Background
How do you transition from a culture of fear to a culture of psychological safety; from control to shared decision making; from disengagement to everybody, everyday engaged in continuous improvement? This is the challenge a 25 bed critical access hospital is addressing through the use of visual management boards.
We call them SMART Huddle Boards, because they provide form and function for our daily huddles and bring improvement activities front and center in departmental management. Prior to using our SMART Huddle Boards, front-line staff would self-organize, each finding unique ways to overcome the obstacles impeding patient care…“whatever it takes to get the job done”. Unfortunately, fear would keep them from sharing their solutions, resulting in variations of processes and patient outcomes. Many staff had been conditioned to follow orders, not to challenge the status quo; their ideas, if not shared, become stuck in a quagmire of bureaucracy. They remain Renters not owners. The question is, would the use of huddle boards encourage staff to share and test their ideas for improvement, engage in shared decision making, celebrate their success, and result in better patient outcomes?
Intervention
Implement SMART Huddle Boards using a variation of New Hanover Regional Medical Center’s (NHRMC) visual management board. We piloted the NHRMC visual management board for six months in one department with one enthusiastic, agreeable leader. Huddles were held daily using the standard format of the huddle board to guide the conversation. Minor additions were made to the board based on participant feedback, but we maintained adherence to the huddle board standard work and training of huddle facilitators developed by NHRMC. Success using the huddle board to improve team communication, innovation, process improvement and leadership development was shared regularly with the leadership team. Eventually, several other leaders expressed interest in using huddle boards in their departments. Standard work for implementation, training and huddle facilitation were used in spreading huddle boards over the course of the next year to all departments. 
What makes this huddle board design and standard work successful?
- Structure and focus on identifying daily challenges
- Innovative ideas to address challenges
- Feedback on performance
- Team recognition.
The board is divided into four columns.
- The first is to discuss the plan of the day. What kind of patient, personnel, equipment or safety challenges are we facing today?
- The next column is for staff suggestions with real-time team evaluation and prioritization of ideas using the built-in pick chart, Just Do It and Parking Lot. Team members volunteer to own the Just Do It ideas for testing and implementation. The ideas stay on the huddle board for follow-up at future huddles to discuss what we learned and next steps. In this way, each idea is honored through team decisions, inspiring team members to submit additional ideas.
- The third column is for tracking and focusing on process improvement projects. Run charts are used to provide feedback on monthly outcome measures and weekly / daily process measures. The team discusses what they are doing today to improve these measures. The final column on the board is for team recognition. Team and individual successes are shared, as well as patient comments from a variety of listening posts.
Results: Huddle boards have inspired staff engagement in making many small and some large changes to improve the safety and well-being of our patients, visitors and staff, as evidenced by:
- 856 documented Just Do Its or 5.5 per FTE in 2015, a 100% increase from 2014 (i.e. “patient’s oxygen humidifier was cross-threaded and therefore not putting out any O2. The staff is aware of this and is always cautioned to double check it. A Just Do It was developed by some staff to pulse ox the patient prior to changing the humidifier and then afterwards. The Just Do It will remain on the huddle board until hardwired.”)
- Reduced the total inpatient harm rate by 65.5%
- Communication with nurses top box score 100% up from 67% baseline
- Hourly patient rounding 99% up from 88% baseline
- 2015 falls with and without injury per 100 inpatient days reduced by 40% to 0.4%
- 2015 30-day all cause readmission rate reduced by 67% to 2%
- 2015 all cause annual staff turnover 18% down from 26% in 2013
Lessons Learned: Be prepared for an initial flood of ideas as staff gain confidence in sharing. Leaders need to learn how to say yes, how can we run a small experiment, instead of no /can’t to their ideas. Having huddles at regularly scheduled times despite all the distractions is key to hardwiring and success. In the ED, they huddle at the same time no matter how busy or who is available to attend. Training all staff how to facilitate huddles using standard training protocol insures huddles will be done as scheduled, and it creates buy-in and leadership skills. Our huddle boards are an important tool we use to transform our culture to one of psychological safety, shared decision making, and everybody, everyday engaged in continuous improvement.
Acknowledgment: A big thank you to Greg Firestone, Director LEAN Strategies, New Hanover Regional Medical Center for sharing your visual management board material with us!
