Promoting Transparency, Teamwork, and Real-time Review: The Morning Safety Huddle St. Christopher s Hospital for Children 1
Agenda Facility Overview Evolution of the Morning Safety Huddle Structure of the Huddle Safety Huddle Video Overview 24 & 72 Hour Events Outcomes: AHRQ & Event Reporting Lessons Learned 2
Facility Overview Beds: 189 Level I Trauma Center Medical / Surgical Units: 108 Beds Oncology / Transplant Unit: 7 beds Level IV NICU: 30 beds Level II Nursery: 10 Beds ICU: 8 Beds CCU: 8 Beds Special Care / Burn Unit: 17 beds ED: 36 Beds including 1 Trauma Room OR: 10 Operating Rooms, 1 GI Suite SPU: 26 Pre-op/Post-op Beds, 11 PACU beds
Recognitions Leapfrog Top Children s Hospital ANCC Magnet site since 2009 The Joint Commission Top Performing Hospital 4
Patient Safety Team Claire Alminde, MSN, RN Joan Anders, BBA, RN Susan Cannon, MSN, RN, CPN, NE-BC, CWCN Danielle Casher, MD, MSHQ, FAAP Celeste Chamberlain, PhD, MS, BSN, CPHQ David Cooperberg, MD, FAAP Gabriel Hauser, MD, MBA, FAAP, FCCM Christina Hall, MHA Barbara Hicks, BSN, RN Anne Krajewski, MSN, RN 5
Evolution of the Huddle Daily nursing huddle CEO/CNO interest in combining nursing huddle and safety huddle Safety huddle initiated: October 2013 Best practice Tenet Safety Huddle 6
Benefits of a Safety Huddle Improve Patient Safety Enhancing working relationships and increasing trust across departments Identify emerging risks and threats and formulate plans to efficiently and effectively resolve them Goldenhar LM, Brady PW, Sutcliffe KM, et al. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013; 22:899-906. 7
Development of Huddle Patient Flow Metrics Nursing Sensitive Indicators ED Metrics Patient Safety Metrics 8
Structure of Huddle 15 minutes: 8:15 AM Monday- Friday CEO Driven Bottom Up Interdisciplinary Team Loop Closure Transparency Pathway to High Reliability Non-punitive Environment It s 8:15 let s get started! 9
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24 and 72 Hour Events Real time review New workgroups established Existing workgroups meet Situational awareness Ownership and accountability 14
18 16 14 12 10 8 6 4 2 0 24 Hour Issues: Q3 & Q4 2014 Q3 2014 Q4 2014 15
24 Hour Events Inpatient delays in registration Workgroup: Admissions/Quality Latex Allergy Bands Workgroup: Admissions/Materials Management/Nursing/Security 16
72 Hour Issues: Q3 - Q4 2014 8 7 6 5 4 3 2 Q3 2014 Q4 2014 1 0 17
72 Hour Events Weight Based Medication Error Workgroup: Quality/Patient Safety/Nursing/BioMed/Informatics/ Residents MEMO: Medication Safety Tips For Ordering Providers Document the weight percentile on the admission History & Physical form Use the power plan when writing medication orders to ensure orders include mg/kg or adult dose Complete medication reconciliation at admission prior to writing admission orders 18
Beyond 72 hours. EMR system related issues ICU Handoff to and from OR Patient handoff from another hospital 19
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Outcomes Electronic Event Reporting & Hotline 2014 AHRQ Survey 21
Percentage Severity A and B Events Event Does Not Reach the Patient 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Q1-13 Q2-13 Q3-13 Q4-13 Q1-14 Q2-14 Q3-14 Q4-14 Total A and B 85 81 81 148 179 360 340 364 Total Reported Events 322 344 244 447 448 721 661 659 % of Events that do not reach the patient Safety Huddle Started 26% 24% 33% 33% 40% 50% 51% 55% 22
AHRQ Results Question Norm SCHC 2014 % Patient safety is never sacrificed to get more work done Our procedures and systems are good at preventing errors from happening SCHC 2013 % % Change from 2013 64% 57% 55% 2 73% 61% 59% 2 We are informed about errors that happen in this unit Staff will freely speak up if they see something that may negatively affect patient care 67% 71% 63% 8 76% 73% 69% 4 23
AHRQ Results Question Norm SCHC 2014 % SCHC 2013 % % Change from 2013 When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? 60% 60% 55% 5 Hospital units do coordinate well with each other 48% 40% 38% 2 Important patient care information is not lost during shift changes 53% 48% 37% 11 24
Lessons Learned Organizational awareness Transparency Standardization Open for new ideas/measures Non-punitive environment Engagement of front line staff 25
Future Initiative/Next Steps 10% increase in 2015 AHRQ Patient Safety Grade from 65% Expand huddle discussions to include solutions Development of Center for Quality Innovation and Patient Safety (CQUIPS) Safety Huddle at unit level Safety Champions (RN/MD) Track longitudinally the 24 and 72 hour events 26
Keys to Success Summary Multidisciplinary safety huddle Organizational buy-in Leadership support Commitment to daily meeting Implementing at your home base CQUIPS Safety Champions 27
Contact Information St. Christopher s Hospital for Children Christina Hall: Christina.Orosz@tenethealth.com Barbara Hicks: Barbara.Hicks@tenethealth.com 28