Recent demands on hospitals to improve patient care and outcomes have led to trials of novel quality improvement techniques. One of these is known as "management by walking around," wherein senior hospital management visit units to observe and interview staff in order to discover problems and, ideally, help solve them. Research on the effectiveness of management by walking around has been mixed, to say the least. Recently, a large, randomized field study was conducted, in which nurses' perceptions of care quality were used as a measure of the technique's effectiveness.
Ninety-two acute care hospitals were randomly selected for the study, from which 24 were randomly assigned to implement the new improvement program (only 20 completed it and provided data for analysis). A Likert scale-based survey was administered before and after the intervention to score nurses' perceptions of care quality. Patient outcomes were not studied. The other 68 hospitals served as controls. Senior managers, such as chief executive officers, chief operating officers, chief medical officers, and chief nursing officers, met with RNs and LVNs on their units to identify problems and then worked with them to prioritize changes and discuss ways to effect them; the average cycle from identification of a problem through to completion of a change was three months.
In contrast to the control hospitals, the average performance rating actually fell in the intervention hospitals. Lead investigator Anita Tucker, associate professor at the Harvard Business School, told AJN that about 20% of the senior managers in the intervention group sample were nurses-mostly chief nursing officers or directors of patient care services.
The researchers also acknowledged that employees' perceptions of such programs would likely be improved if there had been more emphasis on prioritizing and solving the problems rather than merely soliciting suggestions for solutions.
According to Bonnie A. Pilon, professor of nursing in health systems management and senior associate dean for clinical and community partnerships at Vanderbilt University in Nashville, Tennessee, the intervention duration of 18 months was probably not long enough to establish trust in a new process and in an executive team not typically present in the nursing-unit environment (she was not involved in the study).
"It was a one-time model, followed up with a group meeting, then they moved to a different unit," Pilon said. "There wasn't enough time for a culture shift to change the nurses' reactions to the new [climate]. There's a reluctance to trust the process when the process has been artificially put upon the nurses and not sustained." She doesn't suggest abandoning the management technique altogether; rather, she suggests that an intervention lasting several years might work better to change the organizational culture.-Wayne Kuznar
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