Leadership Rounding: How to Run Rounds That Change Practice

Rounds are a promise to the team

Most hospitals already round. Directors walk the wards, managers visit service departments, quality teams carry a checklist. Leaders show up. What matters is whether anything changes after they leave.

A round asks staff to speak up. When nothing follows, staff learn that speaking up is pointless. The evidence on leadership rounding is clear on this point: presence alone does little. Presence that leads to visible action is what counts.

What the research says

WalkRounds began as a safety practice. The Institute for Healthcare Improvement describes Patient Safety Leadership WalkRounds as an informal way for senior leaders to talk with frontline staff about safety. The idea was conceived in 2000, and Allan Frankel and colleagues described their own hospital's programme across nearly 50 clinical areas in 2003. IHI's guidance asks for rounds at least once a week, "with no cancellations."

Participation alone is a weak lever. In a randomised trial across 23 clinical units, Thomas and colleagues found no significant overall difference in safety climate between units that received executive walk rounds and units that did not. Nurses who personally took part scored higher. That comparison was not randomised, so it may reflect who chose to attend.

Feedback is the strongest signal. Sexton and colleagues surveyed 829 work settings, with 16,797 responses. About a third of respondents had taken part in WalkRounds, but only about a quarter had taken part in WalkRounds followed by feedback. Settings with the most WalkRounds with feedback had substantially higher safety culture scores, roughly 15 to 27 percent higher than settings with the least. The study was cross-sectional. The authors note that it cannot show whether feedback creates better norms or reflects them.

Rounds without resolution can backfire. Tucker and Singer ran an 18-month randomised field study of a management-by-walking-around programme in 56 work areas. On average, the programme had a negative effect on performance. It helped where senior managers were made responsible for resolving the problems raised, and where teams chose problems that could be solved quickly.

Asking what goes well matters too. A later cross-sectional study by Sexton and colleagues examined rounds in which leaders asked both what was going well and what could be better. Staff exposed to these rounds reported better teamwork and safety culture and less emotional exhaustion.

Lean offers the same lesson. The Lean Enterprise Institute defines the gemba walk as grasping "the current situation through direct observation and inquiry before taking action." Gemba means the actual place where the work happens. A gemba walk in healthcare is a walk to understand a process, not to inspect a person.

Why rounds turn into box-ticking

The failure pattern is familiar. It rarely starts with bad intent.

• The checklist becomes the goal. A hospital rounding checklist with forty items gets completed, filed and forgotten. Completion is measured. Change is not.
• The route drifts. Leaders visit the units that are easy to reach and skip the night shift, the laundry and the loading dock.
• Rounds feel like inspection. When a visit looks for someone to blame, staff stop telling the truth.
• Notes go nowhere. Observations sit in a notebook or a long form. Nobody owns them, so nobody closes them.
• The team never hears back. Staff raise the same broken door three times, then stop raising anything.

A method that holds

Good quality rounds are simple and disciplined. Five habits make them work.

1. Fix the route and the cadence. Decide which areas each leader covers, how often, and on which shifts. Put it in the calendar like any clinical commitment. Include support services such as pharmacy, laboratory, kitchen and housekeeping, where many patient experiences are shaped. Rotate times so night and weekend teams are seen too.

2. Observe situations, not people. Look at how the work actually flows: handovers, storage, signage, waiting, equipment. Ask open questions. What went well this week? What slowed you down? What worries you about the next patient? Record conditions and processes, not names. A round that profiles individuals will not stay honest for long.

The rounds we design ask plain questions from the patient's side. What is the mood in the waiting area? Does each person know their next step? Who looks left alone? Questions like these keep the round on the path people walk, and off anyone's personnel file.

3. Record in seconds. One observation, one place, one short note, written on the spot. If documenting takes longer than the conversation, it will be skipped or done from memory later. Keep a small set of categories, such as safety, flow, environment, equipment and communication, so notes can be grouped across rounds. Never photograph patients or record their details.

4. Close the loop within days. Every item gets an owner and a target date before the leader leaves the floor. Then tell the team what happened: fixed, scheduled, escalated, or not possible and why. Feedback is the step most often skipped and the one most consistently linked to better culture. A short message to the team within the week is better than a perfect report a month later.

5. Track what changed. Count items closed, not rounds completed. Watch how long items stay open, which themes return, and which areas raise nothing at all. Silence is a finding too. Review the log monthly with the department and decide what to stop, start or escalate.

Start small. Tucker and Singer found that teams that began with problems they could solve quickly did better. An early visible fix earns the trust that harder problems need.

A compact rounding checklist

• Before: confirm the route, the time and the open items from the last round.
• During: ask what is going well and what is getting in the way; observe one process end to end.
• Record: one note per observation, with place, category and time.
• Assign: an owner and a date for each item before you leave.
• Feed back: tell the team the status of every item within days.
• Review: monthly themes, open items and areas never visited.

For example, in a hypothetical surgical ward, staff mention that a supply cupboard is restocked after the morning rush instead of before it. The leader records it in a few seconds, assigns it to the supply team, and returns three days later with a new delivery time. That is what a round that changes practice looks like.

How Reflection supports rounds

Reflection is a mobile app for frontline teams. Coordinators document practice in seconds, departments plan rounds with reminders, and each observation stays linked to its owner and status until it is closed. Notes feed a living department guide and staff development from the field. People decide what to fix and how. The software only organises the evidence.

Sources

1. Patient Safety Leadership WalkRounds (tool). Institute for Healthcare Improvement, 2023.
2. Patient Safety Leadership WalkRounds (Frankel A, Graydon-Baker E, Neppl C, et al.), Joint Commission Journal on Quality and Safety 29(1):16–26. AHRQ PSNet, 2003.
3. The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units (Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL), BMC Health Services Research 5:28. BMC Health Services Research, 2005.
4. Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout (Sexton JB, Adair KC, Leonard MW, et al.), BMJ Quality & Safety 27(4):261–270. BMJ Quality & Safety, 2018.
5. The Effectiveness of Management-By-Walking-Around: A Randomized Field Study (Tucker AL, Singer SJ), Production and Operations Management 24(2):253–271. Production and Operations Management, 2015.
6. Safety culture and workforce well-being associations with Positive Leadership WalkRounds (Sexton JB, Adair KC, Profit J, et al.), Joint Commission Journal on Quality and Patient Safety 47(7):403–411. Joint Commission Journal on Quality and Patient Safety, 2021.
7. Gemba Walk (Lexicon). Lean Enterprise Institute, 2020.

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