Patient Safety Huddle Board
The Patient Safety Huddle Board is a tool used to promote transparency, teamwork and provide a patient safety overview in real time.
The Patient Safety Huddle Board: A new tool for an old-fashioned business practice
Kristie L. Power, MS, RN, VHA-CM, patient safety manager, Orlando VA Medical Center
In summer 2016, the Orlando VA Medical Center (OVAMC) integrated a Patient Safety Huddle Board into its acute, critical and long-term care areas. This was a positive step for OVAMC in its fulfllment of VA’s effort to be a data-driven organization and improve upon patient safety. The Patient Safety Huddle Board is a tool used to promote transparency, teamwork and provide a patient safety overview in real time. It tracks quality indicators, such as: falls, medication events, missing patients, hand hygiene, CAUTIs /CLABSIs (catheter-associated urinary tract infections and central line-associated bloodstream infections), great catches, and allows front-line staf to identify any patient safety concerns. It ensures follow-through, accountability and sustainability through the use of the action tracker. The quality indicators can be changed depending on the particular unit and its specifc needs.
The creation of the Patient Safety Huddle Board was driven by the proactive redesign of the inpatient fall prevention program. It was an effort to integrate patient safety and lean process improvement principles with the goal of engaging and empowering front-line staff to develop a sense of ownership around patient safety. Staff are empowered to identify opportunities for improvement in their own work and make the needed sustainable changes.
The OVAMC’s prototype Patient Safety Huddle Board is a simple, laminated poster that functions as an interactive dry-erase board. When deciding on the modality of the huddle board, several factors were considered, such as configuration time, ease of use and implementation cost. Even though there were electronic modalities available, such as Smart Boards, it was determined that the end users would be too pressed for time for an electronic configuration. Additionally, the poster allowed for the display of data that could easily be referred to without having to turn on a computer. Ultimately, the goal was for the tool to be user-friendly and visible at all times.
A huddle is a daily micro-meeting that keeps teams united and informed. It’s an old-fashioned business practice used in both large and small businesses. A huddle is streamlined, customizable and an incredible opportunity to encourage teamwork. These meetings are brief (five to 15 minutes long) with all members of the team present at the beginning of a shift. They build teamwork through communication and cooperative problem solving, help increase and maintain situational awareness, improve knowledge of front-line operations and transparency of patient safety performance. A huddle also allows team members to identify and communicate the resolving patient safety issues, deliver timely recognition and resolution of problems, and provide an increased focus on operational safety issues for all members of the team.
When the Patient Safety Huddle Board was first implemented, units were provided with key points for success, which were: to ensure leadership attendance, maintain consistency in start time and frequency, establish accountability by making attendance mandatory, assign problem solvers for identifed issues, close the loop/follow-up on identifed issues until they are resolved and to keep the focus on safety-critical issues. The effectiveness of the Patient Safety Huddle Board would be determined by evaluation of the quantifable metrics identifed on the huddle board itself, as well as anecdotal feedback from end users. A staff nurse on the inpatient unit stated: “The positive, objective data associated with teamwork through the patient safety huddles heightens our situational awareness, individual patient and staff needs, improves communications regarding supply and demand, prevents patient safety issues, communicates staff concerns and allows us as a team to anticipate needs at the beginning of each shift or throughout the shift, so as a team we have embraced this process because it helps us as a unit to facilitate positive outcomes.”
Overall, the units embraced the Patient Safety Huddle Board and saw value in its ability to facilitate positive outcomes. Continuous improvements in clinical indicators, such as fall rates, pressure ulcers and CAUTIs were noted by leads on the units and by the OVAMC patient safety office. The objective data, associated with teamwork through the Patient Safety Huddle Board, created a greater sense of awareness in patient and staff needs, improved communication, helped prevent patient safety issues, and allowed staff to communicate concerns. Teams were motivated by the board’s visual trackers of days since last fall, a truly compelling scoreboard for sustainable success. The emergency department recently became the latest service line to utilize the huddle board. They determined what clinical indicators were critical for tracking in their environment/population and helped customize their board. The Mental Health Residential Rehabilitation Treatment Program is the next area expected to implement the Patient Safety Huddle Board. Only time will tell what further benefts are realized from the patient safety huddle boards.
Components of OVAMC’s Patient Safety Huddle Board
The patient safety concerns area engages staff and encourages them to put their concerns in writing. Any staff member can place any patient safety-related concern at any time.
The tracking section ensures accountability and transparency by providing status updates related to patient safety concerns noted by the team.
The great catch component encourages staff to disclose near misses and great catches as mechanisms to identify vulnerabilities in a process. It also highlights how they improve processes to eliminate an actual event in the future.
The quality and safety corner of the huddle board compares OVAMC data against VISN and/or national patient safety indicator benchmarks. It also displays the current specifc unit rates for each safety metric. This section also has a customizable field for unit-specifc identifed concerns or focus areas.
The days free from harm area is an overview of long-term performance related to patient safety indicators and total number of days since last event.
Staff indicate a red “X” for a day with a fall or a green checkmark for a day without a fall in the days free from falls component.
Please contact Kristie.Power@ va.gov for more information about how patient safety huddle boards.
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The Orlando VAMC Patient Safety Huddle Board was also featured on NCPS's "The Patient Safety Huddle Podcast" and is available here and on I-Tunes.
