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.
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.
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.
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.
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.”
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.
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.
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.
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.