Last month’s CQC report showcased improvements across eight trusts, including Leeds Teaching Hospitals where I work. The report prompted me to ask: in a world where morale is low and resources depleted, how do you reach and engage the whole workforce to believe they can make a difference?
Testing the art of the huddle
Four years ago we held a ‘big conversation’ with our ward team about the improvement area we wanted to work on. A colleague from Yorkshire and Humber Improvement Academy suggested we try a team huddle, or focused gathering. We wanted to reduce falls and discussed how we could focus our huddle on who we were worried about falling that day and what we could do as a team.
We tested our huddle during a shift. Our aim was to go 30 days without a fall, although the team didn’t believe this was possible. A week between falls was rare, so the idea of celebrating 10 days between falls as a bronze certificate began. The dream of a gold certificate of 30 days seemed impossible, with a fear that we would fail.
Measuring and celebrating success
Many ‘plan do study act’ (PDSA) cycles later, we found our feet. The huddle brought together doctors, pharmacists, care support workers, housekeepers, nurses and therapists to focus on reducing harm. Five months in, the statistical process control (SPC) charts started to show improvements with step reductions and 50% fewer falls. Natural spread to five other medical wards followed, as did step reductions.
We learnt that one of the key ingredients to the huddle is data. A simple ‘days since last fall’ chart worked best. Asking when the last fall was, why and what could we have been done differently brings about team learning and a change in belief.
Celebration became our second key ingredient. Our chief nurse and chief medical officer would jump at the chance to give certificates. Our medical admissions units reached their impossible dream of 30 days without a fall, while the older people’s ward went 56 days between falls.
Learning how to scale up
Supported by the Health Foundation’s Scaling Up Improvement grant, in partnership with the Yorkshire and Humber Improvement Academy, we went on our journey scaling up huddles across all wards of five hospitals within three acute NHS trusts. This has brought rich learnings and also given us the opportunity to develop and most importantly, learn. This is not about implementing or mandating anything. It’s about using the science of improvement, and learning the art of coaching teams to adapt huddles in their world and their organisation.
The huddle is only as good as the people, team and organisational values behind it. It allows the team to adapt to the complexities of the shift, bringing them all together to see the bigger picture and have a voice in safety. Leading this work is about:
- relentless commitment and patience, improvement and engagement skills, and a willingness to learn with every team
- meeting every clinical team, understanding their world, and their safety concerns. Listening to their challenges, linking teams together to find solutions and coach them through PDSA cycles
- learning to support teams at the right time, not because a particular ward has ‘a problem’
- providing ongoing support and sharing new learning
- other teams celebrating achievements (via social media, staff newsletters and chief executive bulletins)
- being open about failure to share what doesn’t work, as much as what does.
Our executive team have shown immense visible support to wards, genuine pride in their achievements, but allowed the space for the work to develop and flourish at ward level. The art is not to performance manage the scale-up.
After two and a half years, we have:
- learnt how to huddle successfully on more than 90% of our wards
- reduced falls and cardiac arrests
- improved safety culture.
Staff also feel recognised for the great work they do, knowing they can and will do more. Improvement is a continuous journey of learning. You need to map out the path and learn to understand whether each turn is a setback or a step forward.
Dr Alison Cracknell is a Consultant Geriatrician at Leeds Teaching Hospitals NHS Trust and a member of the Q Community