Care Redesign

Senior Staff Safety Rounds: A Commitment to Ensure Safety Is the Top Priority

Article · May 1, 2018

With the explicit goal of improving patient safety, Bridgeport Hospital in Connecticut has been using a subset of the Agency for Healthcare Research and Quality Safety Attitudes Questionnaire (AHRQ SAQ) since 2009 to stimulate conversations about patient safety among senior administration, staff, and physicians, referred to as Senior Staff Safety Rounds (SSSR). Each year, several hundred employees and physicians participate actively in these conversations.

When the hospital implemented a comprehensive safety program in 2013, based on training staff and physicians in principles of high reliability (Cooper et al., 2016), SSSR gained more prominence as a way to regularly, directly, and qualitatively assess physicians’ and employees’ perceptions of the safety of care provided. More important, the direct, face-to-face feedback to senior administration has resulted in real-time improvements that have positively impacted safety and consequent improvement in scores measuring safety across all areas.

The Challenge

In 2007, Bridgeport Hospital experienced a tragic Sentinel Event in which a patient bled to death postoperatively. Prevailing culture — fear of speaking up, lack of attention to detail, and the impression that leadership did not prioritize patient safety — played a central role. Communication among nurses and physicians, staff and administration, and between different disciplines in the care team was severely lacking. In 2009, the raw rate of positive responses in the AHRQ SAQ domains “Openness and Communication,” “Hospital Management Support for Patient Safety,” and “Overall Perceptions of Safety” were under 50%, each corresponding to percentile scores in the bottom half nationally.

Leadership Matters

Senior Staff Safety Rounds was implemented as it became clear that tangible, visible commitment of the executive team would be required to make improvements. Starting in 2009, hospital senior executives began a weekly routine of spending 1 to 1.5 hours with frontline staff in all areas of the hospital, inviting specific conversation and feedback about the staff’s individual safety concerns. Today, on a weekly basis, four leaders — from among a group including the CEO, COO, CNO, CQO, CMO, Senior VP Operations, and Senior VP of Human Resources — form two pairs and each visit a different area.

Safety Rounds

About a week prior to scheduled weekly Senior Staff Safety Rounds, all staff or providers in an area are invited to complete an abbreviated version of the 60-item AHRQ SAQ. Using a 9-item subset for staff or a 5-item subset for physicians, anonymous results are collected and tabulated in advance. The shorter survey instrument works well for physicians because physicians tend to show less interest in completing the questions prior to rounds and need less prompting to generate conversations about safety with hospital executives.

Bridgeport Hospital Senior Staff Safety Rounds - Improving Serious Safety Event Rate

  Click To Enlarge.

To create comfort and safety for staff, rounds are held on units, often in intimate spaces such as nurses’ break rooms, with the CEO and Chief Nursing Officer, for example, seated in a small circle with nurses, patient care techs, and unit-based clerical staff. Rounds with physicians may occur in small conference rooms or in physicians’ private offices.

During rounds, typically co-led by two hospital executives, collated results of the surveys are distributed and reviewed with participants at the time we sit down together. Conversation begins with the question: “Is safety ever sacrificed to get more work done?” All participants are provided aggregated results of responses from their area. Acknowledging that staff are experts in their domain allows for sharing of concerns with senior staff, who are less likely to be as connected. Sometimes provocative questions — beyond the survey questions as worded — help to stimulate conversation. For example, we may ask nurses, “Have you ever worked with a physician to whom you were not comfortable raising a concern?”

We have found that staff and physicians may initially be reticent to speak out, though some will start by saying, “This is not my issue, but a colleague who works nights has a concern.”

Conversations about patient safety between frontline staff and senior executives are not always natural. Leaders must listen carefully — and without flinching — to feedback.

Senior leaders have to swallow their pride and be prepared to graciously accept negative feedback — occasionally very negative. With almost no exception, showing respect to staff results in the same respect being returned — rather than a stream of complaints. Our CEO embraces SSSR as a best practice in engaging staff directly, and we believe that direct, regular face-to-face interactions improve our effectiveness as leaders.

The Art of Following Up

Sometimes, there is a quick fix for an issue. In one case, on the inpatient geriatric psychiatry unit, a nurse noted that patients with dementia can perceive dark-colored floor tiles as holes, and some patients had been observed to take pains to avoid stepping on them. Previously, the floor had been a patchwork of light and dark tiles — potentially terrifying to traverse. Within a month of safety rounds in which this concern was identified, floors were uniformly tiled. Staff now report that with uniformly tiled floors, patients walk more steadily than before.

Most issues, however, do not have such quick solutions. Both by hearing consistent direct feedback and by trending results, hospital executives noticed that handoffs and transitions were an area of concern. In 2011, only 48% of staff responded positively in the 9-item survey to the statement “There is good cooperation among hospital units that need to work together.” Mid-way through 2012, a formal project was initiated to bring together staff from inpatient units and the Emergency Department, with regular meetings and work groups that would last through 2015. By 2013, positive responses to this specific statement had risen to 60%, and the rate has been sustained close to 60% each year since.

Bridgeport Hospital Senior Staff Safety Rounds - Improving Internal Cooperation Scores

  Click To Enlarge.

Specific feedback about staffing concerns over many years throughout many parts of the hospital has allowed Bridgeport Hospital, a safety-net hospital with 32% of inpatient discharges covered by Medicaid — the highest proportion in our state — to invest prudently in ensuring staffing levels are adequate to provide safe care.

You Can’t Fix Problems You Don’t Know About

Issues that may be perfectly obvious to staff in one area are not necessarily on the radar of the executive leadership. A very busy outpatient department is located right next to a parking lot that had been restricted an underutilized. Staff suggested it be opened to their patients — helping their patients avoid a potentially risky street crossing — and within weeks, the change was made.

Focus on Areas of Change — Better or Worse

Dramatic changes in responses to a question usually hint at a backstory. Prior to initiating rounds, hospital leaders will review graphs of trending responses over 2 to 3 years. When SSSR was conducted in the Labor and Delivery area in January 2017, a precipitous drop in perception of staffing adequacy was noted on the statement of having “enough staff to handle the workload” from the 9-item survey — from 91% just 6 months earlier to 56%. Staffing became a major focus of conversation during rounds, and both staff nurses and the nurse manager highlighted that both the number of patients and acuity of patients had risen during the 6 months between surveys.

In response to the rise in number of patients and commentary from nurses about the strain of always being on call, leadership authorized the hiring of additional nurses. At the same time, the nurse manager developed a way to match nursing assignments with acuity of patients in labor. As a consequence of both of these improvements, nurses now get called in from home far less often. As of SSSR in February 2018, 85% of staff reported having enough staff to handle the workload.

Physicians Are Part of the Process

Physicians have the potential to set the tone around safety culture, either by promoting safety as a top priority through collaboration and responding to concerns or by displaying behaviors that may send the opposite message. Physicians are also keenly aware of potential gaps in patient safety through our work every day. Senior Staff Safety Rounds originally focused on hospital employees alone because medical staff were rarely available to participate based on scheduling and coordination of rounds by a nursing or administrative leader. Within the past 2 years, we have begun Senior Staff Safety Rounds specifically with attending physicians, residents, and advanced practice providers

Compared to other employees, residents at teaching hospitals typically have had less interaction, or even awareness, of senior hospital leaders. For attending physicians, our flexibility in time and venue are essential for participation; for example, we recently met a group of private practice orthopedists at their suburban office in the evening to conduct the Senior Staff Safety Rounds. We have just scheduled rounds with a group of obstetricians based on concerns voiced through a recent email.

The Impact

Senior Staff Safety Rounds have been a tangible way for senior leaders to demonstrate an ongoing commitment through regular face-to-face, structured conversations with staff and physicians, regularly addressing gaps that exist and closing at least some of them. SSSR now serves as the hospital executives’ public face of our hospital-wide safety program, implemented in conjunction with ongoing SSSR in 2013.

From the time SSSR began in 2009 through 2013, hospital-wide positive scores on “Overall Perception of Safety” improved from 45.4% to 65.5% as measured by the full AHRQ SAQ. Last measured in 2017, with more than 1,800 employees and physicians responding, the rate had risen to 70% hospital-wide, as SSSR serves as a critical component of the safety program.

The “Openness and Communication” domain in the SAQ results had risen from 49.7% in 2009 to 66.2% in 2013. As of 2017, responses in this domain were 72.4% positive.

“Management Support for Patient Safety” as measured by the same tool was first measured at 46% positive responses in 2009 and rose to 77.8% positive by 2013. As of 2017, responses in this domain were 79.1% positive.

Senior Staff Safety Rounds were started in response to a Sentinel Event impacting a patient. Although Sentinel Events occur rarely, preventable harm in hospitals across the United States has been shown to occur with unfortunate frequency (Kohn et al., 2000; Landrigan et al., 2010; Makary and Daniel, 2016). With SSSR serving as a major component of Bridgeport Hospital’s safety program, preventable adverse events resulting in moderate to severe harm or death have dropped by 86% from 2013 to the end of 2017.

Bridgeport Hospital Senior Staff Safety Rounds - Improving Key Safety Metrics

  Click To Enlarge.

To effectively address threats to patient safety, executives need to meet with frontline staff and physicians to thoroughly understand what risks to patient safety exist and how physicians and staff might lessen or eliminate these risks. But for these Senior Staff Safety Rounds to work, leaders need to shed any defensiveness and encourage honest input; they need to act promptly in response to the feedback to demonstrate that the conversations will lead to change; and they need to maintain and monitor survey results regularly, so that they can quickly detect any slippage and celebrate any improvement.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
odel for Complex Gynecologic Care Team at the Women's Health Institute

An Innovative Approach to Treating Complex Gynecologic Conditions

How the Women’s Health Institute at The University of Texas at Austin designed their clinic to provide comprehensive, team-based, and patient-centered care for women.

Massachusetts Community Health Centers Collaborative Teledermatology Process

A Teledermatology Initiative to Increase Access for Community Health Center Patients

A group of seven community health centers in Massachusetts collaborated to implement a teledermatology program that improved access to specialty care for patients with skin conditions and reduced overall dermatology spending.

Chang05_pullquote interpersonal medicine

Beyond Evidence-Based Medicine

Interpersonal medicine is not just about being nice — it’s about being effective.

Summary of Comprehensive Approach to Physician Behavior and Practice Change

Engaging Stakeholders to Produce Sustainable Change in Surgical Practice

How an initiative designed to improve patient outcomes and satisfaction while containing costs led to sustainable change in surgical practice and physician behavior.

Myths and Realities of Opioid Use Disorder Treatment.

Primary Care and the Opioid-Overdose Crisis — Buprenorphine Myths and Realities

There is a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done.

Coffey02_pullquote family-centered care in medical and surgical procedures

What If Family-Centered Care Were Extended to Medical and Surgical Procedures?

Though the concerns are valid, early experiences suggest that family member engagement may be an effective tool for improving the value of care.

Evidence Needed for Health Systems Change to Address Social Determinants of Health and Obesity and Diet-Related Diseases in Turn

Better Clinical Care for Obesity and Diet-Related Diseases Requires a Focus on Social Determinants of Health

To more effectively treat the problems of obesity and diet-related conditions, health systems need to restructure the traditional medical model of care delivery to address the social determinants of health.

People Living with Dementia Around the World - Value-Based Chronic Illness and Dementia Care

Value-Based Care Must Strengthen Focus on Chronic Illnesses

To effectively control costs and improve value, new models must address our increasingly older patients and chronic care patients, especially those with Alzheimer’s and related dementias.

The Barriers to Excellent Care Vary Widely Across Geographic Regions - both Rural Health Care and Urban Health Care

Survey Snapshot: Rural Health Innovations Born from Challenges

According to NEJM Catalyst Insights Council members, every health system has to develop its own definition of what is meant by “rural” health.

Same-Day Breast Biopsy Workflow at Baylor College of Medicine

How Care Redesign and Process Improvement Can Reduce Patient Fear

Seeing how clinicians take care of their own when they are in frightening situations was the epiphany that led to a same-day breast biopsy program.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


Quality Management

167 Articles

Coach, Don’t Just Teach

The effect of one-on-one communication coaching on clinicians’ communication skills and patients’ satisfaction.

Opioids Epidemic

23 Articles

It Takes a Health Crisis

Health crises often unmask deep, underlying disparities and disadvantage in the communities that health care…

Community Health Workers Are Critical

Community health workers really do need to be from the community.

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now