Huddles, Handoffs, and Heedfulness are Key to Preventing Harm to Patients

HealthLeaders spoke to Truex about how Englewood has achieved such high safety ratings and how other hospitals can achieve the same.

This conversation has been lightly edited for length and clarity.

HealthLeaders: How do most errors, injuries, accidents, and infections occur in hospitals?

Andrea Truex: The biggest opportunity is miscommunication or failure to communicate. In the medical arena we have several opportunities to do what we call handoff communication. Anytime we are transitioning a patient to different levels of care or between caregivers, that opportunity occurs.

[When errors or injuries do occur], it typically involves a process issue, not a people issue. Sometimes we set people up for failure because perhaps a process was set in place, prior to other changes happening in healthcare, and it sounded good and looked good, and maybe it was put in place by individuals that potentially don’t practice at the bedside. And the next thing you know, it really is not an efficient process for staff, and they begin doing workarounds to make it more efficient, and then it presents safety concerns. We need to stop and pause and ensure purpose over tasks to ensure that we’re keeping people safe.

HL: How does a nurse executive build a culture of safety and create that expectation?

Truex: From the very beginning, we teach all caregivers that we have a no-passing zone for call lights. That’s for the patients’ safety but also for the patients’ experience so that they know someone is addressing their needs. And that’s inclusive of me, so when I’m out and about and a call light is on, I go in the patient’s room and that’s a great time for me to assess the patient, their white communication board, the content that’s on that, see what the patient understands about their plan of care, how frequently we’ve rounded on them, and if their nurse leader rounds on them.

That’s another avenue in transcending my beliefs and practices into the nurse leaders that I have hired or groomed. Many of the nurse leaders have been here quite a long time and they’ve grown from basic positions all the way up into director positions now and they know my expectations.

But they also do what is called nurse leader rounding every day where the unit director, the charge nurses, and our nursing supervisors round on every patient every day to ensure not only that we are meeting their expectations, but while the nurse leaders are in the patient’s room, they also are assessing for some of those safety items as well.

HL: How effective are you finding that to be?

Truex: If you look up our Press Ganey score related to this, our patients are saying that 98% of the time they see a nurse leader every day. We record the rounds and any issues that come up, and that gets emailed to me every night so I can compare our percentage of compliance of rounds to what the patients are saying and there’s minimal difference. That means to me that the rounds are very effective and we’re connecting with the patient.

HL: What are some of the industry safety standards that hospitals strive for?

Truex: At HCA, we compare ourselves amongst each other always, and we here at Englewood were just recognized as No. 8 in HCA in preventing harm to our patients, plus, this has been our 18th consecutive reporting period that we’ve been a Leapfrog “A” facility.

The other industry standard is the CMS [Centers for Medicare & Medicaid Services] star rating, and we are a four-star hospital. The highest you can be is a five star and we, at that time, were not able to obtain that because you had to have an intensivist program for your ICU [intensive care unit]. And I’m so excited because we just brought that up live on October 1. So, we believe that in the next reporting period that we will be able to fill in our data and hopefully end up being at true five-star CMS hospital which will be stellar.

HL: Let’s talk about the Leapfrog grades. What are some things Englewood is doing to earn those “A”grades?

Truex: Because opportunities for failure can happen around communication, we have every day in every department at change of shift what we call safety huddle. And in that safety huddle specifically on the unit there is a very big focus on who are high-risk fall patients and what kind of lines we have in, because lines are an opportunity for infection. Are there any concerning patients that we want to keep an extra eye on today? It’s a great sharing of information from the off-going shift to the oncoming shift.

The other strategy is we do bedside shift report that involves the patient. Both nurses [from each shift] physically go into the bedside, introduce themselves to the patient and assess the lines and drains that are in place, ensure the IV is set at the right rate, look at the Foley catheter that’s there, and any other drains they have.

The patient can chime in anytime. We talk about if they’re having pain and how that’s been managed, and also what the plan of care is and what their goal is for the day. It’s a great way to have open communication with the patient and with each other to look that everything is as you want it to be. With a fresh surgical patient, you’re both looking at the dressing and seeing what it looks like so that you can compare shift to shift to ensure there’s no significant change.

We also, as a leadership team, have morning safety huddle as well, so that there’s an extra set of eyes on any of those high-risk items and that we can ask any questions that we have and ensure actions are being taken to get lines out and ensuring people are receiving the appropriate level of care. So those are all great, great strategies that have been a huge help to us.

HL: What is one thing that every hospital could start doing right now and immediately increase their safety rates?

Truex: I would say it has to be a very invigorated focus on handoff communication. Even though that was a National Patient Safety Goal [issued by the Joint Commission] two to three years ago, it is not as hard-wired as it should be. We, ourselves, just started having the ER call report to the floor because it seemed there were a lot of distractions when a patient was going from the ER to the floor.

For every single handoff, not only between departments—when a patient is coming out of surgery, when a patient’s coming back from X-ray—there should be that touchpoint that everything is hooked up and the patient’s doing well. As healthcare, we could probably prevent some events by ensuring that process was very much hardwired.