSince publication of the Instituteof Medicine Report, To Err Is Hu-man: Building a Safer Health Sys-tem,1 increased attention has beenfocused on Patient Safety in healthcare settings.

4 The challenge forhealth care organizations is to fos-ter a culture of Safety and to con-tinually identify opportunities to im-prove and assure the Safety ofpatients being treated at health carefacilities. At Kaiser Permanente (KP),this ongoing process is driven fun-damentally by the organization sleaders. As stated by Kenneth Kizer,MD, MPH, President and Chief Ex-ecutive Officer of the National Qual-ity Forum (NQF) in an NQF consen-sus statement, There simply isnothing more important in oversee-ing a hospital or other health carefacility than to ensure that it is asdeveloping the infrastructure neces-sary to ensure responsible reportingof Safety -related errors and walking through hospital units toconduct face-to-face conversationswith any staff member or physicianwith a Safety concern, leaders canlearn more about errors or hazardsthat could or did cause harm.

5 Andon the basis of issues identified dur-ing the Walkarounds , the leadershipcan identify opportunities for improv-ing Patient Safety . These informaldiscussions are thus an essentialcatalyst for change because they en-able the organization to improve ourreporting systems and enhance ourknowledge about how to ensure asafe Origin andComponentsRecognizing that the Patient SafetyExecutive Walkarounds programcould help the KP San Diego ServiceArea to become a leader in patientsafety (a top-priority strategic goalidentified by the Service Area), theKP San Diego Service Area managerencouraged the KP San Diego Medi-cal Center to become the SouthernCalifornia pilot site for implementingthe Walkarounds program.

6 The pro-gram subsequently began as a nine-month, day-shift pilot program in SanDiego in September 2002. From thebeginning, the Medical Service AreaAdministrative Team (MSAAT) and theKP San Diego Leadership TeamSteven P Feitelberg, MD, is the Assistant MedicalDirector for San Diego. He is also clinical Professor ofMedicine at UCSD. E-mail: Lawrence Patient Safety Award WinnerBy walkingthroughhospital unitsto conductface-to-faceconversationswith any staffmember orphysician witha safetyconcern,leaders canlearn moreabout errorsor hazardsthat could ordid causeharm ..30 The Permanente Journal/ Summer 2006/ Volume 10 No.

7 2clinical contributions (SDLT) gave their strong support andsponsorship to the the Walkarounds program, twosenior leaders are scheduled to visiteach nursing unit, hospital clinicaldepartment, and several medicaloffice buildings at least once peryear to speak with frontline staffabout Patient Safety concerns, whichmust be assigned a priority levelaccording to which the concernswill be resolved. The Walkaroundsteam must include at least one rep-resentative from either the MSAATor the SDLT (these entities partici-pate on a rotating basis), a repre-sentative from either the QualityResource or Risk Management/Pa-tient Safety Department (or a rep-resentative from each department),and a scribe.

8 The Walkarounds teammust conduct rounds for at least onehour each month and interview atleast three members of the staff mem-bers of labor unions as well asnonrepresented staff are encour-aged to participate fully in thesediscussions, which must focus ex-clusively on Patient Safety issues andmay not be combined with anyother type of unit rounds. In addi-tion to verbalizing the organization scommitment to improving patientsafety, the leaders obtain feedbackfrom staff and physicians regardingperceptions of a just culture. Aculture that does not blame peoplewho make mistakes but looks at theroot cause of the errors and pro-motes system improvements that re-sult in a safer environment for thepatients and the Walkarounds , the teaminformally approaches the patientcare area to meet with available staffand physicians.

9 The MSAAT Repre-sentative may take the lead in thediscussions, asking questions to so-licit information regarding percep-tions of Safety as well as Safety is-sues that did or could cause harmto patients . An interview tool wasdeveloped to assist leaders in facili-tating the discussions (Table 1). Asthese conversations take place, arepresentative from Risk Manage-ment/ Patient Safety noted the issuesverbalized by staff and physiciansand subsequently entered these is-sues into a AnalysisTo assess the effectiveness of theProgram, three types of outcomesfrom the Walkarounds Programwere measured: Improvement in Patient Safety (Vincent Factors):3 This mea-sure used a quantitative(Vincent Model) approach to counting the Patient Safety is-sues identified and resolved(Table 2).

10 Components for theVincent Factors (Table 3) werederived from medical publica-tions on error, adverse out-comes, and risk framework incorporatedfactors which influence clinicalpractice and which are used tocategorize, analyze, and priori-tize Patient Safety issues. Dur-ing each walkaround , issueswere entered into a databaseTable 1. Sample questions asked by the MSAAT representativeduring Patient Safety Executive Walkarounds at the KP San DiegoMedical Center Can you t h in k of any events in the past day (or few days) that have resultedin harm t o a Patient ? Can you t h in k of any near misses that almost caused a Patient harm but did not?