"If you wait for people to come to you..."

The famous management guru, W. Edwards Deming, once said, "If you wait for people to come to you, you'll only get small problems.  You must go and find them.  The big problems are where people don't realize they have one in the first place."  Deming was essentially supporting a management technique now commonly known as "Management by Walking Around" (commonly abbreviated to MBWA).  MBWA was first popularized by Tom Peters and Robert Waterman in their 1982 best-selling book, "In Search of Excellence".  A number of leaders throughout history practiced this technique, even if before Peters and Waterman first described the method.  For example, President Abraham Lincoln commonly met his Union generals and troops in camp:

There is a famous photograph of General Dwight D. Eisenhower meeting the airborne troops on the eve of the Allied invasion of Normandy in June, 1944:













There is no question (at least in my opinion) that leaders should spend less time in the executive suite and more time on the front lines, regardless of where those front lines happen to be.  As it turns out, MBWA is not just for the battlefield.

But what does the research have to say on MBWA?  I came across an interesting study while cleaning off my desk this weekend (as it turns out, my wife was right when she told me that I don't even know what papers I actually have in all of my stacks of papers!) by two Harvard Business School researchers named Anita Tucker and Sara Singer.  Their working paper, called "The Effectiveness of Management-By-Walking-Around: A Randomized Field Study" presents the findings of their study conducted in the hospital setting.  The premise of their study was based on recommendations from the Institute for Healthcare Improvement (IHI) and the National Patient Safety Agency to institute executive walk rounds as a general method to improve safety culture, particularly when the walk rounds are focused on patient safety.  These two organizations based their recommendation on a study published in the Joint Commission Journal on Quality and Safety showing that initiation of executive walk rounds at one hospital (Partners Health Care) improved safety culture (measured via surveys of front line providers).  As it turns out, other studies have had mixed results, with one study showing that executive walk rounds actually worsened safety culture.

So what did Anita Tucker and Sara Singer find?  They randomly selected 92 U.S. acute care hospitals to participate in a safety culture survey, and then they randomly selected 24 hospitals from this group for their intervention (the remaining 68 hospitals not selected therefore served as controls).  The MBWA program was implemented in at least one unit of each of the selected hospitals (though some hospitals dropped out through attrition).  Note that the MBWA program focused on patient safety and was fairly robust and labor-intensive.  "Perceptions of improvement in performance" ("PIP")was their primary outcome measure (essentially a before-and-after comparison of safety culture, with some other elements).  Overall, and somewhat surprisingly, the MBWA program was associated with a statistically significant decrease in PIP!  Digging deeper into the results, Tucker and Singer were able to determine that the executives' presence on the inpatient units was not helpful unless it enabled active problem-solving.  Moreover, focusing on easy-to-solve problems, or the so-called "low-hanging fruit" rather than more difficult to solve problems usually produced the greatest increases in PIP. 

How do you explain these results?  I have three thoughts.  First, merely "going through the motions" and simply showing up on an inpatient unit is not likely to be successful.  Yes, it is important for leaders to be visible, but they have to show that they really care about what's happening on the front lines.  Too many leaders "just show up" and expect to be applauded by the front line team members for their "efforts."  Second, at least in this study, leaders are more likely to be favorably received if they identify problems and then solve them.  I do think that leaders can and should identify system-level issues and problems, even if they are likely to be difficult to solve.  Perhaps if leaders can demonstrate that they are actively working to solve even these most-difficult problems, they would be viewed more favorably than what Tucker and Singer were able to show.  Third, and perhaps most importantly, Tucker and Singer's study focused on patient safety.  There are many, many more things that can be addressed with MBWA (for example, employee satisfaction/engagement with leaders expressing their gratitude and thanking front line staff for their hard work) beyond just patient safety.  It would be interesting to see if MBWA had positive benefits beyond just safety culture.

Whatever you call it - executive walk rounds, leadership rounds, or "management by walking around," leaders should be visible at all levels throughout the organization.  Regardless of the results provided by Tucker and Singer, MBWA is probably a low-cost intervention that would be justified by even marginally positive results.  The fact that the MBWA program in Tucker and Singer's study worsened safety culture is concerning, but for now, to paraphrase Deming, "Don't make the people come to you - go to them!"