Monday Morning Safety Huddle
When the pulse is changing rapidly, assess it
frequently.
• Patient Safety and Quality has become the number one
priority at Windsor Regional Hospital since our 2008 Strategic Planning.
• Awareness, communication and timely access to real-time safety & quality data are
solidly anchored in Huddle Reporting.
• Weekly Huddle Meetings (10-15 min) are attended by all Clinical & Support Service
Directors and where:
– Key Indicators and their weekly Action Plans are reported, these form the basis
for improvement; and
– Everyone is accountable and responsible for results and actions.
Huddle Report & Weekly Review
Sample1 of 11 Indicators
Action reviewed and revised based
on indicator tracking
ACTION PLAN
DATA REPORTED
July 9
Education and implementation of the Morse Tool - implement
comfort rounds - review preliminary result from the pt safety
culture survey
July 13
5N continues to use Morse and follow progress. Begin to
investigate the implement Comfort Rounds
July 20
Develop Plan of Care Draft for Fall Risk Reduction Strategies
documentation
Test comfort rounding utilizing trigger tools for staff
Adapt intervention stating accompaniment to procedures to
reflect communication of fall risk to other depts, i.e. DI
July 27
Develop communication tools & methods, e.g. SBAR, white
boards, signage, rounds, transfer to other dept (e.g. DI)
perhaps with ADT flags. Share results of environmental
hazards survey with staff for validation and recommendations.
Next: The “Quality of Care” Report
Checking the pulse is a starting point but that doesn't
say enough...deeper assessment is required to get a
full understanding of the condition.
• Capitalizing on the Weekly Huddle’s momentum, Windsor
Regional Hospital introduced a monthly Quality of Care
Reporting System.
–
Disseminated to Hospital Leadership, Quality of Care Board Committee, Board of
Directors and MAC.
• Quality of Care Reporting features:
– High-level “roll-up” with a red-green-yellow format providing an overview of
each of the 24 quality indicators in relation to target and goal;
– Dynamic representation of data with individualized drilldown; and
– Action plans with built-in accountability which facilitates problem-solving for
corporate-wide improvement.
Quality of Care Reporting – continues to evolve
If the pulse and heart rate fluctuate, visual monitoring is necessary
to increase awareness of the condition and provide treatment.
• The next step was to post the interactive files on
the hospital intranet every month prior to board and
committee reporting enabling staff and
departments to monitor results electronically
Sample List of Indicators
Dynamic electronic reporting
with drilldown capability
Results overview
We’re all in this together
Quality of Care indicator
improvements over
past year:
50% improvement in AMI
Pathway compliance;
90% hand washing
compliance;
20% improvement in
documentation quality;
Reduced Hospital Acquired
Infections
Next on the Quality Agenda
… Taking it Public
www.wrh.on.ca
Asking and answering the question “is this result good
enough for our patients” set the stage for cultural change
across the organization. Meeting face to face each week
with the leadership team to review progress with specific
patient safety and quality indicators and to develop action
plans to improve the previous weeks results kept the focus
on the changes that were required.
Karen McCullough, Vice President, Acute Care, CNE
Once the WRH Board of Directors provided the needed
“shock” to the organization to focus on quality and safety
through its strategic plan – its vision, mission, values and
strategic directions – the pulse of the hospital and its
patient has been consistent, stead and healthy.
David Musyj, President & CEO
Contact Information
Corry O'Neil, RN, BScN, MEd,
Organization Effectiveness, Patient Safety and Quality
1995 Lens Ave, Windsor, Ontario N8W 1L9
519-254-5577 ext. 52414
Nicole M Sbrocca, BMSc
Decision Support
1995 Lens Ave, Windsor, Ontario N8W 1L9
519-254-5577 ext. 52716
Matthew Grayson, CD, BSc
Decision Support
1995 Lens Ave, Windsor, Ontario N8W 1L9
519-254-5577 ext. 52442