Leveraging Frontline Expertise (LFLE) is an intervention to improve safety culture and the quality and safety of work systems by exposing senior managers (SM) more directly to the frontlines of patient care and by increasing their awareness of issues that impact patient safety.
To customize the LFLE intervention to meet the needs of the VA, demonstrate the feasibility and potential effectiveness of conducting LFLE in a pilot site, and demonstrate our ability to evaluate the effects of LFLE.
We implemented LFLE in the emergency department (ED) and operating room (OR) at one VA hospital. LFLE consisted of 4 components: work system observations (WSO), safety information gathering, debriefing meeting, and feedback to staff (one cycle). We conducted a multi-method evaluation that included a formative evaluation prior to the implementation, and process and summative evaluations during and after the intervention. As part of the evaluation, we conducted individual and group interviews with SMs, managers, and frontline staff. In addition, we administered an online feedback form to all ED and OR staff during each LFLE cycle. We had 7 operational benchmarks to determine the effectiveness of the pilot.
Of the 7 benchmarks, we met 6: 1) implementation of 3 LFLE cycles, 2 in the ED and 1 in the OR. The second ED cycle helped demonstrate that LFLE is sustainable and that cycling back through work areas on a continuing basis adds value; 2) a majority of staff participated in all 4 LFLE components and the online form (individuals may have participated in more than one activity); 3) the hospital implementation team took concrete steps to address 86% of the 22 operational failures identified; 55% were sufficiently resolved; 4) of the frontline staff who responded to the online form, 56% felt that management took concrete steps to address the operational failures identified; 5) frontline staff received feedback on 100% of actions taken by SMs to address failures; and 6) reporting of failures and their resolution status on the tracking tool was 100% complete. We did not meet the 7th benchmark; we received positive feedback about the intervention from 64% of frontline staff (our goal was 75%). Most notable categories of failures identified were equipment/supplies and building/facilities. Our evaluations suggested that SMs gained a better understanding of system issues, giving them greater clarity for decision-making. Leaders perceived a higher degree of openness and collegiality between management and staff; likewise, staff felt they were being valued, heard, and empowered. Ninety-five percent of staff respondents said that they would like to see regular WSOs by managers in their work areas and nearly 40% of those respondents said they would prefer WSOs on a daily basis. Based on the online form, implementation team feedback, and evaluations, we were able to make real-time changes to the intervention to improve its feasibility.
This study demonstrated that the LFLE intervention is feasible and potentially effective in increasing the awareness of SMs to issues related to safety in the VA.
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