Journey to High Reliability through the Patient Safety Huddle

Journey to High Reliability through the Patient Safety Huddle

High-reliability organizations prize identification of errors and close calls for the lessons that can be extracted from those events. These organizations develop a mindful approach to Quality and Patient Safety with the focus on learning from events.  One of the most impactful efforts an organization can take toward timely identification of errors is the daily Leadership Safety Huddle.

Leadership Safety Huddles provide a structured method for learning both from safety occurrences and from near-miss safety events. The Safety Huddle process encourages open and timely communication between members of the leadership team to raise awareness of any occurrence that could be considered a safety event. The structure of the Huddle is such that there is no recrimination, and it promotes transparent reporting of potential safety issues. Identified Issues are usually resolved within 24 hours since the issue owners are present to discuss further and follow up immediately following the Huddle.

Mary Lanning Healthcare (MLH) implemented the Leadership Safety Huddle in August of 2013 upon the arrival of Eric Barber, CEO and President. He leads the fifteen (15) minute safety huddle every morning at 8:30 am with an expectation that Directors or their designees attend ready to report any events that occurred within the last 24 hours in their respective areas of responsibility.   This brief focused daily interaction has resulted in enhanced teamwork and timely resolution to quality and safety concerns.

The typical Safety Huddle agenda addresses the following:

–      Safety Success stories, Announcements, and/or Introductions

–      Number of Days since last serious safety event

–      Number of Days since last employee injury

–      Departmental reports concerning events or variances to care.

Examples of issues brought forward:

–      Security Issues or risks

–      Medication Issues

–      Falls

–      Restraints

–      Environment of Care issues

In efforts to further improve the Safety Huddle process, MLH partnered with KPI Ninja, LLC in 2015 to utilize the KPI Safety Tool to capture the Safety Huddle report and push out reports for follow up to the appropriate leaders. The KPI Safety Tool product has allowed for enhanced reporting and tracking capabilities that encourage follow up and discussions through the three major components of the software: the Dashboard; the Electronic Huddle form; and the Reporting capabilities

The daily Safety Huddle champions transparent leadership and fosters communication that not only moves the organization toward achieving goals established for the quality and safety strategic plan, but has dramatically changed the culture of safety within MLH. Internal data affirms an improvement in quality of care and in the transformation of a fear-based culture to an open culture of patient safety in a relatively short period of time. Results of the 2017 and 2015 patient safety culture surveys compared to 2013 results provide quantitative evidence that Mary Lanning Healthcare’s culture is evolving into a high-reliability organization with respect to the culture of patient safety. This relatively simple, and yet highly effective, process has resulted in staff confidence that the culture of the organization is that of creating a safer environment for patients, as well as a safe environment for them to provide care. It requires 15 minutes daily, leadership support, consistency, transparency, mindfulness, and courage to tackle the issues that are brought forward through the Safety Huddle.

 

Charlene Sanders joined Mary Lanning Healthcare as VP of Quality in September 2013. She has over 30 years of leadership experience, working with hospitals, health systems, and academic medical centers to improve patient outcomes, patient safety, and overall quality performance. Built on a tradition of caring, Mary Lanning Healthcare has over 100 years of providing quality healthcare for residents of the central Nebraska area. We continue to grow and expand, working to provide patient-centered care in a positive environment, while implementing some of the newest technologies available.  Mary Lanning Healthcare strives to provide the best care possible for central Nebraska now and into the future.

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