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Executive Walk Rounds in Ambulatory Sites


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Executive Walk Rounds in Ambulatory Sites

By Tom A. Augello, CRICO

Related to: Ambulatory, Communication

Bringing senior executives to outpatient sites for patient safety.


  • Robert Goldszer, MD; Brigham and Women’s Hospital; Boston, MA
  • Doreen Thomases, CPH; Brigham and Women’s Hospital; Boston, MA


A technique for using senior hospital executives to improve patient safety is proving so successful that one hospital in Boston is now applying it to ambulatory sites.

Executive “walk rounds” is the name given to the practice, which Brigham & Women’s Hospital in Boston started several years ago for inpatient units. The CEO, chief financial officer, and the heads of nursing or medicine visit the front lines routinely with patient safety officers to learn from providers about ongoing threats to safety.

Dr. Robert Goldszer is associate chief medical officer and director of primary care at Brigham & Women’s.

“The ambulatory setting is different in that we really are focusing on a different process and typically less equipment-related things. In our inpatient units, there was a lot of equipment. There are monitors, IV poles, and things like that, so in the outpatient unit it is really focused a little bit more on processes, cleanliness, things we can do with the computer system for the patients, how we can make the patient flow a little easier, a little safer for the doctors and nurses…”

One of the keys to success, according to Dr. Goldszer, is to be very flexible. They try to work around the activities of clinicians and staff, and give the office plenty of notice ahead of time.

“Usually it is two or three people who do walk rounds with the walk round team and then we pull people from the different places. So that might be the office manager, the physician leader or the nursing leader as a team on walk round with the senior leader, with the patient safety team, so it will be about 5 or 6 people walking around. We usually are pretty mobile and flexible so we don’t get in the way too much. Then we pull in people from the different units so if we are in the ambulatory lab, we will talk to people from the lab. If we are in a place where the nurses are and the physicians are, we will talk with the physicians or nurses, and being very respectful of people who work there, obviously, and respectful of their time and their work.”

Doreen Thomases: “We felt that a lot of the errors that take place and near misses actually do take place in the ambulatory setting.”

Doreen Thomases is the hospital’s ambulatory patient safety manager. Thomases says more and more providers appreciate the complexity of inpatient care. But the outpatient setting has become increasingly complex as well.

“One of the areas has to do with medication safety, and a lot of research has been done on medication safety and we felt that it was time to extend the efforts to our primary care practices. It could be prescribing errors; it could be transcribing; it could be communication not done properly between patients and physician and maybe referring physicians. And with the primary care physician being the gatekeeper, there are a lot of questions going on too with complex medical patients. Perhaps they had an oncologist, perhaps they had a dialysis physician, and were the communications properly taking place between all those participating physicians?”

As the senior executives and patient safety staff probe during the walk rounds, they try to focus their questions. Often they begin by asking if there is anything that concerns you on a daily basis or keeps you up at night that makes you feel like patients aren’t getting care in the safest manner possible. Thomases says they like to address communication issues. Where are the obstacles that the walk round team can help the outpatient site overcome?

“If they are having difficulty with radiology or whatever the department might be, do they feel comfortable that they can speak to the director of radiology? Say in our practice we have had five examples where an X-ray wasn’t read in a timely manner, we never got a final read. They find out that it is actually a problem not only in their individual practice. There are two other docs that they work with that have the same problem. And maybe it’s time to bring it forth, you know, through the patient safety team to actually facilitate a meeting between radiology and the group and see how we can remedy the situation.”

Walk rounds are supposed to bring information to executives who can make changes. But information can also flow the other way. The ambulatory setting has disadvantages for patient safety that walk rounds can address. Inpatient units have been exposed to considerable discussion and initiatives for patient safety improvement. But Thomases says fewer practitioners in the outpatient setting think patient safety applies. Outpatient staff don’t have the kind of reminders and convenient education or lecture opportunities on patient safety themes that are readily available on inpatient units. Individual roles are less explicit. According to Thomases, walk rounds can re-create for ambulatory sites the kind of learnings that get shared more easily from one unit to another in the hospital.

“I go to three primary care practices, and we find that they have mistakes generated because a physician’s initials are misread on a laboratory requisition. We then found out in one of the practices that all the physicians have a stamp with their initials and signature. So now when we go to sites, when this comes up as a problem that yes, we have results that don’t come back to us or they go back to the wrong doctor, we ask, ‘Do you print it? Do you have a preprinted form?’ And we have now shared with the practices that it might be a good idea to have preprinted forms with physicians’ names and initials on it, as opposed to using signatures. So we can transfer that information now and we’re the conduit of that information as opposed to they never had that kind of sharing before in the ambulatory sites.”

Another example of an improvement that came from ambulatory walk rounds involved the timely communication of diagnostic imaging results.

Dr. Goldszer: “A perfect example is a recent one in endoscopy. In our outpatient endoscopy unit, where patients come for colonoscopy and sigmoidoscopy, have cancer screenings, one of the things that we were concerned about was how the doctors and nurses communicate the results back to the patients. That was brought up on safety rounds, discussed, brought up through the systems. And now we have a better way of the physicians using a template, computer notes, that they will have e-mailed to the primary physician, be saved in the computerized medical record, as well as having results in what’s called our health maintenance section. So that the referring physician can look in the health maintenance section to see exactly when a colonoscopy was done. Those things were being worked on but were brought up again on safety rounds and were moved forward more quickly.”

The hospital is measuring the success of this particular intervention by creating baseline data before the change, and measuring again to see if there is any improvement.

Dr. Goldszer says feedback to the personnel who had offered suggestions is critical to the acceptance and ongoing success of walk rounds. They have to see this leads to a change or at least was heard and considered at the highest levels. Dr. Goldszer says the effects of senior executives hearing concerns from the front lines is beginning to change the culture to one where people increasingly think about processes and reducing errors.

He says walk rounds are gaining popularity because it is not expensive and it generates real results for patient safety.

“For physicians, I would say no matter what office environment you work with, whether it’s a one-person practice, two person, ten person, larger practice, it’s something to consider doing. It’s a matter of taking time, listening to staff, listening to people who are working with the patients. Gee, what are you worried about? What are you concerned about? What could make it a safer environment? Because that’s a huge quality improvement, and there are many benefits, quality improvement. Risk management is one piece, but just having more pleased patients leads to growth, having more pleased and safe staff leads to staff retention, so there are many, many benefits of this that are very, very helpful.”

September 1, 2005
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