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Huddle up: Engaging in a culture of safety Kelly Torrence, MSN, RN, NEA-BC; Michelle Dickey, MSN, RN, CCRN; Lynn Newberry, MSN, RN, CEN, NE-BC; Nathaniel Arnold, BBA, MHA Bon Secours Hampton Roads Mary Immaculate Hospital Background Methods Results Conclusion An interdisciplinary team of hospital leaders convened to research and implement best- practices in enhancing communication and patient safety via a daily safety huddle Post huddle implementation, organizations have reported a 39%-75% reduction in serious- safety events (HPI, 2010) 74%of leaders participating in daily safety huddles report a somewhat- to-significant impact on patient safety (HPI, 2010) Safety huddles leaders focus on hospital operations and work, facilitate aiding the front-line staff, and drive cultural change while improving quality ( Sikka, Kovich & Sacks, 2014). References An interdisciplinary team met to research and develop a reliable and efficient process to raise situational awareness of potential safety hazards in the hospital Senior leadership support was obtained and the huddle model adapted for organizational fit Organizational leaders were educated on the process and expectations regarding participation, engagement, follow- up accountabilty and report format to ensure compliance and consistency of practice Daily huddle agenda includes: a reflection, open discussion of near misses, review of serious safety events in the past 24 hours, nursing supervisor’s report on census and surgical volume, key department’ patient safety concerns (or lack thereof), and ends with a review of resolutions for previously identified problem agenda items Process review used to assess possible barriers and continuous education needs for improved practice in technique. Post-implementation review conducted to ascertain the impact on patient safety indicators and other quality measures. Outcomes have been evaluated in multiple quality and performance improvement domains including patient safety and engagement, demonstrated safety awareness, and sustained leadership engagement and Huddle participation. Graph 1: Trend line of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores Graph 2: Daily huddle line necessity review and resulting decrease in utilization Graph 3: Daily review of all HAIs during huddle allows leaders to develop new strategies with resultant decrease in infection rates Healthcare Performance Improvement, LLC. (2010). Daily check-in for safety: from best practice to common practice. [White paper]. Retrieved July 26, 2015 from http://essentialhospitals.org/wp-content/uploads/2014/02/Daily-Safety-Briefing-HPI-White-Paper.pdf Sikka, R., Kovich, K., & Sacks, L. (2014, December 5). How every hospital should start the day. Harvard Business Review. Retrieved July 1, 2015 from https://hbr.org/2014/12/how-every-hospital-should-start-the-day . Objectives To determine the impact that effective interdepartmental communication and collaboration can have on improving the culture of safety in an organization To identify best practice strategies for implementing and sustaining a facility-wide leadership safety huddle Effective communication of safety concerns and trends that includes the entire care delivery team is imperative to optimize patient care Increasing leadership awareness of safety events and trends creates a culture obsessed with failure Successful Safety Huddle implementation is dependent upon the following: : Leadership buy-in and accountability Transparency and trust within the team A commitment to action and root cause analyses of safety concerns and trends Routine celebration of successes Results In June, 2015, huddle leaders identified a trend in safety events related to missing armbands. A workgroup formed to identify and resolve. The team determined the cause to be incorrectly applied armbands. Education was deployed. The goal of zero missing armbands has been sustained for three consecutive months. 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Patient Experience Scores: Overall Rating Overall Rating- Topbox Overall CMS Percentile Linear (Overall CMS Percentile) Safety Huddle 250 300 350 400 450 500 42370 42401 42430 42461 42491 42522 42552 42583 42614 42644 42675 Foley Line Days per Month - 2015 Foley Line Days 2015 Linear (Foley Line Days 2015) Safety Huddle 0 0.2 0.4 0.6 0.8 1 1.2 42370 42401 42430 42461 42491 42522 42552 42583 42614 42644 42675 42705 Total Orthopedic SSIs - 2015 SSI rate/100 procedures Linear (SSI rate/100 procedures) Safety Huddle 0 0.5 1 1.5 2 2.5 3 3.5 1-Feb 1-Mar 1-Apr 1-May 1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov 1-Dec Patient Armband Identification Events Series1 Linear (Series1) Baseline Interventions Post-intervention

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Page 1: Huddle up: Engaging in a culture of safety - AONE · Huddle up: Engaging in a culture of safety Kelly Torrence ... research and implement best- ... Foley Line Days 2015 Linear (Foley

Huddle up: Engaging in a culture of safety Kelly Torrence, MSN, RN, NEA-BC; Michelle Dickey, MSN, RN, CCRN; Lynn Newberry, MSN, RN, CEN, NE-BC;

Nathaniel Arnold, BBA, MHA

Bon Secours Hampton Roads Mary Immaculate Hospital

Background Methods Results

Conclusion

• An interdisciplinary team of

hospital leaders convened to

research and implement best-

practices in enhancing

communication and patient safety

via a daily safety huddle

• Post huddle implementation,

organizations have reported a

39%-75% reduction in serious-

safety events (HPI, 2010)

• 74%of leaders participating in daily

safety huddles report a somewhat-

to-significant impact on patient

safety (HPI, 2010)

• Safety huddles leaders focus on

hospital operations and work,

facilitate aiding the front-line staff,

and drive cultural change while

improving quality ( Sikka, Kovich &

Sacks, 2014).

References

• An interdisciplinary team met to

research and develop a reliable

and efficient process to raise

situational awareness of potential

safety hazards in the hospital

• Senior leadership support was

obtained and the huddle model

adapted for organizational fit

• Organizational leaders were

educated on the process and

expectations regarding

participation, engagement, follow-

up accountabilty and report format

to ensure compliance and

consistency of practice

• Daily huddle agenda includes: a

reflection, open discussion of near

misses, review of serious safety

events in the past 24 hours,

nursing supervisor’s report on

census and surgical volume, key

department’ patient safety

concerns (or lack thereof), and

ends with a review of resolutions

for previously identified problem

agenda items

• Process review used to assess

possible barriers and continuous

education needs for improved

practice in technique.

• Post-implementation review

conducted to ascertain the impact

on patient safety indicators and

other quality measures.

• Outcomes have been evaluated in

multiple quality and performance

improvement domains including

patient safety and engagement,

demonstrated safety awareness,

and sustained leadership

engagement and Huddle

participation.

Graph 1: Trend line of Hospital Consumer

Assessment of Healthcare Providers and

Systems (HCAHPS) survey scores

Graph 2: Daily huddle line necessity review

and resulting decrease in utilization

Graph 3: Daily review of all HAIs during

huddle allows leaders to develop new

strategies with resultant decrease in

infection rates

Healthcare Performance Improvement, LLC. (2010). Daily check-in for safety: from best practice to

common practice. [White paper]. Retrieved July 26, 2015 from

http://essentialhospitals.org/wp-content/uploads/2014/02/Daily-Safety-Briefing-HPI-White-Paper.pdf

Sikka, R., Kovich, K., & Sacks, L. (2014, December 5). How every hospital should start the day.

Harvard Business Review. Retrieved July 1, 2015 from

https://hbr.org/2014/12/how-every-hospital-should-start-the-day

.

Objectives

• To determine the impact that

effective interdepartmental

communication and collaboration

can have on improving the

culture of safety in an

organization

• To identify best practice

strategies for implementing and

sustaining a facility-wide

leadership safety huddle

• Effective communication of safety

concerns and trends that includes

the entire care delivery team is

imperative to optimize patient care

• Increasing leadership awareness

of safety events and trends creates

a culture obsessed with failure

• Successful Safety Huddle

implementation is dependent upon

the following: :

• Leadership buy-in and

accountability

• Transparency and trust within

the team

• A commitment to action and root

cause analyses of safety

concerns and trends

• Routine celebration of successes

Results

• In June, 2015, huddle

leaders identified a trend in

safety events related to

missing armbands. A

workgroup formed to identify

and resolve. The team

determined the cause to be

incorrectly applied armbands.

Education was deployed. The

goal of zero missing

armbands has been

sustained for three

consecutive months.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Patient Experience Scores: Overall Rating

Overall Rating- Topbox Overall CMS Percentile Linear (Overall CMS Percentile)

Safety Huddle

250

300

350

400

450

500

42370 42401 42430 42461 42491 42522 42552 42583 42614 42644 42675

Foley Line Days per Month - 2015

Foley Line Days 2015

Linear (Foley Line Days 2015)

Safety Huddle

0

0.2

0.4

0.6

0.8

1

1.2

42370 42401 42430 42461 42491 42522 42552 42583 42614 42644 42675 42705

Total Orthopedic SSIs - 2015

SSI rate/100 procedures

Linear (SSI rate/100 procedures)

Safety Huddle

0

0.5

1

1.5

2

2.5

3

3.5

1-Feb 1-Mar 1-Apr 1-May 1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov 1-Dec

Patient Armband Identification Events

Series1 Linear (Series1)

Baseline

Interventions

Post-intervention