In the early 2000s, the Institute for Healthcare Improvement helped popularize the idea of Leadership WalkRounds, encouraging health care leaders to regularly visit frontline clinical units to hear directly about safety concerns.1 With the subsequent proliferation of Lean methodologies in health care, the promotion of leaders “going to Gemba” became widespread.2 However, leadership rounds are variably applied at different institutions and have yielded mixed results regarding their effectiveness to improve patient safety and culture.3,4
At Dell Medical School and Dell Seton Medical Center at The University of Texas (DSMC-UT), in Austin, Texas, our leadership rounds model was created and has evolved to be structurally and functionally different from traditional Leadership WalkRounds.
Led by our internal medicine associate chair for quality and safety, members of the leadership team from the hospital, medical school, and the department of internal medicine (see sidebar) join different medical wards teams for one hour of patient rounds at least twice per month. Most of our leadership rounds participants are physicians. While leadership rounds are not a new concept, this article aims to describe some of the experiences and insights from our unique model. Our approach brings both systems thinking to the bedside and the bedside to systems thinkers. This bidirectional learning embodies and enables core functions of learning health systems.5
Bidirectional health systems insights
“Farming looks mighty easy when your plow is a pencil, and you’re a thousand miles from the cornfield.” – President Dwight D. Eisenhower
DSMC-UT is a level-1 trauma center, safety-net hospital in a non-Medicaid expansion state (Texas). It’s common for hospitalized patients to lack access, coverage, and resources necessary for ongoing care. Additionally, the health care landscape in Austin is particularly complex with multiple partner organizations that don’t share electronic health records (EHRs), secure messaging platforms, evidence-based protocols, or value-based purchasing agreements.
During leadership rounds, rather than focus solely on having executives observe daily work, we encourage teams to round as usual and the leaders engage as more active participants in discussions of medical complexity, clinical conundrums, health-related social needs, and structural barriers to effective care.
Medical ward teams often choose to present patients facing seemingly unsolvable puzzles to achieving appropriate discharge and follow-up care. Such discussions allow systems leaders to gain greater awareness of individual patient-level challenges while simultaneously creating opportunities to provide further context to help our physicians and trainees understand the bigger picture, key drivers, and root causes contributing to the problem in front of them. From their vantage point of the larger health system landscape, our leaders also can share resources or solutions that may be hidden or less obvious to frontline clinicians and learners.
For example, during the early stages of the COVID-19 pandemic, discussions with the clinical team highlighted gaps in processes for obtaining home oxygen and for providing patients with pulse oximeters at the time of discharge. These issues were quickly addressed by the leadership team, enabling our social workers, outpatient pharmacists, and oxygen suppliers to eliminate barriers across all three domains within days. This intervention is more akin to traditional leadership rounds, in which problems raised by those doing the work are solved by leaders who have resources, authority, or convening power to address them.
In another instance, a clinical team attempting to obtain apixaban for an underinsured patient at the time of discharge had no roadmap for navigating around the cost-prohibitive standard process. The leadership rounds participants imparted their institutional knowledge of the nuances of outpatient formularies for underinsured patients, funding assistance programs, and bridges for gap coverage models between the hospital and primary care clinics. This contribution is, we believe, relatively unique: leaders supporting and enhancing the team’s clinical reasoning and care planning in real-time, rather than solving issues raised by the team later.
Recurring themes in the real-life problems our leaders encounter on rounds represent persistent gaps and ongoing blind spots in our current care-delivery model that will inevitably require higher-level improvement interventions championed by the executive rounding team. Repeated instances of patients having difficulty accessing necessary and expensive outpatient care for chronic rheumatologic or oncologic conditions require systems-level solutions.
For example, leaders can spend a lot of effort trying to address readmissions, only to hear from a team about a patient readmitted overnight because when she returned to her apartment, the building elevator was out of order and there was no way to get up the stairs; the ambulance returned the patient to the hospital. These discussions help build empathy and shared understanding among all attendees for the daily challenges that patients, frontline physicians, and our leaders face in striving to better serve our community.
Teaching attendings could, in theory, do all of this without leadership rounds. Many of our leadership rounds participants are also attending physicians on the hospitalist service at DSMC-UT. We have noticed, however, that listening to patient presentations during leadership rounds with the distinct lens of systems thinking (rather than as the attending of record responsible for the case) provides a catalyst for seeing different opportunities and insights related to both the patient and the systems of care. Our dedicated leadership rounds structure provides a mechanism to ensure we incorporate big-picture perspectives even on busy clinical services, which additionally furthers the systems-based practice competencies of our trainees.
Real-time super consults enhance clinical care and teaching
“Alone we are smart. Together we are brilliant.” – Steven W. Anderson, educator
Our leadership rounds also allow the sharing of experiential knowledge from senior internists and master clinicians. Learners and hospitalist attendings have likened them to a “super consult.” Clinical teams often choose to present clinical conundrums or interesting medical cases during leadership rounds, generating active discussions that incorporate team consensus, expert opinion, and novel clinical approaches that augment patient care. Harnessing the collective intelligence of multiple physicians has been shown to improve diagnostic accuracy.5
Recently, a medical student presented a young patient with a headache who was found to have new-onset malignant hypertension, severe acute renal failure, diastolic heart failure, and an intracranial hemorrhage. The initial differential diagnosis was broad with concern for primary hyperaldosteronism in the setting of low potassium and an incidental adrenal nodule. The leadership team helped focus on the profound nephrotic-range proteinuria as evidence of glomerular damage, refining the differential diagnosis and management prioritization. While the clinical team continued to round, a leadership team member returned to his office after rounds and sent an article to the team further informing their care for this complicated patient.
Lessons and next steps
This model of leadership rounds provides a rich array of clinical, operational, and educational insights. An added bonus is that our frequent observation of the clinical learning environment allows us to detect and respond expeditiously to changes in hospital culture that may impact care optimization. Noting practice variation, system biases, multidisciplinary team dynamics, and trainee performance trends inform potential focus areas for curricular and process improvement opportunities. Following leadership rounds, we repeatedly found ourselves huddled in the hallway summarizing our observations and prioritizing future steps. This led us to formalize a scheduled debrief immediately following each leadership rounds to ensure that unresolved action items are appropriately delegated for rapid resolution.
It would have been easy to abandon leadership rounds early in the COVID pandemic. Instead, our leaders leaned into this well-established means of gaining on-the-ground situational awareness as a conduit for direct feedback and resource requests from frontline providers. For example, teams raised concerns early in the pandemic about availability of consultants, timeliness of diagnostic studies and procedures, and variation from standard practice resulting from a combination of fear, uncertainty, infection prevention, and personal protective equipment-conservation strategies. Our chief medical officer quickly addressed this through her authority overseeing the medical staff. Engaging health care worker concerns during leadership rounds early in the pandemic enhanced trust and dialogue among providers and leaders sustaining the cohesion of our teams throughout uncertain times.
As our leadership rounds model matures, we’re expanding to include other clinical sites, including our ambulatory clinics, which we expect will broaden the impact of our model across the spectrum of care. We continue to refine and standardize mechanisms for follow-up and feedback on actions taken as a result of leadership rounds.
Our experience with a redesigned model for leadership rounds suggests this can be an effective mechanism to provide situational awareness for leaders in our department, school, hospitals, and clinics regarding the experiences of our residents and faculty, as well as visible leadership, presence, and support in our clinical learning environments. By bringing systems thinking to the bedside, we are helping our teams treat the patient in front of them as well as the system around us.
References
- Frankel A, Graydon-Baker E, Neppl C, et al. Patient safety leadership WalkRounds. Jt Comm J Qual Saf. 2003;29(1):16-26. doi:10.1016/s1549-3741(03)29003-1.
- Plsek PE. Accelerating Health Care Transformation With Lean And Innovation: The Virginia Mason Experience. 1st ed. Productivity Press; 2013.
- Martin G, Ozieranski P, Willars J, et al. Walkrounds in practice: Corrupting or enhancing a quality improvement intervention? A qualitative study. Jt Comm J Qual Patient Saf. 2014;40(7):303-310.
- Schwendimann R, Milne J, Frush K, et al. A closer look at associations between hospital leadership walkrounds and patient safety climate and risk reduction: a cross-sectional study. Am J Med Qual. 2013;28(5):414-421. doi:10.1177/1062860612473635.
- Grumbach K, Lucey CR, Johnston SC. Transforming from centers of learning to learning health systems: The challenge for academic health centers. JAMA. 2014;311(11):1109-1110. doi:10.1001/jama.2014.705.
Sidebar: Making the rounds
Regularly invited attendees for internal medicine leadership rounds at Dell Medical School/Dell Seton Medical Center
- Chair of the department of internal medicine
- Associate chairs of the department of internal medicine
- Division chief and associate division chief of hospital medicine
- Chief medical officer
- Dean of Dell Medical School
- Internal medicine residency program director
- Department of internal medicine administrator
Dr. Moriates is the assistant dean for health care value, associate chair for quality and safety, and associate professor of internal medicine at the Dell Medical School at the University of Texas at Austin.
Dr. Pierce is chief of the division of hospital medicine, associate chair for faculty development and well-being, and associate professor in the department of internal medicine at the Dell Medical School at the University of Texas at Austin.
Dr. Hudson is an assistant professor of internal medicine and infectious disease, and the program director for the internal medicine residency at the Dell Medical School at the University of Texas at Austin.
Dr. Miller is associate chair for education, a professor, and interim chief at the Dell Medical School at the University of Texas at Austin.
Dr. Nieto is an associate professor in the departments of internal medicine and pediatrics, and associate chief for the division of hospital medicine at the Dell Medical School at the University of Texas at Austin.
Dr. Schulwolf is an associate professor in the department of internal medicine at the Dell Medical School at the University of Texas at Austin.
Dr. Pignone is the Dr. Lowell Henry Lebermann endowed chair in internal medicine, assistant dean for veterans’ affairs, and professor at the Dell Medical School at the University of Texas at Austin.