Improving patient care through leadership engagement with frontline staff: a Department of Veterans Affairs case study

Jt Comm J Qual Patient Saf. 2013 Aug;39(8):349-60. doi: 10.1016/s1553-7250(13)39049-7.


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 multimethod 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

MeSH terms

  • Benchmarking / organization & administration
  • Cooperative Behavior*
  • Data Collection / standards
  • Feasibility Studies
  • Feedback
  • Health Plan Implementation / organization & administration*
  • Hospitals, Veterans / organization & administration*
  • Humans
  • Interdisciplinary Communication*
  • Leadership*
  • New England
  • Patient Safety / standards*
  • Quality Improvement / organization & administration*