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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