As Studer Group coaches, we are sometimes asked for that 'one thing'that will improve results, drive cultural change, hardwire behavior or create lasting quality. We've come to realize that there is no magic bullet; becoming a high reliability organization is a long-term journey. This journey requires leaders at all levels to be deeply committed to setting expectations by aligning standardized behaviors and creating a culture that has a relentless focus on safety, where 'stopping the line'is not only encouraged but expected and rewarded.
Whether an organization is expressly striving for 'high reliability'or creating goals to provide the highest quality and safety in care delivery, there are tactics such as shift huddles that are key to fostering a culture of hardwired behavior, consistency between shifts and constant awareness of risk of harm. It is important to note that High Reliability Organizations or HROs are focused on five specific principles on their journey to getting to zero harm:
- Preoccupation with failure
- Reluctance to simplify
- Sensitivity to operations
- Deference to expertise
- Commitment to resilience
Shift Huddles and High Reliability
Shift huddles, or brief meetings conducted at each shift to exchange information, have always been a necessary component of driving outcomes and are vital in the development of robust process improvement and quality efforts. Huddles, whether they are safety huddles or shift huddles or gatherings for any other reason, all exist for the sole purpose of communicating critical information to mitigate risk. The Joint Commission has identified miscommunication during handoffs as playing a role in an estimated 80 percent of serious medical errors. Implementing a regular shift-change huddle, in which frontline staff are directly involved, helps ensure that all team members are aware of safety issues and informed on key strategic initiatives intended to improve quality, experience and safety.
To assist with your shift huddles, download this Elevated Shift Huddle template.
Characteristics of Huddles: When, How and Who
Shift huddles should be done in advance of an organization-wide meeting so that information at the department level can be escalated to an organizational level as needed. Starting at the department level prevents safety events or potential safety events from remaining siloed in the area of occurrence, thus enhancing awareness, and ultimately safety, throughout the organization.
During a huddle, leaders should begin with a 'bright spot'or recognition of a team member(s) for a specific achievement. This allows staff to hear what is working well, or if a staff member is recognized for exhibiting a desired behavior, it demonstrates 'what right looks like.”
Most importantly, well-run huddles create an interactive setting where team members feel they are contributing to the overall success of the department. Frontline staff and key ancillary partners should be included. A leader or charge nurse should run the meeting, following a defined structure, to keep the team on track.
Department-based shift huddles should be a 5- to 7-minute 'stand up'meeting, meaning that everyone is on their feet and attentive. The expectation is that the meeting will be fast and relevant. It is critical to keep key metrics front and center during huddles and use visuals to focus the huddle on outcomes. Conduct huddles around the metric board or bring a visual representation of the department's or unit's metrics out to the huddle to keep the team focused and informed. For example, the huddle leader might reference fall rates and engage the team stating, 'What are we going to do differently today to make sure we don't have a patient fall?”
Carolina East Medical Center has seen an increased awareness of specific safety issues since instituting shift huddles. 'During the huddles, we identify patients who have an increased risk for falling. Nurses then identify the interventions that are in place to protect the patient from harm,'explained David Lau, RN, BSN, a clinical nurse manager at the organization.
The result has been a stretch of over 60 days without a patient falling on a 24-bed unit that encourages patients to improve their mobility.
Kristin Pastore, RN, BSN, a clinical manager on the orthopedics unit at Carolina East has seen similar results. 'By far the most positive effect from an elevated huddle process is that the staff demonstrates a higher sense of unit ownership, accountability and communication. As a result of increased communication, we were able to go 83 days without a fall on orthopedics, which is significant since every patient is a high risk for falls.”
Kristin's team no longer views huddles as just another thing to do. They are invested and understand the rewards. When the team did experience a fall recently, every staff member working was extremely upset and took the patient fall personally. The increased awareness created by the huddles has enhanced their teamwork and the way they communicate with each other.
Safety Risks and the HRO Huddle Difference
An HRO displays a preoccupation with failure. They acknowledge the high-risk, error-prone nature of their organization and take steps to mitigate that risk. The difference between a traditional huddle versus one that is intentionally HRO-focused is that patients' names are used when identifying risks. These questions should always be asked:
- What safety issue(s) are we at risk for today?
- Who is going to fall today?
- What are we going to do differently today to keep Mr. Smith safe from falling?
This allows the team to interact and take ownership. By discussing patients by name, we are caring for Mr. Smith's safety, instead of a vague reference to 'the patient in 210.'Additionally, we are proactively calling out any potential risks Mr. Smith may face that day. This enhances awareness and allows for steps to be taken in advance of an injury based on an identified cause.
Next, focus should be on key department metrics where the team is falling short of expected outcomes. Don't emphasize every metric, but rather post one or two key HCAHPS domains that are underperforming and one quality metric that has been a challenge (e.g. CLABSIs, SSI, etc.). Focus could also be placed on HCAHPS domains like care transitions, which Studer Group's research has shown is the domain most closely correlated to overall patient ratings of a hospital as 9 or 10.
If the organization utilizes a tactic like nurse leader rounding, the focus could be placed on feedback from the previous shift or feedback from recent call-backs to discharged patients. The goal is to keep key indicators top of mind without inundating the team with data. Report on the metrics that are tied to desired actions and outcomes, and connect staff to what they can do differently that day to impact and demonstrate their commitment to keeping patients safe.
More traditional huddles might ask, 'How many central line access ports/lines are in today?'In an elevated HRO huddle, the inquiries become more focused on action.
- Tell me why we can't pull Mr. James's central line today.
- Tell me why Mr. James's central line cannot convert to a regular IV line.
The final part of an HRO-focused shift huddle addresses operational and patient throughput factors such as patient admissions, discharges, transfers, need-for-sitter, patients awaiting beds, etc. Particularly on units with high patient turnover, the operational review helps with planning for the expected activity during that shift such as:
- Who may be discharged?
- What are the names of pending admissions or transfers?
- Where will the first 2-3 admissions be placed?
- Who on the team will be taking the first admission?
Leaving these huddles with an identified room and nurse for the next admission or transfer will aid in efficient throughput in the organization, especially when this practice of 'staying a bed ahead'continues throughout the shift. Also, you might consider including environmental services so they can plan for adequate resources as well.
With all huddles, it is understood that a plan is dynamic. However, if you begin with elevated huddles it will better prepare the team for any changes that may arise during the day.
Jean Davila, RN, MSN is a Studer Group coach, nurse and nurse executive with more than a decade of experience at a level-one trauma center. Jean has a passion for helping healthcare organizations improve patient experience and provide quality of care.
Erin Shipley, RN, MSN has more than 15 years of leadership experience as a clinical nurse manager and service line administrator. As a Studer Group coach, Erin's passion, entrepreneurial spirit and professional drive set the stage for a continued push towards operational excellence.
Diana Topjian, RN, MSN, DM, C-ENP is a Studer Group coach with more than 30 years of experience ranging from direct line staff nurse to executive leadership roles in both academic and community-based hospitals.
Kim Vyers, RN has more than 30 years of healthcare experience with 12 years in nursing leadership.