Background

In 1999, the Institute of Medicine published the report "To Err Is Human"1 that emphasized the importance of improving patient safety in hospitals. The report estimated that as many as 98,000 people in the United States of America died from preventable medical errors in any given year.1 Based on the report, patient safety became a global healthcare issue, and in 2000, the Institute of Healthcare Improvement2 established a group of patient safety experts to develop an ideal medication system.3 They specified strong commitment from senior leadership to a culture of safety as an important element in the medical system. Similarly, the Joint Commission4 has required hospitals to create a culture of safety since 2002. The accreditation process regarding patient safety standards is focused on educating staff and leaders on identifying and managing patient adverse events and measuring performance improvement.5

Since 2003, hospitals have conducted Patient Safety Leadership WalkRounds(TM) (PSLWs) to improve patient safety and to create a culture of safety.6 Patient Safety Leadership WalkRounds is a systematic approach to patient safety that provides an informal method for hospital leaders to talk with frontline staff about safety issues.6 In 2003, Frankel et al.7 described the format for PSLWs, suggested questions to ask staff and indicated which senior leaders should participate in PSLWs.7 Patient Safety Leadership WalkRounds are conducted in clinical departments with participation from three to five staff members and senior leaders.3 The recommended frequency of PSLWs is once per week, for a minimum of one year, and the conversation consists of pre-defined questions about patient safety in the specific department.3 The conversation can be structured in various ways, for example, hallway conversations, individual conversations and conversations with staff in a specific function.3 After each PSLW, the senior leaders prioritize patient safety issues with the staff, and actions taken are shared throughout the hospital department.3,7

During PSLWs, senior leaders signal commitment to patient safety by frontline staff.3,7-8 The formalized concept of PSLWs supports the creation of a culture of safety and the learning element in accreditation.8 There are similarities between the organizational approach of PSLW and the educational approach of mentorship.9 Both approaches are related to accreditation of hospitals. However, PSLWs try to capture and adjust errors in practice, whereas mentorship facilitates the development of skills in individual employees.

Qualitative studies of PSLWs report a positive impact on hospitals with increased awareness about safety issues among senior leaders10-12 and that frontline workers, who participated in PSLWs, felt more willing to be open about safety issues and to discuss these.10

A systematic review suggests that adverse events affect one out of 10 patients during hospital admission and most of these events are preventable.13 Thus, there is continuous focus on identifying patient safety strategies that work to reduce patient harm in hospitals. Conducting PSLWs may hence be a useful strategy to improve patient safety and prevent adverse events. Since recommendations for research in patient safety include evaluating the effect of patient safety strategies,14 for example, PSLWs, on outcomes and to include patient safety culture (PSC),14 this review will examine how PSLWs affect PSC.

Patient safety culture can be defined as the product of shared values, attitudes, perceptions and patterns of behavior that determine the organization's commitment to manage patient safety.15 Patient safety culture is a complex phenomenon that addresses patient safety issues and encompasses hospital staff and management at all levels in hospitals. Despite the complexity, a qualitative review identified seven sub-cultures of PSC - leadership, teamwork, evidence-based, communication, learning, just and patient-centered.16 Patient safety culture can be measured with validated surveys among staff at both hospital and unit levels, and addresses patient safety issues, for example, leadership, staffing, communication and reporting.17 Culture is local, and although a hospital-specific PSC exists, variability in the PSC is greater between disciplines and work units within a hospital than between hospitals.18-21 Measuring the PSC provides hospital management with a basic understanding of the safety-related perceptions and attitudes of its managers and staff, and the assessment of PSC can also identify areas for improvement.22

Enhancing the PSC has been linked to better patient safety. A quality improvement initiative23 and a randomized controlled trial (RCT)24 suggest that cultural change is associated with reducing bloodstream infections in intensive care units. A systematic review links PSC to better patient safety outcomes such as decreased mortality, lower re-admission rates and fewer hospital-acquired pressure ulcers.25 Furthermore, a follow-up study shows that higher levels of PSC are significantly correlated with better patient experience and patient satisfaction26 and that higher levels of PSC are associated with fewer adverse events in hospitals.27 Therefore, hospitals are increasingly concerned with adopting patient safety strategies that can improve the PSC and thereby patient safety.

Patient Safety Leadership WalkRounds has been suggested as a strategy to support and increase PSC in hospitals.6 As per the above, it is feasible for hospital leaders to enhance the PSC. Conducting PSLWs might be a useful strategy to enhance PSC, improve patient safety and prevent adverse events. Thus, the aim of this systematic review is to evaluate the effect of PSLWs on the PSC in hospitals.

A preliminary search in MEDLINE, the Cochrane Database of Systematic Reviews, JBI Database of Systematic Reviews and Implementation Reports and CINAHL revealed one systematic review28 published in 2013.

Morello et al.28 conducted a systematic review to determine the effectiveness of strategies aimed to improve PSC in hospitals, including PSLWs, team training and communication.28 Studies in English, published from January 1996 to April 2011, using validated surveys to measure the PSC, were included.28 The surveys were Hospital Survey on Patient Safety Culture, Safety Attitudes Questionnaire, Safety Climate Survey, Patient Safety Cultures in Healthcare Organizations and the National Health Service National Staff Survey.28 Focusing solely on the effect of PSLWs on the PSC, the review identified two studies and concluded that PSLWs have a positive impact on the PSC.

The first study was a RCT conducted by Thomas et al.,29 where 23 units from the same hospital were randomized to PSLWs or customary practice.29 Thomas et al.29 found no difference in the PSC between the intervention group and the control group (mean safety score: 78.3 versus 77.9 [P = 0.854]) after PSLWs.29 However, stratified analysis did show a positive effect of PSLWs for nurses participating in PSLWs compared with those in the control group (mean safety score 81.0 versus 74.9 [P = 0.02]).29

The second study was a historically controlled study conducted by Frankel et al.,30 where seven hospitals implemented weekly PSLWs, but only two hospitals undertook the intervention that lasted 18 months.30 Frankel et al.30 found an increase in the PSC after PSLWs with >=10% points. The result was statistically significant in Hospital A (62 versus 77% [P = 0.03]), which was not the case in Hospital B (46 versus 56% [P = 0.06]).

The review by Morello et al.28 had limited conclusions about the effectiveness of PSLWs, while the heterogeneity among the studies, the measures and settings limited the results.28 Based on this and the age of the existing review, conducting a new systematic review is appropriate. Thus, the aim of this systematic review is to summarize existing knowledge to evaluate the effect of PSLWs on the PSC in hospitals.

Inclusion criteria

Types of participants

The current review will consider studies conducted in the hospital sector. Since PSC is a reflection of how all members of a workplace interact,16 all professions working in hospitals will be included.

Studies from primary health care will not be included.

Types of intervention(s)

The current review will consider studies that evaluate the effect of the concept of PSLWs, for example, safety teams with senior leadership, weekly visits to different areas of the hospitals and specific questions about patient safety to hospital staff.7

Outcomes

The current review will consider studies that measure PSC with the validated surveys, Hospital Survey of patient Safety Culture15 and Safety Attitudes Questionnaire.19

Types of studies

The current systematic review will consider all RCTs to evaluate the effect of PSLWs on the PSC. In the absence of RCTs, other experimental designs including non-RCTs, quasi-experimental studies, descriptive case series, cohort/case-control and before and after studies will be included in the systematic review.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE, Scopus, Cochrane Database of Systematic Reviews, Embase and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional theses. Studies published in English language will be considered for inclusion in this review. Since validated surveys of PSC and the concept of PSLWs were developed in the early 2000s, only studies published from January 2000 to present will be considered for inclusion in this review.

The databases to be searched include:

MEDLINE

CINAHL

Scopus

Cochrane Database of Systematic Reviews

Embase

The search for unpublished studies will include:

ProQuest Dissertations and Theses

Mednar

Initial keywords to be used will be: walkaround, walkarounds, gemba walk, gemba walks, interdisciplinary rounding, interdisciplinary rounds, multidisciplinary rounds, safety walks, patient rounds, walkrounds, ward rounds, safety culture, safety climate, organizational culture, patient safety and leadership.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Patient safety culture can be measured at both hospital and unit levels, and as mentioned in the inclusion criteria for the participants, the population will be all professionals working in the hospital. Therefore, it is appropriate to collect data at both hospital and unit levels, and if possible, to group the data into different professions for stratified analyses at the group level.

To minimize errors during data extraction, the authors of primary studies will be contacted for clarification or missing information.

Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Appendix I: Appraisal instruments

MAStARI appraisal instrument

Appendix II: Data extraction instruments

MAStARI data extraction instrument

References