During Patient Safety Week, the American Organization of Nurse Executives salutes all the nurse leaders who persistently work on improving patient safety. Bob Dent, a senior vice president, chief operating officer and chief nursing officer, is one such nurse leader. He leads 1,400 employees, including 600 nurses, at the 464-bed Midland Memorial Hospital in Texas. The hospital’s use of daily leadership huddles has become a critical way for the hospital to address patient safety issues.
Every day at 8:16 a.m., 30 to 40 leaders from all departments gather in the hospital’s main lobby, reciting the Pickle Pledge, a promise to “turn every complaint into either a blessing or constructive suggestion” and no longer waste time on “blaming, complaining and gossiping.” Lasting no more than 14 minutes, each huddle provides patient safety insights. Dent spoke with Terese Hudson Thrall, managing editor of AONE’s Voice of Nursing Leadership.
What was the impetus for beginning the daily leadership huddle?
Dent: We had been through a transformation to a culture of ownership, including a new mission, vision and core values. Part of that change involved creating a sustainability measure on the cultural improvements, and using huddles helps to anchor the culture of ownership. Leaders need to set the example for huddles to be happening throughout the organization, so that we would improve communication to the front-line staff. The huddles didn’t start happening consistently throughout the organization until the daily leadership huddles began, about a year ago.
Who attends the leadership huddles?
Dent: Anyone who wants to attend can, but leaders are pledged to sustaining a culture of ownership, and part of that is being present at the daily leadership huddle. If you are a leader anywhere in the building at 8:16 a.m., you will be in that huddle. Manager, directors, vice presidents from all departments attend, not just those in care provision. Because it is in the main lobby, physicians may join if they are walking by and front-line workers may listen if they are on a break — it takes down some of those barriers among disciplines because everyone is included. Meeting in the lobby sends a message of inclusivity and transparency. Patients and family have stood just outside the huddle and afterward made comments about how impressive it is to bring our senior leadership together this way.
Can you walk me through a typical leadership huddle?
Dent: Thirty to 40 members of the leadership team gather and recite the Pickle Pledge and a self-empowerment promise that changes daily. We start and end with positive notes and have operations in the middle, including a discussion of that day’s throughput issues. We might have a situation in which we need to open up to 15 percent of our beds in anticipation for patients who need to be admitted that day. Next, we discuss any patient safety-related events that may have occurred since the last time we met. This could involve pressure ulcers, falls and infections. We also talk about safety events we need to be aware of, both in looking back 24 hours and in looking ahead. These could be small or major. When something is brought up, a leadership huddle member is assigned to address the matter, and the next day he or she reports on the action taken. After the huddle concludes, a summary of the huddle is emailed to 186 leaders — those in attendance and those off-shift — by 9:30 a.m. Units or departments are expected to have their own huddles with participants who repeat the Pickle Pledge and the self-empowerment pledge, review anything from the leadership huddle pertaining to their operations and any issues or safety-related events they may have.
What is something that came up at a daily leadership huddle that improved patient safety?
Dent: A physical therapist brought up hallway traffic concerns on one floor of our patient tower. On that floor, staff are working with post-surgical patients on walking, and the physical therapist said several near misses had occurred between patients and staff who were pushing carts, beds or wheelchairs. We looked into that; when I went on rounds, the staff on other floors were having similar experiences. We ended up installing bubble mirrors in the corridor corners not just on that floor, but also on every floor where near misses were occurring.
Explain the Pickle Pledge and how it came to be used in the leadership huddle.
Dent: In 2012, we were building a $165 million patient tower, and we spent a lot of time and energy in the building’s design. But we lost some focus on the patient experience. I thought we would get a boost in scores once we moved patients into the new tower, but eight months later, patient satisfaction scores were still going down. We knew we had to take action. We led staff training on behavioral expectations related to the patient experience and, eventually, educated all employees about the culture of ownership. In 2014, employees were presented with the Pickle Challenge, which is to eliminate all workplace toxicity. One result: We collected $1,930 in quarters for staff language violations that we then donated to our employee catastrophic assistance fund. But the new culture also paid off. Our patient satisfaction scores went from all-time lows to all-time highs. In the emergency department, we went from being below the 10th percentile to consistently being above the 90th percentile. Keeping the Pickle Pledge in the leadership huddle keeps the culture of ownership front and center.
What recommendations do you have for others struggling with daily leadership huddles?
Dent: Part of reason these may not be successful is that front-line leaders may be fearful of what might be said or done if they speak up — they think they will be blamed or penalized for bringing up a problem. I encourage huddle leaders to create and participate in activities that support the daily huddle. For instance, I host a weekly Breakfast with Bob program for directors and managers, which fosters open dialogue and makes these leaders more likely to speak up in the huddle. In addition, senior leaders have to take action on everything that is brought up. If nothing is done, leaders won’t feel their contributions are valued and the huddle loses integrity. It’s part of my job to creative a positive workplace environment, where issues can be communicated and the messenger won’t fear facing some kind of punishment. This idea is incorporated into the AONE Nurse Executive Competencies in the area of patient safety, which includes language on supporting a nonpunitive reporting environment.
How have you integrated the AONE Nurse Executive Competencies regarding patient safety into the way Midland nurse leaders practice?
Dent: I have embedded them into the competencies of all nursing directors and front-line managers and they are measured against those competencies during their annual performance evaluation. I also use the AONE competencies as part of job descriptions, and work with directors and managers so they understand the activities listed in the competencies’ patient safety section. We meet to discuss them on a regular basis.
Why is the huddle important to patient safety?
Dent: It creates a transparent forum to bring up patient safety issues, and with all the leaders there, we can devise a way to resolve it. The power of that meeting is that it’s a face-to-face dialogue. We develop relationships, realize we are all on the same team and working toward the same goal.