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Implementing Daily Leadership Safety Huddles in a Public Hospital

Bridging the Gap

Castaldi, Maria, MD, FACS; Kaban, Jody M., MD, FACS; Petersen, Martina, RN; George, Geena, MPH; O'Neill, Andrea, RN; Mullaney, Kathi, RN; Pennacchio, Suzanne, RN; Morley, John, MD

Quality Management in Healthcare: April/June 2019 - Volume 28 - Issue 2 - p 108–113
doi: 10.1097/QMH.0000000000000207
Quality Management Applications
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Background: A Leadership Safety Huddle was instituted in efforts to improve communication and make safety culture a priority at our institution. The Huddle is a transparent, regularly recurring forum of clinical and administrative hospital leaders, in which safety issues and concerns are identified, shared, and swiftly addressed.

Methods: Metrics regarding huddle effectiveness in 3 areas are studied: information technology (IT) services ticket resolution time, bladder catheterization, and one-to-one inpatient monitoring.

Results: Analysis revealed effectiveness of the huddle on quality of inpatient care and cost savings. Survey revealed 75% or higher favorable responses to huddle improving communication, transparency, time to resolution of issues, ability to voice concerns, and patient safety. As a result of huddle implementation, metrics showed 46% reduction in IT ticket turnaround time (P = .0001), 28% reduction in non–intensive care unit bladder catheter days (P = .011), and 10% decrease in continuous observations (P = .008), allowing a 24% reduction in cost (P = .001) with quarterly savings of $139 107.00.

Conclusion: These metrics demonstrate how huddles are instrumental in infusing and sustaining a culture of patient safety in hospitals.

Jacobi Medical Center, Bronx, NY (Drs Castaldi, Kaban and Morley and Mss Petersen, O'Neill, Mullaney, and Pennacchio); and Westchester County Medical Center, Valhalla, NY (Dr Castaldi and Ms George).

Correspondence: Maria Castaldi, MD, FACS, Jacobi Medical Center, Department of Surgery, 1400 Pelham Parkway South, Bronx, NY 10461 (maria.castaldi@nychhc.org).

The authors thank Mr M. Alam and Ms B. Wikoren for their help in data compilation. Adherence to ethical standards has been upheld.

The authors report no conflicts, financial or commercial.

The Daily Safety Huddle is a powerful communications strategy quickly gaining traction with health care agencies across the country. The Huddle is a transparent, regularly recurring forum of clinical and administrative hospital leaders, in which safety issues and concerns are identified, shared, and swiftly addressed. Patient and staff welfare is a primary focus in health care safety. The Joint Commission has developed a monograph in collaboration with the National Institute for Occupational Safety and Health, National Occupational Research Agenda (NORA) Healthcare and Social Assistance Sector Council in an effort to excel in providing safe and effective care of the highest quality and value.1 Described are benefits to improving safety for both patients and workers and the potential synergies between patient and worker health and safety activities.

As huddles become increasingly important in health care settings, the structure, function, and efficacy of huddles are being evaluated. Although institutions implement huddles in different ways, there are a number of characteristics that are common among the majority of institutions. These characteristics include having huddles that are brief (typically less than 15 minutes), routine, and structured (a clear set of objectives).2,5 Huddles that meet these characteristics are able to improve various outcomes such as patient and staff safety, hospital length of stay, multidisciplinary teamwork, information sharing, management of impending crises, mitigation of existing problems, and trust across departments.3,4,6,7 Regular huddling allows for collective learning by allowing participants to draw from a variety of resources and knowledge.3 One institution, Advocate Health Care, found that its detection of safety events improved by 40% after the implementation of daily, hospital-wide leadership huddles.8 Another medical center, the Denver Health and Hospital Authority, found that implementing huddles resulted in communication that was both more efficient and effective. Staff at Denver indicated that the team huddles meant fewer interruptions throughout the day as well as immediate clarification when a problem did arise.9

The Health and Hospitals Corporation (H+H) of New York City is the largest municipal health care system in the country and includes 11 acute care hospitals. Our hospital, among the largest in the H+H network, initiated a Daily Hospital Leadership Safety Huddle to align with the H+H goal of improving the patient experience with safety as a top priority. Our huddles were inspired by the Hospital Patient Safety Council. The Patient Safety Council has been established as a result of joint commission expectations and CMS requirements charged with identifying patient safety risks within the hospital. The Council, chaired by the CMO, through monthly meetings, promotes a culture that recognizes risk and empowers staff to engage in patient safety. To achieve these goals in establishing and sustaining a safety culture within our institution, as well as transparency in shared efforts for ensuring well-coordinated patient care, the daily leadership safety huddle was created. Its purpose is to serve as a senior briefing that addresses current, past, and future safety and quality issues that affect our institution's patients and employees. We report on how a huddle has been instrumental in improving a variety of outcomes and the mechanism by which the effects are exerted and sustained in a public hospital system. Although huddles are becoming routine in health care settings, there is limited information about the mechanisms and metrics that contribute to effective huddles.7 Our model describes a leadership safety huddle that improves teamwork with proven capacity to reduce harm in our academic tertiary care, level 1 trauma center.

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METHODS

The huddle is a mechanism to gather and trend metrics with the goal of improving teamwork to reduce harm, ensure safety, and maximize positive patient experience. The creation of the huddle involved 3 phases of development: establishment, operationalization, and selection of meaningful metrics. Our institution is the largest safety net hospital located in the poorest borough of New York City.10 The hospital is a 483-bed, level 1 trauma and tertiary care teaching center.

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Establishment of the huddle

The Patient Safety Council convened a small focus group of hospital leaders to champion a new huddle system. Initial research involved conducting phone interviews with leaders running huddles at other institutions followed by visits to observe daily team huddles. The focus group then identified key stakeholders and developed participant roles and responsibilities in huddle-related activities and structured how the huddle would run (Figure 1). A standard work flow was developed and expectations were set. Huddle participants are uniform in selection across all disciplines, meaning that the same functional titles are required to participate. The designated mandatory attendees are manager level and above, including department chairpersons and directors of nursing, unit leaders, or their designee. Certain departments required only 1 designee, while others used rotating directors. However, participating individuals are required to know the status of operations in their areas of responsibility.

Figure 1

Figure 1

All departments and disciplines running within the hospital are represented at the huddle. The huddle facilitator maintains an ongoing attendance record. Clinical participants are directors of nursing and department chairpersons. The huddle is, however, open to all employees with encouragement for frontline staff attendance and participation. During the huddle, each unit designee gives report out in 30 to 60 seconds. Metrics to be reported on are set by the patient safety council and include staffing levels, patient volume, clinical quality indicators, environmental and biomedical issues, significant events of the past 24 hours, and safety or service concerns.

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Operationalization

A designated space was allocated for gathering and running the huddle. The space had to be large enough to accommodate more than 100 staff members, free of patients and separate from patient care areas. The huddle takes place 9A to 9:15A, Monday through Friday. This time frame most consistently integrates into the daily workflow. Initially facilitated by the chief medical officer (CMO), the huddle is now run on an alternating basis by the CMO, deputy CMO, chief nursing officer, chief of staff, and chief operating officer. Chairpersons participate in leading the huddle on designated days on a rotating basis. On weekends, a modification of this regimen has been instituted, whereby huddle occurs but representation from each department is limited.

A visual template (Figure 2) that includes all areas of the hospital expected to give report is mounted on the wall. The huddle is a “stand-up” meeting. The huddle leader uses the template as a quick reminder of the reporting order. The designee for each area gives the standardized report of information when called upon. Report-outs are typically given by unit managers. A clinical matter is directed to the department chairperson/designee or senior administration if a nonclinical issue for resolution. Follow-up report-out occurs at the next day's huddle. The huddle facilitator will announce safety issues that require more immediate follow-up at the safety huddle as well as set a time for an update that same day. The facilitator assigns an owner for each identified issue in real time. Resolution is expected prior to the next day's huddle unless otherwise specified. Additionally, the top-2 items that require follow-up at the next day's huddle are identified. It is understood that work rounds take place before the huddle. The issues identified are then brought to light at the huddle and the problem solving begins immediately after the huddle.

Figure 2

Figure 2

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Metrics

We have used the huddle as a mechanism to detail a number of metrics related to patient safety and quality of care. Metrics chosen were those that could be quantified and reliably trended. Metrics were analyzed for 1 year posthuddle implementation. Comparisons were made between the calendar quarter before and after the huddle implementation. They are as follows: Bed count, to include the number of patients awaiting placement on medicine or surgery units, intensive care units, or stepdown units with wait times grouped in categories >24, >48, and >72 hours awaiting unit placement; the use of continuous (1:1) observation on each ward; patients requiring isolation; indwelling bladder and central venous catheter days; patient and staff occurrences that include issues that adversely affect a patient or staff member such as a medication error or injury; falls; pressure injuries upon admission versus hospital acquired; environmental; biomedical/supply; telecommunication; information technology (IT) issues. Of the listed metrics, 3 measures had reliable recorded data for a before and after comparison of huddle effectiveness. Those metrics are IT ticket turnaround time, bladder catheterization, and one-to-one inpatient monitoring.

IT tickets are generated in response to clinical or operational issues such as electronic medical record system, equipment installations or moves, system access, system installations, enhancements and changes, and new telecommunication services and moves that impact patient care and hospital operations. Faster IT ticket turnaround can improve operations. Bladder catheterization, when monitored closely regarding need and timely discontinuation, can result in decreased bladder infections. Use of one-to-one inpatient monitoring only when deemed necessary if patient poses a threat to oneself or others can result in cost savings.

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Survey of effectiveness

Eight weeks after the huddle initiation, a questionnaire was distributed to measure participants' reaction to the new process of our safety huddle. Survey responses were collected from clinical, nonclinical, managerial, and executive staff. We aimed to use the survey to explore perspectives of hospital administrators and frontline staff on the effectiveness of huddle implementation. The survey was distributed at the huddle over a 3-day period and consisted of 6 questions. A 5-point Likert scale was used (1 = strongly disagree; 5 = strongly agree) to assess the effectiveness of the safety huddle. Survey respondents had the option to record their job title.

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RESULTS

The goal to keep the huddle under 15 minutes has been routinely met and is one of the keys to the success of the initiative. The huddle facilitator ensures timely start and finish. Attendance requirements have been met and sustained with required unit leader, manager, chairperson, or designee present (97%). Ninety-seven huddle participants completed the survey. Fifty-eight out of 97 surveyed listed their job title. Of those who listed their job title, 19 were involved with direct patient care (physicians, nurses, patient care associates), 10 were support services (environmental, nutrition, IT, pharmacy, respiratory, patient relations, admitting, departmental coordinators, infection prevention), 22 were managerial-level personnel, and 7 were executive leadership. All 6 questions had 75% or higher favorable responses (Figure 3) overall by survey respondents. The highest scored and most beneficial element identified by the questionnaire was the ability of staff to connect with leaders directly following the huddle. This result held true for the survey overall and when broken down by hospital function. Of the metrics identified for tracking, the use of close observations and IT ticket resolution time have shown the most dramatic results.

Figure 3

Figure 3

A Student t test (α =.05) was used to compare the prehuddle data with the posthuddle data. Continuous observations have decreased by 10% (P = .008), allowing a 24% reduction in cost (P = .001). This has translated into a quarterly cost savings of $139 107.00 for the study period. Additionally, bladder catheter days in the non-ICU (intensive care unit) adult inpatient units were reduced by 28% (P = .011) while a 19% reduction in catheter days was seen in the ICUs (P = .075). These metrics are shown in Table 1.

Table 1

Table 1

Communication with IT has improved with a 46% (P = .0001) reduction in the number of hours to issue resolution when comparing metrics pre- to posthuddle implementation. There was an overall 30% increase in the total number of tickets submitted to IT, with a 34% increase in the number of ticket resolutions (Table 2). This increase in ticket resolutions was slightly greater than the overall increase in ticket numbers. The reduced time to resolution demonstrates a marked improvement in handling of IT issues. The trend by month for the year to date continues to show improvement (Figure 4).

Figure 4

Figure 4

Table 2

Table 2

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DISCUSSION

The Safety Huddle was created to improve communication and transparency as well as to make safety culture the number 1 priority throughout our large urban public hospital. The results and feedback from implementation of the Safety Huddle at our institution were similar to findings from other institutions. Cincinnati Children's Hospital Medical Center (CCHMC) also found that regular meetings allowed staff to improve communications as well as increased the sense of shared safety and risk. In particular, charge and bedside nurses reported feeling comfortable speaking up about safety concerns even when it contradicted with those in power. Furthermore, there were fewer serious safety events at the CCHMC.11 The multidisciplinary nature of these huddles allowed for a comprehensive hospital view of patient safety.7 Similarly, at our institution, the survey confirmed that our staff are not only comfortable in voicing concerns but empowered to implement solutions. They felt that they recognized an increased awareness of patient safety events. Although subjective, interpretation of survey comments shows that communication and collaboration have improved. There has been buy-in at all levels for the safety huddle as demonstrated by the survey responses. The survey reveals staff perception of improved transparency and communication, both the ability to talk face-to-face and to resolve issues more expeditiously. The sharing of information and sense of accountability have resulted in a hospital-wide increase in responsibility toward promoting a culture of safety. The huddle has brought success by emphasizing the importance in consistently safe operations on a daily basis, promoting collaboration across ranks and disciplines to seek solutions to patient safety problems and providing an organizational commitment of resources to address safety concerns.

Another institution, Adventist Healthcare System, had up to 10 hours of saved time per day for various health care providers and ancillary staff.6 Nemour's Children's Hospital in Florida also found that there was improved coordination of efforts. They reported that before implementing the huddle it was possible that 2 groups would simultaneously (albeit unknowingly) work on the same problem or that no one was working on a particular problem.5 Their daily huddle prevented redundancy and contributed to increased effectiveness and efficiency. Similarly, a major impact of our safety huddle has been the awareness of hospital-wide issues that affect more than 1 area or department within the hospital. Important safety concerns that are shared in the huddle are broadcast to all employees via hospital flat screen monitors that are located in high traffic areas throughout the hospital. This is an effort to amplify the huddle goals of patient safety via strategic messaging. Recent flat screen messages included reminders about the importance of hand hygiene, sharps alerts, among other very specific safety issues. This intervention helped coordinate hospital-wide efforts and prevent redundancy. A few instances of huddle success can be found in Figure 5.

Figure 5

Figure 5

Other institutions have also reported increased reporting of near misses.12 Although this was not one of our original metrics, we have recently added it to our daily metric reporting as “good catches.” Several seconds of recognition for good catches are incorporated into the end of each huddle. While we are not able to include all regularly reported huddle metrics in this article, we look to the huddle for continued improvement in these areas. The huddle has dramatically cut down on the amount of e-mails, phone calls, and “work arounds” needed to resolve issues. This comes from the ability to have face-to-face dialogue between clinical and nonclinical personnel of the hospital. Understanding the impact that nonclinical services have on the function of clinical areas allows for clinical areas of need to be prioritized. This has resulted in shorter time to resolution of IT, environmental, and engineering problems on the inpatient and outpatient units. Conversely, it has allowed the nonclinical services to broadcast information related to systemwide issues out to the entire hospital community in a more efficient manner.

Unlike other institutions, we examined the effects of continuous one-to-one observations. Risk benefit and cost-benefit analyses related to constant observation are under way as the result of the huddle. With safety as a top priority in this initiative, a clinical risk assessment is done before discontinuing continuous one-to-one sitters and replacing with close observations. There has been enough awareness raised via the huddle that efforts at replacing continuous sitters with close observation defined as up to 1:4 observer-to-patient ratio with observations every 15 minutes have been successful. We found that after only a short period of time we had significant cost savings by decreasing the use of continuous one-to-one observations. Furthermore, we found that the shift to close observation from continuous observation has not been associated with any increase in adverse patient events. The cost savings in reducing the number of patients on one-to-one monitoring is achieved because overtime hours are eliminated as the need for continuous sitters is reduced. The staff requirement for close observation is met from within the existing staffing numbers as opposed to one-to-one sitter requirements that often lead to redeployment or hiring of agency personnel or overtime hours for existing staff. Various levels of observation and supervision are now being evaluated to replace the continuous one-to-one monitoring where appropriate. The huddle has thus been an opportunity to educate and remind managers and staff of new initiatives and cost saving measures such as close observations as described earlier.

Our huddle was also effective in reducing bladder catheter days, which in turn is expected to decrease catheter-associated urinary tract infection rates. Although ICU bladder catheter days showed less change than the non-ICU areas, these results could be because the ICU already has mechanisms in place to scrutinize indwelling catheter necessity. Additionally, IT service improved as well. With shorter IT ticket turnaround time, providers feel their needs are better met. For a long term this has led to an increase in willingness to place tickets as time to resolution is faster due to huddle. The huddle serves as a way to have all hospital departments understand their part in the safety and quality of care of our patients. It provides hospital leadership an opportunity to be attentive to the issues that frontline workers face that often guide behavior.13 Furthermore, in an era of financial strain, the safety huddle has been both effective and cost-efficient. It has required no additional resources to become operational. As such implementation of this huddle and its effects will continue to be studied, tracking if adjustments are required for different departments within the hospital. The Patient Safety Council continues to develop widespread communications around topics of hospital safety and performance improvement to engage everyone in maintaining safety. They are actively seeking feedback from staff as well as consulting literature on the topic, such as the National Patient Safety Foundation's recommendations for systems safety.14 In this way, safety across the entire hospital is addressed and the health care workforce is supported in its role to enhance safety initiatives.15 Perspectives of administrator and clinical leadership are explored as are daily obstacles and challenges. We feel that this allows bridging the gap between various divisions within the hospital.

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CONCLUSIONS

The Safety Huddle improves communication and makes safety culture a priority throughout our large urban city hospital. Implementing the huddle requires planning, culture change, and accountability. Executive Leadership supports an organized approach to education, and clearly defined expectations have all contributed to the success of this project. The safety huddle allows for conflict resolution and problem-solving approaches hospital-wide rather than on a unit level, bridging the gap between various units of the hospital and across clinical services.

Daily safety huddles create situational awareness in a nonpunitive environment, ensure a common understanding of focus and priorities for the day, and assign resources to reduce the risk of potential events of harm to patients and the health care team.

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REFERENCES

1. The Joint Commission. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation. Oakbrook Terrace, IL: The Joint Commission; November 2012. http://www.jointcommission.org/.
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3. Provost SM, Lanham HJ, Leykum LK, McDaniel RR Jr, Pugh J. Health care huddles: managing complexity to achieve high reliability. Health Care Manage Rev. 2015;40(1):2–12.
4. Melton L, Lengerich A, Collins M, et al Evaluation of huddles: a multisite study. Health Care Manag (Frederick). 2017;36(3):282–287.
5. Donnelly LF. Daily management systems in medicine. Radiographics. 2014;34(2):549–555.
6. Brady M, Brinkley B, Ali SI. Effective multidisciplinary huddle implementation: key components. Nurs Manage. 2018;49(9):9–12.
7. Goldenhar LM, Brady PW, Sutcliffe KM, Muething SE. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22(11):899–906. doi:10.1136/bmjqs-2012-001467.
8. Sikka R, Kovich K, Sacks L. How every hospital should start the day. Harvard Bus Rev. https://hbr.org/2014/12/how-every-hospital-should-start-the-day. Published December 5, 2014. Updated 2014. Accessed October, 2018.
9. Dingley C, Daugherty K, Derieg MK, Persing R. Improving patient safety through provider communication strategy enhancements. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 3: Performance and Tools. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008.
10. New York State Community Action Association. Poverty report 2011. http://www.nyscommunityaction.org. Accessed February 15, 2018.
11. Muething SE, Goudie A, Schoettker PJ, et al Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130(2):e423–e431.
12. Wilbur K, Scarborough K. Medication safety huddles: teaming up to improve patient safety. Can J Hosp Pharm. 2005;58:151–155. http://www.childrenshospital.org
13. Singer SJ. Our maturing understanding of safety culture: how to change it and how it changes safety. Perspectives on Safety. Patient Safety Network. https://psnet.ahrq.gov/perspectives/perspective/220/our-maturing-understanding-of-safety-culture-how-to-change-it-and-how-it-changes-safety. Published March 2017. Accessed February 25, 2019.
14. National Patient Safety Foundation. Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. Boston, MA: National Patient Safety Foundation; 2015.
15. Gandhi TK, Berwick DM, Shojania KG. Patient safety at the crossroads. JAMA. 2016;315(17):1829–1830. doi:10.1001/jama.2016.1759
Keywords:

communication; huddle; patient safety; teamwork

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