Hospital leaders create strategic plans for their institutions, ideally based on the best information available. These plans are often carried out with a command-and-control type of leadership, where the executive relies on second-hand information and written reports to understand performance. However, quality improvement experts have begun to realize that many leaders are actually too insulated from “facts on the ground.” Conventional wisdom might rely on vertical chains of command for knowledge, but this often doesn’t fully capture what is happening on the frontlines of patient care. Many effective senior leaders have decided that the best way to gain a thorough understanding of their hospital is to connect more directly with frontline staff, care delivery processes, and patients themselves.
Executive Rounding is a tool which allows senior leaders to further engage executives with “the trenches” and demonstrate, that even at the highest levels of the organization, the hospital is committed to solving issues and improving the experiences of their patients and customers. It requires senior leaders to rotate through the hospital cyclically and engage with staff, patients and visitors alike. The feedback they gather provides important insights into what is working well and reveals opportunities for improvement. It also ensures that any operational issues are quickly addressed.
It is very similar, in many respects to the popular and effective Lean tool of a Gemba Walk. A common tool utilized in many industries that are pursuing continuous improvement and performance excellence, the Gemba Walk is designed to allow leaders to identify existing safety hazards, observe machinery and equipment conditions, ask about the practiced standards, gain knowledge about the work status and build relationships with employees. The word “Gemba” is a Japanese term meaning the real place where value is created and the actual work is done, i.e. the shop floor in a manufacturing plant. The aim of a Gemba Walk is to provide the leader with the opportunity to observe floor activities as they happen and ask questions about them, thus becoming more aware of what is going on in the organization. As part of the Kaizen (improvement in Japanese) philosophy, managers are encouraged to “Go, See, and Observe” the work processes for themselves at Gemba in order to gain a better understanding of their operations.
The goal of Executive Rounding is very similar. It allows senior leaders to gain exposure to the day-to-day environment of the hospital while also demonstrating to patients and front line staff that their experience is valued at the highest levels of the organization. In the Gemba, managers are primarily concerned with relationships to the employees, while Executive Rounding additionally seeks out patients to gain input about their experiences.
The idea is that senior management of the hospital, routinely “round” or cycle through various areas of the hospital or an organization to interact with patients and staff in those areas, to discuss their concerns or frustrations as well as successes. In our example below, the executives round various areas of the hospital system in a 2 week cycle.
Whenever conducting rounds, it is important to learn to view the hospital from the patient’s perspective. For example, something as simple as outdated lighting fixtures can affect the perception of an entire organization. Speaking directly with patients can provide an understanding of what is working well and issues that need to be addressed. While in the area, it is beneficial to watch how work is actually performed. Often, a large gap exists between comprehending a process on paper and understanding it in reality.
In the process of rounding and after meeting patients, the leader should also meet the area staff to discuss his or her findings. It is important to correct observed problems on the spot wherever possible. It is also crucial to focus on the positives and celebrate jobs well done. Whether directly observed or informed by a supervisor, publicly acknowledging exceptional deeds can improve the work environment.
After rounding, the leader will utilize an online survey reporting system to input survey results and feedback from his or her experience. Those results are then automatically tabulated and reported monthly to all senior leadership. Any negative trends can be discussed in the appropriate forums.
Some of the many benefits of Executive Rounding include
A major public and largely government-funded hospital system in 2011 underwent a review by the Center for Medicare and Medicaid services (CMS). CMS is a federal agency that administers the Medicare program and works in partnership with state governments to administer Medicaid. Medicare and Medicaid are two governmental programs that provide medical and health-related services to specific groups of people in the United States.
Medicare is a national social insurance program that uarantees access to health insurance for Americans aged 65 and older and younger people with disabilities. Medicaid is a medical services program for certain individuals and families with low incomes and few resources. Per this review by CMS, the hospital system found itself in a position where it needed to quickly demonstrate that it was committed to making changes in many areas, including patient safety and quality of care. To achieve this, the hospital entered a Systems Improvement Agreement with CMS by the end of 2011.
As a part of that agreement, the hospital was forced to realize and embrace wholesale change in the mindset, operations and culture. The hospital developed and quickly began implementation of a Corrective Action Plan (CAP) that not only required specific improvement in many facets, but also great cultural change, and demonstrated sustainability throughout the hospital system.
This cultural change required an environment of personal accountability for all hospital employees, managers and physicians. Personal accountability meant that everyone was focused and working together to create a safe environment in which high quality patient care could be delivered. At this hospital, executive leadership looked upon the CAP as an opportunity to implement systems and performance improvements to create sustainable change within the organization and secure their future as a leading health care institution.
As a tool to drive this culture change at even the highest levels of the organization and breed communication between executives, staff and patients who work and experience hospital processes every day, an Executive Rounding initiative was included for implementation.
The implementation was phased in two parts. First, a crossfunctional team was assembled for design and implementation. The team continued with the creation of the program and decided to roll it out for an 8 week pilot period. During that time, they captured metrics and conducted interviews with leadership participants to talk about their experiences and how the program could be improved. The team then rolled out a new and improved Executive Rounding program in Phase 2 and a system for continual update and improvement.
The first step to creating an effective executive rounding program is to develop a standardized patient survey that still encapsulates the patient’s needs and cares. The survey that was developed for the pilot unfortunately did not meet this goal. As mentioned, the hospital was operating in a climate that was highly reactive to the regulatory violations they were dealing with. A survey that was focused mainly on patient rights and patient safety was the result and while very crucial and important, it was not the first thing on the minds of the patients.
In phase 2, a cross-functional team was set up to include both clinical and operational resources. By leveraging the lessons learned throughout the pilot phase and feedback received, the team was able to create a survey that was much more aligned to patient needs, covering factors such as service times, quality of care, and environmental issues in the hospital. This survey engaged patients and enabled executives to have more beneficial conversations with patients and staff in their rounding areas.
Another major change made to the survey was to allow a much less structured approach to the interaction with patients. To do this, the survey included some open text questions whereas the majority of the other survey questions have a yes or no answer option to make tracking of survey results easier. An example of an open text question regarding patient experience could be:
If we could make one thing easier for you at this institution, what would it be?
To ensure that feedback from this question was captured, a section of the survey input system known as “Executive Feedback Page,” was created, where the individual conducting the survey was able to input specific feedback in the form of text for the leaders in the area that was rounded.
This feedback was forwarded directly back to the leadership in the area for action. The page also included a section for the user to provide feedback on the executive rounding process, suggestions for enhancements, etc. thatwould filter back to the owner of the Executive Rounding initiative.
The survey was not the only change that was instituted in Phase 2 of the implementation. When the hospital developed the schedule for the initial implementation, it was done in haste. Besides the survey, this was one of the largest areas of concern received through the feedback gathered during the pilot. Executives were concerned with rounding in areas that they weren’t familiar with. By more aptly pairing executives with areas or responsibility, certain benefits were gained. This ensured better communication with staff members that they were familiar with but also allowed them to speak more aptly to patients and visitors about their concerns as well as any improvement projects that were in process within the department.
Many other changes were implemented in Phase 2 as a result of feedback garnered during Phase 1 of the implementation. The entire survey input and reporting system was moved from a homegrown system stored on the local intranet to a newly implemented survey tool at the hospital, entitled Select Survey. This survey tool was much friendlier and easier to navigate and allowed substantial streamlining of the survey process. This new survey tool also facilitated several other changes that were of great benefit.
Because different types of patients could be surveyed during a rounding session, it was important to have customized surveys for both inpatients and outpatients, so that the executive could speak to a visitor whose experience was completely different to that of a patient. The new system allowed the executive to easily select the survey that was most appropriate to his or her interaction, instead of having to use one generic survey for all interactions.
The hospital was located in the southwestern part of the United States and a large percentage of the patient population was of Hispanic descent. It was important that they had a voice within the Executive Rounding process, which meant that it was crucial that the executives were able to interact with Spanish-speaking patients and visitors. A Spanish version of the survey was created that could be used whenever appropriate. This form was meant to be provided to interviewees where a language barrier existed. It could then be entered back into the Executive Rounding Survey. Also, executives were encouraged to utilize translators that were available in each area of the hospital when more conversation was desired and the resources were available.
Based on feedback that executives had no standardized way to ensure that patients and visitor input was valued and utilized, a simple business card was created that could be passed to the survey participant after the conversation. This card gave them a number to contact at Patient Relations if they had further feedback or did not see improvement to any issues they might have had. It was also an additional method to give patients and family members a way to communicate about their experience.
One of the biggest struggles to overcome early on was participation. It was very important to the hospital’s Chief Operating Officer that the executives were actively participating and understanding the impact that this initiative could have for the hospital, so, in addition to participation metrics that were to be distributed monthly, other avenues were attempted to stress the importance and the impact that rounding could have. The hospital’s internal publication was utilized to market the initiative not only to other executives, but also to let the hospital staff knows that they should be looking for rounding taking place and urging them to provide feedback. During phase 1, select executives were engaged to write testimonials on their experiences to be published in the weekly publication.
Several other improvements were also made, such as an email box specifically for Executive Rounding that was monitored routinely to address any questions which came up about the process or as a place for executives to communicate their concerns and comments about the program. Automated email reminders were set up and sent to executives, encouraging them to complete their rounding assignments in line with the chedule and to try and enhance participation. An e-learning course for new executives was introduced and held during their on-boarding process, to familiarize them with the program and the surveys.
Furthermore, a monthly reporting system of survey results was set up to be reported and communicated not only to the COO but to all members of the program. These communications were distributed in the form of a scorecard and included multiple metrics, such as executive compliance (participation) as well as a list of all non-compliant executives. This list was communicated directly to the COO, who was highly committed to ensuring that everyone was participating. The scorecard also listed survey results distributed between Yes, No, N/A for each question and survey participant type – inpatient, outpatient and visitor. The comments and feedback in each of the areas were also collected and distributed on a monthly basis for each survey participant type.