Why It Matters
What would compel you to attend a voluntary, standing-room-only meeting every morning at 8:15 AM for four years? For the people at University Hospital Hairmyres in East Kilbride, Scotland, it’s the patient safety huddle they call “The Onion.” Helen Mackie, MD, Chief of Medical Services, and Susan Friel, RN, Chief of Nursing Services at Hairmyres sat down with IHI to talk about how their huddle with the unusual name has helped improve patient flow and reduce mortality.
On Hairmyres Hospital
Helen Mackie (HM): Hairmyres l is a district general hospital with around 500 inpatient beds located in Scotland, just south of Glasgow.
On the structure of the safety huddle called “The Onion”
HM: Our morning huddles have three components — the bed meeting, the flow meeting, and The Onion, which is the safety part. The three meetings run concurrently. They’re all finished within 20 minutes to half an hour. We’ve refined the process over the years. A lot of the metrics and data are pre-collected now. During The Onion, we focus on two questions — “Did you have any patient safety issues last night or in the last 24 hours?” and “What can we do today to make our patients safe?”
Susan Friel (SF): Everyone understands they can speak out. The management team understands this isn’t a forum for us to lecture or criticize. We’re strict about not allowing it to be hijacked by people with agendas.
HM: We have the huddles daily from 8:15 onwards. This includes weekends. There obviously aren’t as many people available then, but the huddles still go on. [During the week], we have representation from all clinic areas, including wards, the radiology departments, outpatient departments. We often get representation from our community nursing teams and ambulance crews as well. There are probably about 20 to 40 people.
On how the huddles are run
HM: The most senior doctor or most senior nurse leads the meeting. It was very important to us to lead the huddle with a clinical voice and not the hospital manager because our clinical leadership frames every problem or issue as a patient safety or staff safety issue.
SF: We use flip chart paper. Any issues raised are written up and [a senior clinical leader’s] name is put against it. Or maybe it’s a nurse or somebody in another ward. Somebody will say, “Oh, I’m needing a bariatric recliner chair,” and someone in the room will say, “I’ve got one. I’ll get that over to you,” and their name will go up.
HM: The first thing we do every morning is provide feedback. If an issue came up at yesterday’s huddle, we tell how we’ve resolved it. If we fixed the fridge or sorted the lack of drug supply, for example. If we can’t solve an issue, we explain why, and we decide how we’re going to address it.
On how the safety huddles started and evolved
HM: Daily huddles were being promoted in Scotland as part of the work the Scottish government was leading on patient flow and whole system improvement.
SF: Before 2014, we made a couple of attempts at having safety huddles. Staff voted with their feet and didn’t attend. We were going through a checklist. Staff didn’t see the value in it.
HM: We became particularly interested in The Onion after one of our Scottish patient safety fellows heard Samantha Jones [Chief Executive of West Hertfordshire Hospital, NHS England] at an IHI conference. [Her organization] was concerned about quality of care and were looking for a way to address this. They introduced a “board-to-ward” [organization-wide] daily huddle which they called The Onion. Why onion? Because it requires “peeling back the layers” of safety issues day by day.
SF: It took a while for the staff to trust it. We would go into the room and say, “Any safety issues?” and it was quiet. We would explain over and over what the point was, and then leave the room and staff would stop us in the corridor and say, “Oh, I just wanted to tell you . . .” and they would describe some major safety issue. So, we would gently say, “That’s what you should be sharing during the huddle.”
HM: We knew we had problems with flow. We knew we had problems with safety. We knew we wanted to make a change. We thought The Onion was a powerful idea because the image of a senior leader standing in a room with that kind of horizontal hierarchy — immediately accessible and visible — really resonated with us.
On why The Onion has lasted
HM: We started it in 2014. It’s stuck because of consistency of ownership, leadership, and message. Our staff also got behind it. They saw we were making progress and it fostered a sense of team. Everybody realized that no matter where they were in the organization, they had a part to play in the patient journey. You realized that if you were in a downstream ward, you getting your patients home before lunchtime [meant that] the patients in the emergency department would flow through the system better.
SF: Now the whole site knows what’s happening at the front of the hospital. Nurses understand that their patient has to be safely discharged as early as possible to help keep all the patients safe.
HM: I think it’s also continued because we’ve been responsive to staff. Initially, we did the safety bit first, but a lot of times what came up were the bed metrics and the staffing metrics. So, now we have that information collected and pre-populated. This means we can get the numbers out of the way and move on to the more qualitative safety issues.
HM: We also created a daily email newsletter to all staff. People have said it has helped them feel more connected to the hospital and more informed than they’ve ever been. A secretary types it up from the flip chart paper we used during the huddle. It takes her 10-20 minutes. It’s just short bullet points.
SF: It’s always on one page. It has the new safety issues at the top. It says who’s on site with key phone numbers. It also goes to our board-level senior management team. Occasionally, you get a phone call or an email from them, so we know they’re reading it. People at all levels are reading it.
On the results of their safety huddles
HM: The Onion isn’t all we did. We were doing huge whole system improvement work. But I think The Onion created the heart of our hospital. Since we started in 2014, we have metrics that show that our flow improved, and as did our hospital standardized mortality rates which met and surpassed the targets set for Scotland. We were one of a few health boards to achieve our target and the only one to do so in all of our acute hospitals
SF: There are fewer surprises. We don’t hear about things two days or two weeks later. For example, IT problems never used to go to our level until the staff had been frustrated for weeks. After we kept hearing about IT problems, I met with IT. They said, “Why don’t we join the huddle once a week?” So, on Wednesdays, we’ve got an IT rep in the room. If there are any issues, staff can raise them directly.
HM: We’ve also seen a better sense of engagement. There is a palpable feeling that the culture has changed. For example, a patient told me, “I can’t thank you and your nurses enough for how I’ve been looked after. I never used to be a fan of this hospital. I was in four years ago, but something has changed. I’ve never been treated with more dignity and respect. I can feel it’s changed.” It’s powerful when you hear that from patients.
On how to get started
HM: You need to have senior buy-in and senior leadership. [Senior physician or nursing leaders] have to be there. You can’t delegate this. Visibility, accessibility, and approachability matters.
SF: Understand that it won’t happen overnight. You have to explain it, initially, quite a lot.
HM: If it’s not useful for your staff, you’ll find out if you [pay attention]. If the huddles are useful, people will want to come, and they will read the newsletter if they can’t.
SF: Make it clear that no issue is too small. We’ve heard about ridiculously tiny issues, and we’ve heard about huge safety issues or potential safety issues. You need to listen to both to build credibility with staff.
On how safety huddles can be joy in work huddles
HM: Early on, people would put their hands up and say, “Yesterday was really hard, but I’d like to thank Mary from ward five because she was good with an upset patient and delivered great care.” The staff spontaneously started sharing these kinds of stories. One day someone said, “Well, give them a star.” After that, when someone wanted to express appreciation, they’d say, “I want to award a star.” Some days we have none, some six or seven. All nominations for a star get a mention in the newsletter. It means something to be appreciated by your peers. It definitely contributes to joy in work.
Editor’s note: This interview has been edited for length and clarity.
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