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Improving Patient Care Through Leadership Engagement with Frontline Staff: A Department of Veterans Affairs Case Study

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Background: Leveraging Frontline Expertise (LFLE) is a patient safety intervention for engaging senior managers with the work-systems challenges faced by frontline workers and ensuring follow-up and accountability for systemic change. A study was conducted to assess the ability to refine, implement, and demonstrate the effectiveness of LFLE, which was designed for and tested in private-sector hospitals, in a Department of Veterans Affairs medical center (VAMC), typically a more hierarchical setting.

Methods:LFLE was pilot tested in an urban, East coast–based VAMC, which implemented LFLE in its emergency department and operating room, with the medical/surgical ward and ICU serving as controls. A 20-month multi-method evaluation involved interviews, observation, data-tracking forms, and surveys to measure participant perceptions of the program, operational benchmarks of effectiveness, and longitudinal change in safety climate.

Results:Implementation showed fidelity to program design. Participating units identified 22 improvement opportunities, 16 (73%) of which were fully or partially resolved. Senior managers' attitudes toward LFLE were more positive than those of frontline staff, whose attitudes were mixed. Perceptions of safety climate deteriorated during the study period in the implementation units relative to controls.

Discussion: LFLE can be implemented in the VA, yield work-system improvements, and increase alignment of improvement aims and actions across hierarchical levels. Yet the results also warn against dangers inherent in adapting improvement programs to new settings. Findings suggest the need for active listening and learning from frontline staff by senior managers and trust building across hierarchical levels.

Document Type: Research Article

Publication date: August 1, 2013

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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