Safety | Safety Culture

Implementing multidisciplinary ward safety huddles to improve situation awareness- The Royal Free hospital experience

Royal Free hospital
Dr Jane Runnacles
The initial problem and its impact

This work was aimed at improving patient safety on a general paediatric ward 6N at the Royal Free hospital London, a pilot site for the National S.A.F.E (Situational Awareness for Everyone) Health Foundation/RCPCH programme [1]. This is the children’s inpatient ward for a north London teaching hospital serving a diverse population, with approximately 1200 admissions annually.

There are an estimated 2,000 preventable deaths each year in the UK’s paediatric departments compared to the best performing countries in Western Europe [2]. National reviews of inpatient paediatric mortality have shown that there is failure to recognise deterioration, but also junior members of staff and parents are not empowered to speak up, leading to poor situation awareness [3].

References 

  1. RCPCH S.A.F.E. Programme: https://www.rcpch.ac.uk/resources/situation-awareness-everyone-safe-tool...
  2. Comparison of five year average mortality in childhood in European countries and excess deaths in UK (relative to comparator countries) according to method of first access to medical care, 2003-7 World Health Organisation Regional Office for Europe. European Detailed Mortality Database. www.euro.who.int/en/what-we-do/data-and-evidence/databases/european-deta....
  3. NPSA (National Patient Safety Agency): Review of patient safety for children and young people www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=4518
  4. RECALL (Rapid Evaluation of Cardio-Respiratory Arrests with Lessons For Learning): Developing a Tool to Learn from Paediatric Arrests. Runnacles et al. Arch Dis Child 2013;98:A56 doi:10.1136/archdischild-2013-304107.131
  5. Brady, Patrick W., and Linda M. Goldenhar. "A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk." BMJ quality & safety (2013): bmjqs-2012.
  6. Goldenhar, Linda M., et al. "Huddling for high reliability and situation awareness." BMJ quality & safety 22.11 (2013): 899-906.
Causes of the problem

The ward had already implemented Paediatric Early Warning Scores (PEWS) and the structured communication tool, SBAR (Situation, Background, Assessment and Recommendation) to improve early recognition and response to the deteriorating child. However, review of cases of deterioration on the ward described parents/carers and junior staff members identifying a “gut feeling”.  Feedback from parents suggested that there were missed opportunities to listen to their concerns. We started to use the RECALL tool [4], a structured template to review the medical and nursing notes and identify areas for improvement, then disseminate the results via a new monthly multidisciplinary risk newsletter owned by frontline clinicians. This highlighted the importance of improving situation awareness by studying the exchange of information between members of the multidisciplinary team and listening to parental concerns.

Project aim statement

Our aim was to improve situation awareness on ward 6N, with the outcome of improving patient safety and reducing deterioration. Ward safety huddles allow all members of the team to share relevant information, including parental concerns, and thus improve situation awareness. As one of the pilot sites for the SAFE collaborative, we had a collective SMART aim: To implement twice daily multidisciplinary ward safety huddles on 6N 100% of the time between October 2014 and March 2015.

Stakeholders

Through the National S.A.F.E collaborative (IHI model) we agreed as a multidisciplinary team to implement the Cincinatti children’s hospital “huddle” technique, a ten minute open exchange of information between all staff members on the ward to encourage information sharing and equip professionals with the skills to identify children at risk of deterioration by identifying, mitigating and escalating [5].

We started by designing a driver diagram (see separate file) as a team with an aim to improve the ward safety culture, and then focused on the exchange of information between multidisciplinary team members by mapping out the handover and ward round process. This led to an agreement to test ward safety huddles. The huddle aims to identify (or “flag”) patients as “watchers” (e.g. those at risk of deterioration with increasing early warning scores, on high risk/unfamiliar therapies, parental concern, clinician “gut feeling”, safeguarding concerns). We agreed on this list of criteria adapted from the Cincinatti model, relevant to our local context.

We identified huddle champions from different staff groups including the nursing and medical team, hospital school, housekeepers and pharmacists. A Consultant paediatrician and paediatric matron led the team. Patients and parents were engaged from the start in the design of the huddle questions and how this safety intervention was communicated to patients on the ward through a welcome pack and noticeboard. We have parent representations on our local project team and their ideas have also resulted in the implementation of a safety leaflet and noticeboard (educating and empowering them to recognise deterioration) and the introduction of daily plan whiteboards to further improve communication during ward rounds.

We started by designing a driver diagram as a team with an aim to improve the ward safety culture, and then focused on the exchange of information between multidisciplinary team members by mapping out the handover and ward round process. This led to an agreement to test ward safety huddles.

The huddle aims to identify (or “flag”) patients as “watchers” (e.g. those at risk of deterioration with increasing early warning scores, on high risk/unfamiliar therapies, parental concern, clinician “gut feeling”, safeguarding concerns). We agreed on this list of criteria adapted from the Cincinatti model, relevant to our local context.

PDSA Cycles / solution(s) tested

Using the model for improvement we designed and tested a safety huddle proforma to be completed by the nurse in charge during the huddle.

PDSA 1: In October 2014 we tested morning huddles when the matron was around to lead and engage the nursing staff, and when the consultant leading the work was attending on the ward.

PDSA 2: We adapted the process and educated the staff to ensure the huddles last no longer than 10mins with the purpose of identifying “watchers” (not a full board round) prior the medical ward round.

PDSA 3: We then encouraged other consultants to observe the process and ensured the morning huddles were sustained before implementing the evening huddles 6 weeks later.

PDSA 4: In December 2014 we needed to motivate the staff again so inspired by a Christmas TV advert our team devised a “MONTY the penguin” acronym:

(M)aking safety the priority

(O)n ward 6N so that

(N)o child deteriorates

(T)o  a condition that is unexpected

(Y)ou all play a part!

The documentation on the evening huddle was less reliable so we made it easier to complete the proforma and the play specialists designed and laminated credit card size reminders of the criteria for “watchers” for all staff and decorated MONTY the penguin posters with help from children on the ward to display in clinical areas

Data results

Initially we implemented morning ward safety huddles during a two week period when our early adopters were the Consultants attending to ensure they could be embedded, and the percentage of morning ward safety huddles improved over the subsequent two weeks. Since the end of October 2014, morning (0930) ward safety huddles are occurring 100% of the time, and evening (2130) huddles are now also at 100% since January 2015. We attempted to implement a third huddle in the afternoon but  time pressures on different staff groups (specifically nursing break times and collecting day surgical patients from theatres) meant this was not sustained, despite testing out different times. Instead we concentrated on adapting our “Sit-reps” in the paediatric emergency department to focus on safety as well as flow/bed status. A nursing champion re-designed our multidisciplinary whiteboard patient “bed board” display for the ward with the opportunity to highlight “watchers” visually and include PEWS scores.

A recent evaluation of our huddles has shown that at least half of the ward nurses, a consultant and junior doctor, and a teacher from the hospital school attend our morning huddles 100% of the time. Apart from the medical and nursing teams, staff from the eating disorders unit, ward administrators, domestic staff, hospital school teachers, play specialists, safeguarding advisors, student nurses and medical students also attend the huddles at least 50% of the time. We have achieved this through engaging champions from different staff groups, who have demonstrated the benefits to their teams. There has been positive feedback from staff members- huddles improve situation awareness and empower all staff, however junior, to raise concerns. Huddles also improve team working with the opportunity to learn about each other and improve care for the patients through improved communication. These results are consistent with published findings that huddle implementation leads to empowerment and sense of community, creating a culture of collaboration and enhanced capacity for eliminating harm [6].

A survey of 20 staff on the ward (nurses, doctors, teachers and pharmacists) showed that 100% found the huddle process useful, comments include: ‘improved knowledge of patients on the ward’, ‘real sense of support’, ‘pre-empt problems’, Effective at ‘highlighting patients at risk’.  Qualitative case studies have demonstrated the impact of our huddles (e.g. highlighting a safeguarding concern the medical team were not aware of, parental concern that had not been mentioned on admission).

Results of staff surveys to measure safety culture and site visits from the National SAFE team are currently being analysed.

How this improvement will be sustained

Twice daily ward safety huddles have been embedded into daily practice since 2015 by strong nursing and medical leadership, and the use of champions from different staff groups. New and temporary staff now realise that the safety huddles are so embedded in the culture that they form part of the day-to-day routine of the ward. They are valued highly by the different staff groups and occur at a time that works for everyone- immediately after medical handover and at a time when the nurses have had a chance to meet their patients for their shift. If one of the staff groups fails to turn up on time (which rarely occurs), they are contacted and the expectation is that the huddle occurs even at the busiest times, as this is when situation awareness is most important. When our ward had a recent refurbishment, the room behind the nurses station where the huddles take place was named “Huddle room” on a permanent sign, illustrating how well it is embedded.

Challenges and Learnings

We learnt that the multidisciplinary project team needs to meet regularly to keep motivated and focused on the improvement work, and that this has many unforeseen positive consequences. For example, a PEWS nursing champion was identified resulting in a sustained improvement in PEWSs chart compliance, and play specialists have made a huge contribution to related safety work (daily plan whiteboards and design of a parent safety noticeboard) as they feel more empowered to contribute. The opportunity to share and learn from other S.A.F.E. pilot sites through the IHI collaborative model was extremely powerful.

Engaging the entire multidisciplinary team including practice nurse educators, junior doctors and play specialists was crucial to ensure huddles were implemented, along with strong nursing leadership and champions including play specialists (who can provide continuity to day shifts). Case studies to show the benefit of huddles at the early stages was also powerful to persuade resistant members of staff. Although parents were engaged in the initial design of the safety huddle, and specifically how we communicated this improved safety culture to other patients and parents, we are keen to work with more patients and families in the future through our “What matters to you?” project.

Suggestions for further implementation

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