No room for high horses

A small group of us have been working together at HQ Sign up to Safety for the last year.  Together we have found meaning, even joy, in working on a common purpose together.  These are the insights, the things we are noticing that are different from the work each of us has done before:

Locally owned self directed safety improvement really does trump top down initiatives

Helping people work on things that matter to them is vital; there are a ton of things that can be done on a wider scale and by those at a national level but the closer the implementation is to those who are delivering care the better

No room for high horses

Each of us need to try to unfreeze our fixed positions or move away from the entrenched views and assumptions we have long held; moving away from an attachment to a particular point of view opens us up to hear different perspectives and shift from polarised positions of us and them

Who do we think we are

The answer exists not in any one of us but in all of us; we are not the experts and nor should we look to other experts;  the answers lie all around us – in those that are working day to day in the NHS

Model the world you want to live in

When people speak, really listen, take in what they are saying and use silence as a positive – show you appreciate their contribution, listen with respect.  Value those that don’t obviously contribute – who are not the first to speak – these are people who listen and see patterns from simply paying attention

Pay attention to the question as much as the answer

Frame your dilemma as a question rather than a problem – seek to identify the right question to answer; a question that if explored thoroughly will provide the breakthrough you are seeking;  a question that  generates hope, new thinking and action for the future rather than keep us focused on the past and obstacles

Free up people from having to reach an outcome

Avoid predetermined outcomes – instead focus on bringing people together to explore a safer culture, a way of working which allows people to speak up, a safer NHS…. regardless of all of our opinions we can explore issues even if we have different views on how to get there

Conversations – who knew!

Move away from powerpoint presentations and speeches from ‘deemed’ experts on a stage to a structured conversational approach which helps the audience work together on complex challenges and questions.  Using conversations can support a core human need of being able to share our stories and to be heard – it is amazing what can happen when you provide a simple but profound format for people to really talk together as equals

 

 

 

 

 

 

 

Brief encounter

Moving on from Huddles to briefing and debriefing….

Briefings are short gatherings at the beginning of either a day, a shift, a clinic or session; basically any duration of event or time that involves working as a team.  They can also be before an action such as the removal of a central line or naso-gastric tube, at the start of a conference or at the beginning and end of training sessiona.  They dont have to be ‘a call for action’ but can be used to:

  • introduce everyone to each other – really important if the team individuals are different every day
  • review the tasks, activities and time ahead
  • check who is doing what and when
  • encourage anyone to speak up before anything starts

It can take as little as 30 seconds to conduct a briefing and should be no longer than 15 minutes.

briefing is best complimented by a debriefing at the end

They both work well if people understand that individuals will behave differently but these different roles or behaviours should be valued, respected and are all equally important:

Speakers / extroverts – those that like to speak and share their concerns outwardly – allow them to explore and talk things out, let them dive right in and let them shine

  • suggest …… ask the ‘speaker’ to perhaps use a framework for ensuring they get all the information across as quickly as possible using tools like SBARR (situation, background, assessment, recommendation and response) – this may prevent the speaker from dominating the brief or debrief and keep them focused

 Active listener – those that like to listen but also ask questions (on the extrovert/introvert cusp)

  •  suggest…… using these individuals to respectfully ask clarifying and open questions to help everyone’s understanding

Observer / introverts – those that like to listen in silence – respect their need for privacy and never embarrass them in public.  Let them first observe and give them time to think (dont demand answers).  Dont interrupt them when they do speak

  •  suggest….. they pay attention to their thoughts and feelings and if they do not feel they understand what the speaker is saying or the active listener has failed to clarify – ask them to consider pointing out at the end what has been missed or what is absent from what people need to do – give them notice of this and set this out at the beginning so that they can have time to think and gather their thoughts by the end

Brief Checklist

During the brief, the team should address the following questions:

___ Who is on the team? introductions by firstname

___ Do all members understand and agree upon goals or aims and objectives?

___ Are roles and responsibilities understood? what are we all doing

___ What is our plan of care or the plan for the shift / day / clinic or session?

___ What staff do we have available throughout the shift / clinic / session?

___ How is the workload shared among team members?

___ What resources / equipment / devices / drugs are needed and available?

___ What can we anticipate could go wrong? how will we try to mitigate against that?

Debrief Checklist

The team should address the following questions during a debrief:

___ Was communication clear?

___ Were roles and responsibilities understood?

___ Was situation awareness maintained?

___ Was workload distribution equitable?

___ Was task assistance requested or offered?

___ Were errors made or avoided?

___ Were resources available?

___ What went well?

___ What should improve?

References

Health Quality & Safety Commission’s teamwork and communication workshop in Auckland – 18 June 2015 via https://www.youtube.com/watch?v=czTyae-R0G8

Team working tools – via http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.html#passbaton

Extraversion and introversion via https://en.wikipedia.org/wiki/Extraversion_and_introversion

 

To huddle or not to huddle

The huddle concept is not new.  Many organisations and teams have tried this out and either succeeded or failed.  Huddles take a variety of formats and are used for a variety of purposes.

Make them brief – 5 to 10 minutes

Know when to make them multi-disciplinary or uni-disciplinary

Challenges include:

  • getting everyone to stop what they are doing and gather into a huddle
  • viewing the huddle as yet another task that takes you away from patients
  • clearly demonstrating the benefits
  • finding the right time

Be clear about purpose

A huddle can be reactive – for example is triggered by an event such as a patient fall then ensure that you use the huddle to quickly assess how the fall could have been prevented, what can be learnt from it and what could be done differently in that moment – it is more of a real time conversation rather than a full debrief

Huddles can be proactive – preventing patient safety issues and staff concerns.  A process that gathers the team together to talk about the day, the shift, the next few hours.  This is different from the beginning of the day briefing because it can happen at any point of the day.

A huddle is not a handover

There needs to be a process of linking and therefore learning from one to the other.  Issues highlighted in the morning briefing for example can be then discussed at the huddle and then through to the debriefing.  Checking in and taking the pulse of the department at any given time.  They need to be helpful and focused and create a shared understanding of what is needed and when.  Different types include:

  • Formalised huddles – planned huddles at specific times with attendance being mandatory in a designated area and with the huddle facilitated by the most senior person
  • Information capturing huddles – others use tools to capture information such as a ‘huddle sheet’ which can list the areas of discussion such as a list of patients with indwelling catheters, a lits of patients at risk of falling and so on
  • Unplanned impromptu huddles  – called at any time – to regroup, or seek collective advice and can be called by anyone from the team.  This could even happen in a patients room – for example if they have fallen it is a way of assessing the environment in real time with everyone inputting their views on what could have been done differently

Huddles are not purely for clinicians

Some organisations have created ‘meeting free zones’ from 7 till 9 and provided time for managers and leaders of particular areas to come together to talk from about 10 mins on issues that affect across the whole organisation.  This can include representation from operational services; catering, cleaning, portering, procurement and so on.

Other organisation wide huddles have included all the senior clinical leads covering a hospital at night for example where they come together at different times of the night to discuss the high risk patients who could deteriorate.

While the safety huddle is one tool in our patient safety kit, it is also much more. It connects people and helps drive the organisation-wide culture change needed to improve safety and quality across the board.

References

Dr Alison Cracknell via http://www.health.org.uk/programmes/scaling-improvement/projects/scaling-patient-safety-huddles-enhance-patient-safety-and

Dr Alison Cracknell video via https://www.youtube.com/watch?v=2JfSBwA-vm0

Western Sussex Hospitals via https://www.youtube.com/watch?v=2DUgg8yRpvc and https://www.youtube.com/watch?v=RVlQDJitTjo

Nottingham University Hospital via https://www.youtube.com/watch?v=NHSnGaqelCQ

Great Ormond Street Hospital via https://www.youtube.com/watch?v=ZzH-DSPQkyQ

Agency for Healthcare Research and Quality. About TeamSTEPPS. http://teamstepps.ahrq.gov/about-2cl_3.htm.

Institute for Healthcare Improvement. Use regular huddles and staff meetings to plan production and to optimize team communication. www.ihi.org/resources/Pages/Changes/UseRegularHuddlesandStaffMeetingstoPlanProductionandtoOptimizeTeamCommunication.aspx