The publishing of the Francis Report in 2013 on the tragedy at Mid-Staffordshire NHS Foundation Trust rang alarm bells in healthcare around the world.
The report showed that a hospital could appear to meet performance targets while concealing appalling standards of care.
One of the problems identified by the Francis Report was that senior management at Mid-Staffordshire was not listening to patients and their families, or to staff. Despite continual signs of dissatisfaction in staff and patient surveys, no action was taken. Leaders were distanced from what was happening on the front lines and did not fully understand the reality of care being provided to patients.
Leaders at Counties Manukau District Health Board (CMDHB is also known as Counties Manukau Health or CM Health) were left wondering if a similar tragedy could happen in their organisation. CM Health routinely gathered quantitative data under its Patient Safety Framework – including the incidence of falls and pressure injuries and hand hygiene compliance rates – but the Francis Report proved that this sort of data didn’t tell the whole story. CM Health decided it needed to gather different information about safety in its wards and units, and this information needed to be from the points of view of staff, patients and patients’ families.
In early 2014, a collaborative team led by clinical nurse director Jacqui Wynne-Jones created the Patient Safety Leadership Walk Rounds. In the fortnightly Rounds, a team of six staff, including at least one member of the executive leadership team, visits a Middlemore Hospital ward or unit. (There are plans to expand the Rounds into CM Health satellite clinics.) The Rounds team uses three qualitative tools to assess how safe the ward is and capture the experience of staff and patients on that ward (see ‘Qualitative Safety’ box).
Tools to help assess patient safety
The first of the tools used during the fortnightly Rounds is ‘First 15 Steps’, adapted from a National Health Services (NHS) toolkit called ‘The 15 Steps Challenge’ that assesses how safe a ward is based on first impressions of the ward environment. The development of the NHS toolkit was sparked by a comment from the mother of a young patient in an NHS hospital: “I can tell what kind of care my daughter is going to get within 15 steps of walking onto a ward.”
The other two tools are a patient experience questionnaire and a staff experience questionnaire that each comprise 10 questions. The patient experience questionnaire also contains a scale to measure how patients feel about ward processes, routines and interactions with staff.
Wynne-Jones brought together a range of leaders and advisors to co-design the questionnaires. Further staff and patient input was also sought.
Keeping leaders in touch with the front line
The Francis Report warns of the dangers of healthcare strategic and operational leaders becoming distanced from the reality of everyday care. Patient Safety Leadership Walk Rounds are regarded as a mechanism for CM Health leaders and other staff to see first-hand the care provided on the wards, and to hear the voices of staff and patients.
Wynne-Jones’s team contacts charge nurses the week prior to the visit to inform them about its purpose and background. The visiting team of six is made up of a consumer, clinical leaders, heads of departments, clinical directors, senior medical officers and members of the executive leadership team. During the Rounds two of the leaders assess the ward using the First 15 Steps, while two interview patients and two interview staff. Leaders typically interview about three people each per visit.
The team tries to speak to a cross-section of medical, nursing and allied staff and does not collect personally identifiable information during interviews. The Rounds were developed using PDSA (plan, do, study, act) cycles, with the aim of being perceived positively rather than as a specific mechanism for ‘checking up’ on staff.
Celebrating what’s great and improving what isn’t
At the end of each walk round, leaders produce a summary identifying what they saw or heard that was great about the ward, and what could be improved. The summary, along with a copy of the completed tools and notes, is supplied to the ward charge nurse, head of department, service manager and clinical nurse director within 24 hours. Also supplied is a facility for wards to track improvement actions and to request support. Wynne-Jones’s team also keeps in touch with wards.
Sometimes intervention to resolve problems is more direct. “We feel very responsible when we interview patients. We have to be careful that we don’t just open up an emotional wound and then walk off and leave them. So if there is a specific complaint, we discuss this with the charge nurse or help the person to access the complaints process if they prefer this option,” says Wynne-Jones.
The Rounds also often help staff to identify and address isolated problems. For example, one Rounds visit provided traction for a charge nurse to obtain some long-needed documentation privacy cupboards that the ward’s budget could not cover. With assistance from the director of nursing, Denise Kivell, surplus cupboards were located elsewhere in the hospital and moved to the ward that needed them.
However, responses are often broader. Clutter was noted as a problem in a number of ward environments during Rounds. As a consequence, Kivell made a formal request for refresher training in 5S Workplace Organisation methodology for these wards to improve their environment. Interestingly, clutter was less of a problem in wards with strong leadership.
Strong leadership, good communication and systemic issues
The Rounds repeatedly reinforce the importance of leadership development on wards. “We are seeing best practices where there is strong leadership,” says Wynne-Jones. This has led to the creation of a new programme for charge nurse managers on clinical quality leadership that is informed by learning from the Rounds.
Patient Safety Leadership Walk Rounds act as a vehicle for spreading good practice and new ideas, particularly around communication, with the need to improve communication being one of the strongest themes to have emerged.
There is also helpful evidence about the effectiveness of communication tools, such as hourly vigilance rounds, huddles and bedside handovers involving the patient in the plan of care. This feedback was given to a rehabilitation ward that had changed its model of care to accept post-op orthopaedic patients earlier due to the ERAS (Enhanced Recovery After Surgery) Programme. This patient population is at high risk of falls. Following recommendations by the Rounds team, the ward’s charge nurse manager developed a team nursing model that included a walk-round handover and huddles to improve safety.
Some issues identified, such as after-hours staff shortages, are systemic. Kivell informs the CM Health board of systemic issues emerging in the feedback across wards. In this way, qualitative input from patients and staff complements other evidence used to guide the development of CM Health policies and processes. For example, feedback from the Rounds is helping to inform the development of a workload planning and acuity tool for CM Health (see box 1 for more information).
The approach with staff is one of ‘appreciative inquiry’ – Rounds aim to learn, support and encourage, not to find fault (see box 2 for staff feedback).
“All the charge nurses have fed back afterwards that staff appreciated us listening to them,” says Wynne-Jones. “And the patients love it, because they love someone to talk to them about these important aspects of care. People are asking us when we’re coming to their ward!”
The Rounds link with other initiatives at CM Health designed to improve the design and delivery of services. Most importantly, the Rounds complement the Patient Safety Framework, providing qualitative feedback from staff and patients on the wards.
“If there is a mismatch between what the data tells us around safety and what the narrative from patients and staff tells us, then that is an alert to us,” says Bev McClelland, organisational development consultant. The aim is to ensure no tragedy like Mid-Staffordshire happens at CM Health. ✚
- Jacqui Wynne-Jones is clinical nurse director, surgical and ambulatory care services, at Counties Manukau Health (CMH).
- Dr Lynne Maher is director for innovation at CMH’s health education and improvement hub, Ko Awatea.
- Bev McClelland is an organisational development consultant at Ko Awatea.
Francis R. (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry: Report of the Mid Staffordshire Foundation Trust Public Inquiry. Available at:
NHS Institute for Innovation and Improvement. The 15 Steps Challenge. 2006–2013.
Rounds: NZNO feedback
It is still early days but staff are happy the Rounds give them the chance to talk directly with senior management, says Deb Chappell, one of the New Zealand Nurses Organisation organisers working with CMDHB staff.
“At the moment it is working well. Our staff are liking it because they [senior management] are actually talking and engaging with staff on the floor – they are not just coming through and talking to the charge nurses and the patients,” says Chappell.
“In the past, senior management would come into the ward but they would normally go straight to the charge nurse and that’s where the conversations would begin and end.”
Chappell says with Rounds still only a new initiative staff are a little wary over how long it will be maintained, but hope it continues as a way for staff to engage with DHB management, particularly as Middlemore is a very busy hospital and members were feeling the increased strain.
Workload planning: CMDHB and Care Capacity Demand Management Update
Counties Manukau was one of three demonstration sites in 2009 for the joint union/district health board Safe Staffing Healthy Workplace (SSHW) Unit, but is yet to come on board with the safe staffing tools the unit has evolved.
The set of tools – known collectively as the Care Capacity Demand Management (CCDM) system – require a ‘validated patient acuity tool’ and were built using the patient acuity software TrendCare, which the majority of DHBs now have, but Counties Manukau and three other DHBs do not. During last year’s New Zealand Nurses Organisation/DHBs MECA talks the NZNO sought and gained a commitment from DHBs to implementing CCDM, including a “timely response” to when the safe staffing tools data show the need to adjust staffing levels.
Denise Kivell, director of nursing at CMDHB, says the DHB is planning to introduce the CCDM tools by seeking validation of its existing McKesson rostering system. She says it keeps SSHW unit director Lisa Skeet up-to-date with the DHB’s plans – including Skeet sitting in ex-officio to governance meetings – and is working with Waikato DHB, which has the same system.
Kivell says the board’s first step will be rolling out the CCDM workload tool with its McKesson Rostering system and the next step will be gaining validation for the rostering system and this would lead onto the rolling out of other CCDM tools like the staffing base design and the responding to variance tools.
Asked by Nursing Review what current safe staffing measures the board has, Kivell says it has had a capacity planning tool, CAPPLAN, for many years and its data is currently around 95–97 per cent accurate. She says this data is used in combination with daily charge nurse manager meetings and a 15-minute midday ‘huddle’ of all services that provides a bed management and staffing update. Also Middlemore Central (the hospital’s integrated centre) provides bed and staffing management oversight and the hospital’s web-based ‘dashboard’ is updated every 15 minutes. She says the Rounds feedback provides the ‘reality factor’ of what is occurring on the ward from the patient and staff perspective.
The qualitative safety assessment tools
The First 15 Steps:
- Using my senses – what can I hear, smell, see, feel, touch?
- How does this ward make me feel?
- What is the atmosphere like? Is it calm? Chaotic?
- What interactions are there between staff/patients/visitors?
- Is there visible information that is useful and reassuring? What is it?
- What have I noticed that builds my confidence and trust?
- Is essential information about each patient clearly visible?
- What makes me less confident?
- Do storage rooms look well organised and clean?
- Are areas well maintained?
Things to look out for:
- Welcoming reception area
- Clear signage
- Acknowledgement on arrival – eye contact, smiles
- Information available, clear and visible
- Contact information for relatives and visiting times
- Information about who the staff team are
- Is there evidence that the ward is disabled accessible?
The Experience of Staff:
- How did you feel about coming to work today? How do you feel now you’re here?
- What would you like to see changed that would support you more?
- What stops you providing the safest care?
- Is this ward safe 24/7? Does this ever change and if so can you tell us more about when and why?
- What patient safety initiatives are happening on your ward?
- What do you consider are the biggest risks to patients and their safety on this ward?
- How would you feel about your grandmother or close relative being cared for in this area?
- How useful do you find the Patient Safety Measure boards?
- Tell me about the last incident report you submitted?
- Are there any further comments you’d like to make about anything we haven’t touched on?
The Experience of Patients
- When staff are with you, how does this make you feel?
- How are you kept informed about your treatment? Do you know your plan of care?
- Do you know your nurse for today?
- How safe do you think this ward is? What would make you think this ward is unsafe?
- When you have your visitors, family and caregivers come to see you what things about the ward and your care have they commented on?
- What stands out on this ward? Is there anything that makes it special?
- How do the days compare to the evenings and nights?
- Is the care we provide responsive to your cultural needs?
- Do you feel safe when mobilising? When going to the bathroom?
- Do you see staff sanitising their hands before and after being with you?
*Scale not included.