The Joint Commission says daily safety briefings, or huddles, as they often are called, are a hallmark of a high-reliability organization. But how does one keep such sessions from devolving into just another task that must be checked off every day as opposed to a vehicle for reducing harm?
While hospitals design safety huddles in several formats, most organizations that have enjoyed success with the process say these huddles must be driven and supported by executive leadership. However, just as important are filtering mechanisms that bring frontline clinicians into the process and foster a culture of reporting and transparency that penetrates deep into the many layers of a modern healthcare system. In fact, when executed effectively, safety huddles can be a primary tool for driving effective organizational change, experts note.
Focus on Communication
Certainly, a revamp of the safety huddle process was a top priority at Providence Little Company of Mary Medical Center in San Pedro, CA, and it was one of the first steps hospital leaders took in their quest to improve safety and high reliability. Steven Brass, MD, MPH, MBA, director of medical affairs at the hospital, says the organization’s focus on this issue was all about communication.
“The way our day begins at the hospital is with everyone getting together. It’s where communication happens,” he says. “We know that 70% of errors relate to communication problems. The huddle is the perfect way to improve communication and, therefore, to reduce these errors.”
In designing a new process, developers were not starting from scratch. There already was a morning meeting that took place every day during which nursing leaders would report on key metrics, such as bed occupancy and staffing issues, to the house supervisor.
“It would take less than five minutes, and then quickly disband,” Brass notes. “There was no structure; it was not used to do quality metrics or to review data, and it was solely limited to the nurses.”
However, a sister hospital that already was well into its journey toward high reliability had recently revamped its safety huddle process, and Brass took full advantage of the organization’s experience.
“I attended their safety huddle and observed how they did it,” he says. “We put together an agenda based on what they had done and then added a couple of areas we thought were very relevant to our hospital.”
However, that was just a starting point, as the agenda and the process went through several iterations — even after the new safety huddle process went live in April 2015. For example, since that starting date, the length of the huddle has been trimmed by more than half to 20 minutes and 20 specific agenda items, beginning with reflection and safety messages, but then quickly moving on to concrete safety issues such as:
• ED boarding;
• psychiatric holds;
• excessive lengths of stay (LOS);
• readmissions within 30 days;
• medication errors;
• hospital-acquired infections (HAIs);
• use of restraints and Foley catheters;
• unexpected deaths;
• skin ulcers;
• electronic medical record (EMR)-related problems;
• delays of service;
• any physician or caregiver safety concerns;
• equipment-related issues.
To go along with the agenda items, developers designed documentation tools to facilitate the tracking of various HAIs, the use of Foley catheters and restraints, skin ulcers, 30-day readmissions, and excessive LOS.1 Further, certain topics or themes are covered in more depth on specific days.
“On Monday, we review our finances and how we are doing. Tuesday, we quickly review our recruitment and open positions, and on Wednesday we look at readmissions over the past 30 days,” Brass explains. He adds that Thursday is set aside for a discussion of HAIs and falls, and on Friday the huddle attendees discuss issues pertaining to the patient experience. “We have leaders on each of these areas come into the huddle and provide information on the [specific] topic area,” Brass adds.
With such a lengthy list of agenda items, it can be challenging to control the duration of the huddles. However, Brass says it is a matter of setting expectations.
“We start at 9:30, whether everyone is in the room or not, and we close the door. The expectation is that everyone will arrive on time. That is crucial,” he says.
Further, Brass explains that when an issue comes up that clearly will require much more discussion, huddle leaders direct participants to take the matter offline, perhaps in a smaller group following the safety huddle.
“We manage time throughout the huddle,” Brass notes. “If there are 10 minutes left, we make people aware that the goal is to get out of there at [10:00] at the latest.”
When the leader of a particular unit cannot make it to the huddle, he or she is expected to send a representative in his or her place.
“We actually monitor attendance, so when people stop showing up, the executives will start sending emails to the people involved, saying that they would really like their participation in the huddle; that it is vital for the safety of the hospital,” Brass says. “It is not something that is optional. We calendar it into a no-meeting zone from 9:30 to 10. That is on everyone’s calendar in the hospital.”
Given that clinical unit leaders, department leaders, executives, and physicians are expected to attend the safety huddles, how does the safety culture exemplified during the huddles filter down to frontline caregivers and staff? Brass explains that individual, frontline caregivers are, on occasion, asked to observe the huddles.
“That is one way of having them there at the table so that they can see what is going on safety-wise at the hospital,” he says. “Also, we ask that the information shared during the huddle be reported back on the individual units.”
Further, each unit has a patient safety huddle board where the hospital’s goals or pillars are posted. “Under each pillar is a metric, and the whole hospital has the same strategic goals, but each unit has a metric [that unit staff] are trying to attain,” Brass explains. “What they do is update the huddle boards either weekly or monthly.”
For example, regarding falls, the huddle boards will show the number of falls that have occurred every year and how the unit is doing, Brass says.
“They are supposed to be huddling every day on their units at the huddle board. That is a source of their data and how they are doing on the individual units,” he explains. “The best way to change a metric is to have it visible. That way, you can see where you are and where you are going.”
While it is hard to draw a direct line between the safety huddles and specific outcomes, Brass notes that the hospital has made good progress on several key metrics since the new huddle process was implemented. For instance, physician hand hygiene compliance has increased from 76% in 2014 to 94% in 2017. There also have been improvements in patient experience scores, the incidence of some HAIs, and overall mortality.
Further, Brass notes that the organization has been able to maintain the effectiveness of the huddle process. In fact, he believes people actually look forward to the daily sessions, and that is by design as well.
“We make them fun. We make announcements about what is going on in the hospital, and we recognize people at the end of the huddle for their hard work,” he says. “We start the huddles with educational safety stories and regulation updates. That keeps people engaged.”
Establish a Vision
The huddle process has worked so well that in January 2017, the hospital started conducting an additional safety huddle for its behavioral health campus immediately following the general safety huddle.
“We have a 24-bed inpatient unit, 25 chemical dependency beds, and a psych ED,” Brass explains. “There are so many behavioral health issues with boarding patients and risk matters that come up that trying to cover all of those issues in the main hospital huddle is impossible, so even though those issues are relevant to safety and operations, we need to have a separate focus.”
Participants in the behavioral health huddle include Brass, the director of the inpatient behavioral health unit, the director of the main ED, the chief nursing officer, hospital administrators, and representatives from risk management and security.
“It has worked out amazingly well,” Brass reports. “A lot of the things that come to the surface create situational awareness among staff ... and improve operational issues.”
Brass’s advice to other hospitals interested in designing a new safety huddle process is to establish a vision of what one wants to accomplish and how it will benefit patients and the hospital specifically. Then, solicit input from leaders in each department to determine what should be on the huddle agenda. This will help with buy-in as well.
“Make sure that hospital executives are involved to show support for the process,” he adds.
It can be helpful to start the process with a baseline agenda, so feel free to borrow one from the literature, and then personalize it, depending on the needs and characteristics of your hospital, Brass offers. Further, make sure that accountability is built into the process.
“If you are going to have metrics that you display at the huddles, which we do on our hospital-wide huddle board, you need to assign responsibility for who is going to take care of that every week,” he says. “Also, who is going to be the notetaker? You need to [determine] that up front.”
Other keys to an effective process include consistency, punctuality, and respect for everyone’s time, Brass says. “Also, be open to change. After a month, if things aren’t working or there is something that is going wrong, be adaptable to altering the agenda,” he says. “Assess the temperature of the room, and get feedback on how you can make things better.”
Drive Culture Change
Charlene Sanders, CPHQ, MHA, the vice president of quality at Mary Lanning Healthcare, a community hospital in Hastings, NE, also methodically implemented a safety huddle process, and has come away from the experience thoroughly impressed with what can be accomplished when such a mechanism is used effectively.
“I think it is one of the most significant and effective tools for enhancing the culture of safety in an organization,” she says.
After the hospital’s safety huddle process started four years ago, there was a significant upward trend in the perception by staff that safety is a hospital priority as measured by a culture-of-safety survey tool.
“We are also seeing faster turnaround times on occurrence reporting and notification on events that happen,” Sanders explains.
The safety huddles are held at 8:30 every morning, giving unit leaders time to walk through their departments and find out what has happened in the last 24 hours and to anticipate whether there are any issues that are going to occur in the next 24 hours, Sanders says.
“We have been able to address IT issues, medication issues, and medical errors,” she says. “It is just an effective tool for identifying risk to the organization ... and for getting people talking.”
At Mary Lanning Healthcare, the safety huddle includes all nursing unit directors and department leaders.
“For us, that includes about 30 people,” Sanders observes. “We always start out with patient safety success stories. After that, we go into how many days it has been since our last serious event and how many days it has been since the last employee injury, because that is an organizational focus.”
Later, each leader has time to report what has happened in his or her department or unit, and how any specific issues are being addressed. “It is just very, very focused,” notes Sanders, explaining that the safety huddles last, at most, 15 minutes.
Build in Accountability
The meetings take place in a boardroom, but often there is standing room only because physicians are invited to attend if they have a concern.
“We had one of our pathologists come because he had an issue that occurred between the lab and surgery, and he was there the next morning to discuss the issue,” shares Sanders, noting that a meeting has been scheduled to delve into the issue further. “Many times after our safety huddle, you will see people who have brought up issues huddling even in the room because they are anxious to address an issue so that we don’t see a repeat of the problem.”
It is a priority to get all the leaders to the safety huddle. “They are then going to go back to their units after the meetings, and if there is something that has been identified as a house-wide risk, they are talking to their staff,” she says. “There is that expectation.”
However, after the safety huddle was in place for about three months, administrators saw the need to talk about matters relating to beds and the census, and coordination with social work and care management. “So, now we have a 15-minute leader/safety huddle, and then go directly into a bed huddle,” Sanders explains. “Then, after that, there is a 9 a.m. ED huddle, so [we cover] all of our high-risk areas.”
Accountability is built into the safety huddle process, in part, by recording all the issues discussed in writing, and then disseminating the report to all participants on a daily basis. With this approach, anyone who is out of the office for the day still can keep up with what is going on at the hospital. Also, these summaries include reminder flags to the directors of departments that have issues that need to be resolved, along with a deadline for completion.
One thing Sanders learned from benchmarking her safety huddle approach with the practices at other health systems is that the CEO must drive the process.
“That is first and foremost. If the CEO isn’t present or part of the sessions, there is a lack of engagement and buy-in to the process,” she says. “I was at an organization a couple of years ago where the leaders were derisively referring to their process as the ‘safety muddle.’”
In that case, the chief nursing officer was present, but not the other members of the executive team, and the lack of buy-in was obvious, Sanders observes. “That is the biggest lesson ... it has to be driven by the CEO and supported by the executive team,” she says. “Then, it is a matter of having follow-up to the discussion and building in an accountability structure. That is the other key to making this successful.”
1. Brass S, Olney G, Glimp R, et al. Using the patient safety huddle as a tool for high reliability. Jt Comm J Qual Patient Saf 2018;44:219-226.