A health system is using weekly adverse event safety huddles to improve transparency. Each of 16 hospitals shares information about patient safety incidents.
• The meetings have a strict 30-minute time limit.
• A structured format ensures efficiency.
• Hospitals report on how they have addressed earlier incident reports.
Indiana University Health in Indianapolis is using a carefully structured adverse event huddle across its entire health system to encourage hospitals to share information about patient safety.
About three years ago, the 16-hospital network began scheduling a 30-minute, systemwide phone call once a week to discuss patient safety issues, explains Michele S. Saysana, MD, vice president of patient safety.
“Each hospital shares whether there have been any adverse events or near misses in the hospital, and any lessons learned from them. Sometimes, they have already done a deep dive into what happened, and sometimes, they have not,” Saysana says. “It improves transparency among our hospitals, but the real purpose is that if it could happen in one hospital, it could probably happen anywhere else. We want to share that information as quickly and as broadly as possible.”
The adverse event huddle calls are attended by the risk managers, chief medical officers, chief nursing officers, and quality leaders of each hospital, along with the chief medical officer and chief nursing offer of the system, and Saysana representing system-level patient safety. The risk manager at each hospital typically prepares information for the call and leads the discussion for events at that facility, she says.
Initially, there was reluctance about sharing information that might be perceived as negative, with hospital leaders fearing that the disclosure of an adverse event or near-miss might discourage other hospitals from transferring patients, Saysana says. There also was a practical challenge in simply scheduling the weekly call.
With so many busy hospital leaders involved, it was impossible to negotiate a time that worked well for everyone.
“We finally picked a day and time and just told everyone it’s Thursdays at noon. No time was going to work for everyone so we had to choose,” she says. “We committed to the meeting lasting only 30 minutes and ending at 12:30 p.m. sharp, so that helped people with their schedules.”
The strict time limit is made possible by using a formal structure for the meetings and a facilitator. The meeting facilitator calls on each region in the health system to see if any hospital there has an incident to report. Any hospital that will be reporting sends a written summary to the meeting participants beforehand so they can follow along.
Meeting participants were taught to provide the information about a patient safety incident in a succinct way. At this point in the meeting, there was little to no discussion among the participants, Saysana says. Discussions were held to the end of the meeting to ensure there is time for the presentations.
“We encourage them to reach out to each other after the meeting,” Saysana says. “The goal is to get these incidents out on the table so that everyone knows, and then we can follow up appropriately outside the time restrictions of this meeting.”
After the weekly meetings were well-established, the format was modified. On the first and third Thursdays, regions bring forward events. On the second and fourth Thursdays, all the regions share what they have done to follow up on that information, she explains.
At that point, there was more time for discussion in the meetings because participants had more experience with what information to bring, how to present it, and the most effective ways to talk about possible responses, Saysana explains.
The regular meetings were paused during the COVID-19 outbreak because of the pressure hospitals were under, but Saysana expects them to resume soon. The patient safety huddle model was modified for daily huddles, with the incident command structure about COVID-19 issues, such as how to move patients around in response to staffing and resource shortages, Saysana says.
“The safety huddles helped us learn to work better and have more transparency among our institutions. That translated well when we needed to do the same thing to help each other work through COVID-19,” she says. “We are now bringing harm back into these meetings with our CMOs and CNOs, because at the same time we’re addressing COVID-19, we want to be sure we are staying vigilant about other patient safety issues.”
- Michele S. Saysana, MD, Vice President of Patient Safety, Indiana University Health, Indianapolis. Telephone: (317) 948-2700.