SafetyInsights.org

This explored the practice of walkarounds in the English NHS and how they have been implemented in practice and adapted to suit particular contexts and goals.

Data is via semi-structured interviews with 82 staff.

First, they cover background on walkarounds and use in healthcare.

The intended benefit is to “bring together the “sharp end” of care delivery at the front line with the “blunt end” of organizational leadership and administration”, thereby “emphasizing connectivity between different levels of the organizational hierarchy” (p2). In principle, walkarounds should “, translate into multiple small-scale improvements tailored to frontline staff’s needs” (p2).

A particular iteration of walkarounds for healthcare was said to be in use – and the initiative is what the authors call the “espoused model”; that is, the work-as-imagined initiative.

In practice though research on the validity and benefits, at least in healthcare, are said to be mixed and patchy. Other recent work has challenged claimed benefits of walkarounds suggesting “that in practice they may have perverse, unintended effects” (p2), for instance walkarounds:

• may reinforce existing power differentials rather than flattening organisational hierarchies and empowering frontline staff
• may encourage staff to “be on their best behavior” during executive walkarounds and thereby provide inaccurate pictures of reality
• may become more exercises of “public relations” that “overshadows other functions” (p3) and highlight things that managers may commit to fixing but not act on
• have been described by some staff as “disruptive “seagull management,” in which managers “fly in, make a lot of noise, dump on everyone, then fly out.” (p3)

The authors highlight that espoused (WAI) concepts of walkarounds may be at odds with the actual enacted (WAD) iterations of walkaround initiatives, and just how walkaround initiatives are adapted and distorted needs further research; which this study sought to address.

Results

Given the richness of results, I can only provide a few points. A quick summary of key findings before I dive in are:

• Local and pragmatic adjustments to walkarounds “could radically alter its character and the way in which it is received by those at the front line (p1)
• The modifications and expansion of walkaround initiatives to increase the scope could increase the value that executives and managers draw from them but “risks replacing the main objectives of walkrounds—specific, actionable knowledge about safety issues, and a more positive safety culture and relationship between ward and board” (p1)
• And because of the unintended consequences of managers expanding walkaround scope, they risk replacing an engagement activity with “a form of surveillance that could alienate frontline staff and produce fallible insights” (p1).

Managers emphasised their view of the benefits of walkarounds. For them it meant an “unparalleled” means to hear about challenges that frontline staff experience. It enables them to hear and observe insights and awareness of issues that standard metrics cannot deliver – and to fast-track the resolving of issues which could sit in their in-tray for months.

Several iterations and modifications of walkarounds were observed by participants. One change was from a rather pure engagement activity to one of policy complicity and regulator expectations. In these instances, walkarounds “started to resemble opportunities for surveillance and audit rather than opportunities for engagement” (p6).

Pragmatic Adaptations—Or Distorting Deviations?

Frontline staff appreciated the value of informal chats with executives. However, besides direct observation and discussion with frontline staff, “some executives even went as far as explicitly “going behind the backs” of frontline staff, again, ostensibly to obtain a more accurate picture of the realities of care than they felt they could achieve through conversation alone” (p7).

For executives, this modification allowed them to, in their view, get closer to the “truth” and observe work, routines etc. by walking around in their own time, on their own, without a chauffeur. In some cases these visits were unannounced and allowed a more “unsanitised” version of insights.

For frontline staff however, these came across as surveillance activities and a different experience compared to the espoused model of walkarounds, meant to be about open communication and a blame-free environment. Staff saw the free roam executives and unannounced visits more as big brother watching over them.

In contrast, walkarounds focused on transparency and conversations were received more positively.

This example highlights that walkarounds “shifted away from conversation and toward inspection” (p8). This then generated a sense of subjection and distrust for staff, seen to be “at best unhelpful, and at worst counterproductive” (p8).

Further, the “unsanitised” view executives got from their free roam and unannounced visits were felt by staff to provide them with, in actuality, an illusory and inaccurate picture. The view executives received would rather be very select windows inherently incomplete and absence of the complexities of real work. Instead, by expanding the scope of walkarounds executives “risked creating an intervention that was fit for neither purpose” (p9).

That is, “repurposing walkarounds” could undermine the main objectives of walkarounds and inhibit the promotion of an open and trusting environment.

Other issues related to environments without adequate trust where staff would not open up, or provide glossier “window dressing” responses on what they think the manager wanted to hear.

Enhancing Walkrounds

The authors note that not all alterations to walkarounds led to unintended consequences. A more promising approach for gleaning insights and inculcating a more open and trusting environment seemed to be an approach where all of the parties embraced the values and nature of walkarounds.

That is, executives actively worked to ensure all parties “were aware of the purpose of the conversation, what was to be covered, and the “terms of engagement” governing the encounter” (p10).

For environments where openness between staff and executives wasn’t the norm – ensuring all parties understood the purpose of walkarounds and were given full transparency and aware that the core goal was about learning “not about censure” was even more pertinent to achieve the intended goals of walkarounds.

In these environments, adapting the approach for executives beyond the sample “script” of questions etc. was more important. One participant noted that their iteration of walkarounds were not rigid in structure but rather focused on encouraging discussion.

One adaptation was “putting the shirt on”, where executives put on a blue uniform with their named stitched on for their walkarounds; ensuring people were aware whom from the executive was in the ward and when [*** in construction these blue shirt approaches are often called “shiny arses” for the new and shiny high-vis shirts that are often worn by managers.]

In wrapping up feedback from participants – surveillance-oriented walkarounds were “inherently premised on a relationship of distrust that put executives in the role of checking up on frontline staff—and correspondingly, enjoined frontline staff to hide, to cover up, or to present false assurances” (p10).

In contrast, walkarounds focusing on discourse and relationships developed trust where “executives and frontline staff could have frank conversations with one another (p10). This, however, sometimes required beyond the standard walkaround script to reveal “the “privileged” nature of the conversations, and the terms of engagement that governed them” (p10).

They note of course, that both approaches could still lead to concealment from staff – but an approach predicated on surveillance “made concealment the natural choice” whereas an approach based on framed conversations provided a more likely possibility of developing more mature relationships.

Discussion

The authors then discuss the core findings. They note that surveillance-oriented walkarounds take on the guise of engagement walkarounds in the sense that they focus on conversations with frontline staff; but they then take on additional forms of intelligence-gathering, like concealed observations of practice.

Instead of being about trust, relationships and open discourse, walkarounds can become initiatives where “making staff feel monitored and sanctioned” and shifting the focus to “checking up on, rather than listening to, staff “(p11); undermining the core objectives of walkarounds.

Furthermore, it’s highlighted that this expansion of walkarounds may thwart “authentic insights into frontline realities [that executives] seek” (p11). Thus “By reproducing an atmosphere of distrust, they risk making concealment the natural choice for frontline staff” (p11) and the act of a walkaround actually becomes “self-defeating”.

However, importantly, engagement-focused walkarounds are also no “no panacea; no matter how faithfully deployed, it too is limited in what it can achieve” (p11).

Finally, it’s argued that:

• “executives recognize walkrounds for what they are—a constructed, imperfect, and partial account of the challenges of quality and safety and the chance to demonstrate commitment to learning and improvement rather than a magical window on the ward that reveals what is hidden by other methods” (p11)
• Executives aren’t always good at creating the right environments or using the insights garnered from walkarounds appropriately.
• Importantly, “Good intentions must be borne out by good faith in the way that executives use the intelligence produced by walkrounds” (p11)
• Considerable care must be taken for how walkarounds are implemented and executed. For instance, the authors argue that walkarounds should be clearly differentiated from interventions like observation audits if “their potential to broach frank discussions of delicate issues is to be retained” (p11).
• With each modification to walkarounds, executives should ask themselves if the changes will foster trust or reinforce suspicion; or whether these changes will enhance the intel on improving work for staff or risk breaking trust with employees in order to maximise their own goals.

Authors: Martin, G., Ozieranski, P., Willars, J., McKee, L., Charles, K., Minion, J., & Dixon-Woods, M. (2014). The Joint Commission Journal on Quality and Patient Safety, 40(7), 303-310.

Study link: https://doi.org/10.1016%2Fs1553-7250(14)40040-0

Link to the LinkedIn article: https://www.linkedin.com/pulse/walkrounds-practice-corrupting-enhancing-quality-study-hutchinson