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One Boston hospital gives executive walk rounds a grassroots twist
Sending a risk manager to the floors helps clinicians air their patient safety concerns
by Edward Doyle



Published in the February 2007 issue of Today's Hospitalist.

While hospitals around the country are using executive walk rounds to shed light on problems within their walls, one hospital has given the concept a decidedly grassroots twist by taking the executives out of the equation.

When leaders at Dana-Farber Cancer Institute in Boston were looking to ramp up their efforts to improve patient safety, they briefly considered the concept of executive walk rounds. The strategy typically calls on hospital leaders to meet with clinicians to talk about problems they deal with day to day.

While Dana-Farber officials had heard good things about the
"A mistake doesn't mean that there was a patient event."

Deborah Duncombe, MHP
Dana-Farber Cancer Institute
model, they thought it sounded too formal for their facility. Instead, the cancer center decided to exclude executives from its walk rounds and replace them with a risk manager-and in some cases, actual cancer patients.

Starting a dialogue
Dana-Farber launched what it calls patient safety rounds in 2001 with a fairly simple goal: to have a risk manager who was very familiar to the clinicians ask them what issues kept them up at night. In doing so, the institute hoped to spotlight obstacles to patient safety that were not being identified through conventional means.

The risk manager who helped spearhead the project was Deborah Duncombe, MHP, who has worked at the center for years. In keeping with the informal nature of the program, Ms. Duncombe says she avoided the scripted questions that are typical during executive walk rounds.

She admits, however, that she has a short list of questions that are particularly effective in engaging nurses and physicians to talk about obstacles to providing safe care. One question that often elicits a response: "Do you have any work-arounds?" That question, says Ms. Duncombe, "really encourages people to think outside of the box."

One of the challenges of getting peers to talk about problems, she says, is that many people at first don't understand how broad patient safety issues really are. When she first began conducting patient safety rounds, for example, most staff wanted to talk about problems with medications and physical safety.

To start a dialogue about what exactly constitutes patient safety, she often uses a question that many providers find provocative: "What was your last mistake?"

That question, she notes, causes staff to really stop and think. Some people assume she's asking for information about an incident that was either "their fault" or resulted in harm to a patient, she says. The real objective, however, is to help staff understand that not only does everyone make mistakes, but that mistakes should be shared so others can learn from them.

"When I explain that a mistake doesn't mean that there was a patient event, it opens up a dialogue," Ms. Duncombe says. "I've had people say, 'Do you mean the times I return a drug because it wasn't labeled correctly?' There's a lot of education involved."

Spurring new initiatives
When it comes to results, the rounds have led to a variety of new initiatives. Many changes have been incremental, Ms. Duncombe says, such as tweaks and modifications to the cancer center's medication order entry system.

Another change was first suggested by a relatively new staff member, who asked why she had to walk to the utility room to dispose of chemo bags. While she found the walk to be a nuisance, she also thought that carrying chemo bags around the cancer center's halls was an accident waiting to happen. Today, Ms. Duncombe points out, each infusion area has its own disposal unit.

Not all the changes made in response to the rounds have been incremental. Communication issues that come up during her conversations, for example, are typically more complex and harder to address.

Take the example of patient orders, which physicians may create before a patient appointment.

"If orders have to change because of changes in a patient's labs," Ms. Duncombe says, "communicating that change can be difficult." Since that issue was raised, the cancer center has piloted and implemented a number of unit-based initiatives to improve communications between the ordering physicians and treating nurses, including morning "huddles" on one unit, and team work projects among physicians, nurses and pharmacists.

Lessons learned
When rounds first started, Ms. Duncombe tried visiting units every other week, but she quickly learned that was too often. One big problem was that she ended up talking to the same people over and over.

Now, she visits each of the infusion units about 10 times a year and exam units five to six times a year, approaching staff at workstations, hallways and workrooms. She spends 45 minutes to an hour in each unit. She also tries to mix up the time and day she visits, so she has a chance to talk to people who work different shifts.

Ms. Duncombe attributes the program's success in part to the fact that she's worked at Dana-Farber for a long time; most people know and are comfortable with her. And she says the institute's risk management program is clinically oriented and viewed more as a staff resource for patient safety issues than as a more traditional program that stresses compliance or insurance and regulatory issues.

"That helps set the stage," she says, "for people to not be threatened."

Getting patients involved
The patient safety rounds program worked so well that a few years later, clinical leaders at Dana-Farber came up with a way to take rounds to another level: Have inpatients talk to other patients about issues they face.

Dana-Farber is in a unique position to enroll patients in such a project, Ms. Duncombe notes. Because so many current and former cancer patients take an active interest in their disease, the cancer center has two very robust patient and family advisory councils, one for adults and one for pediatrics. Representatives from those groups already sit on the hospital's quality committees, she says, so asking them to serve as "patient rounders" as part of a six-month research project seemed like a good fit.

In 2003, two patient rounders came to the hospital once a week for four hours and talked to cancer patients in one of Dana-Farber's adult infusion clinics. Unlike Ms. Duncombe, the patient rounders used scripted questions, some of which were fairly direct.

One question, for example, asked patients whether staff had used at least two patient identifiers during every encounter. Other questions were more open-ended, such as, "Do you know the side effects of your medication?" and, "Do you know who or how to call in an emergency when at home?"

While Ms. Duncombe can't discuss the results, which have been submitted for publication, she notes that one common theme was service quality. While she acknowledges that the findings may not address typical patient safety issues, she says the research team would like to see more research explore how patient attitudes toward service quality issues affect their overall perception of safety.

Edward Doyle is Editor of Today's Hospitalist.
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