This paper has described the fidelity, time to embed and impact on teamwork and safety culture of patient safety huddles implemented in five hospitals across three UK NHS Trusts as part of The Huddle Up for Safer Healthcare project.
Consistent improvements occurred including: briefings being seen by staff as common, the culture making it easy to learn from others’ errors and the overall patient safety grade assigned to units by staff. These findings align with other studies showing that huddles improved both the number and quality of communication opportunities (2, 14). However, that the improvement in overall patient safety grade was not reflected in improvements in other measurement items suggests the TSC may not reflect factors that staff consider when responding to this question.
Across 92 wards, the rates of embedded PSHs were high (64), taking an average 19.6 weeks to embed. No ward demonstrated all fidelity criteria as originally described by the HUSH implementation team; an average of 4.9/9 criterion was observed. A non-judgemental ‘fear free’ space was observed in almost all PSHs but run chart completion was never observed. Teamwork and Safety Culture scores tended to improve over time across all Trusts. The greatest improvements across the most items were seen in critical care wards but reductions in some items were also seen. The majority of staff reported positive changes but this varied by job role and by TSC item. Nurses in particular demonstrated the most positive changes while doctors showed very few: they were the only staff group who did not relate improved ratings of the safety of their unit. Overall, the findings suggest that embedding PSHs is feasible and effective for changing TSC scores but fidelity to the full set of originally designated criteria is moderate. Therefore, certain criteria may be less essential for promoting a positive teamwork and safety climate and could therefore be adapted as necessary.
The current findings support studies showing that implementing huddles is feasible, effective, and huddles themselves are acceptable to hospital staff (4, 6, 14). Given the extensive barriers to successfully scaling up a quality improvement initiative - for example, the politics of organisations, user engagement and the role of the team (15)- the number of wards that achieved embedded status can be considered a success. However, that moderate PSH fidelity was observed suggests some of the original criteria were problematic for staff. Quality improvement literature emphasises the importance of programme fidelity as the degree to which the initiative is implemented is a potential moderator of its effect (16). Failing to have a PSH led by a senior clinician may appear to be of concern (only 9% of wards succeeded) but, given the high rate of embedding, it does not appear to have worked against the initiative. In fact, this may have facilitated the frequency with which a ‘non-judgemental ‘fear free’ space’ was observed. Therefore, while an effective leader is key for fidelity as in a high performing hospital, (17, 18), the level of seniority may not be.
Of more concern was the poor uptake of the review of the number of days since the last harm (28%), debrief of any harm since the last huddle (35%) and the review of run charts (0%), all of which involve an assessment of the ward’s recent history of safety/harms. The HUSH implementation team speculated that some criteria may be more or less central to a successful PSH and that PSHs would be adapted to the ward team’s needs. It may be the case that staff are reluctant to focus on past harms for fear of reprisal. Cohen et al (2003) surveying nurse attitudes to medication error reporting found that staff were fearful of reporting errors and subsequently being perceived as a poorer nurse and/or having a blemish on their record. More generally, Okuyama et al (2014) (19) found that staff are reluctant to voice safety concerns for multiple reasons including discipline, efficacy and responses of others. However, the frequency with which a ‘non-judgemental ‘fear free’ space’ was observed refutes the proposal that staff were fearful of reprisal. Criteria that were consistently observed may have been simpler to achieve, pragmatic, and perceived as more relevant. Further research should explore these hypotheses and determine whether certain criteria are deemed more or less useful by frontline staff.
Nurses perceived more improvements in TSC items than other staff groups, especially doctors. It is possible that while nurses saw the benefits of regular, current, short and fear free forums to their own practice and therefore the culture of their unit, doctors required different PSH criteria to experience culture change. For example, reviewing historical harms, run charts and days since last harm may have been more demonstrative of culture change for this group, as they would provide a concrete demonstration of improvements in ward safety. Alternatively, the ward-based nature of nurses, compared to doctors who tend to move between wards, might mean that nurses are better placed to observe subtle improvements in communication and culture. Importantly, the poor PSH fidelity may explain why changes in TSC, though positive, were not consistently so across wards and staff roles.
Some ward characteristics identified by the TSC still need improvement. HUSH shows infrequent improvements in some of these factors but these could be built on: for example, staffing levels, reporting concerns/events and difficulty in discussing errors. Reis et al (2018) (20) in a worldwide study of the need for safety culture improvement suggest that the latter could be linked to a culture of blame. In addition, the few negative changes in some TSC items may reflect raised awareness of these factors. Aldawood et al (2020) (14) found that the use of patient safety huddles served to increase awareness of and improvements in safety culture. Critical care wards indicated an increase in frequently being unable to express disagreement; given the high-stakes nature of critical care wards, huddles may have increased perception of a necessarily highly hierarchical setting. Other wards reported an increase in not knowing staff names, which PSHs may have made more apparent. Nursing support staff reported a reduction in the perception that the hospital did not knowingly compromise safety. It may be that by taking part in regular huddles with a range of senior staff who are more familiar with addressing them, they may have become more aware of safety issues, how they occur and how they are managed (14).
The HUSH study had limitations. HUSH was not the only quality improvement initiative running in the hospitals and therefore it is possible that outcomes were confounded by other initiatives. However, other studies have found that huddles are typically a component of a wider patient safety programme, so this is not unusual (21). In addition, Kristensen et al (2015) (22) suggest that there are positive associations between the implementation of quality management systems and improvements in teamwork and safety culture.
Another potential limitation was the use of Developmental Evaluation: having the evaluation team working closely with, and providing feedback to, the implementation team. This meant that the evaluation should be considered as part of the intervention itself, meaning outcomes may have been confounded by the evaluation process. In turn, the evaluation was impacted by the implementation – with the order of ward recruitment continually fluctuating due to coach availability, staffing changes in both the HUSH team and ward staff, and other practical issues such as ward mergers. Additionally there was both a lack of engagement as well as early enthusiasm from some wards. While the evaluation team responded flexibly, some planned data collection opportunities had to change and some wards were lost over time. For example, the first TSC was delivered after implementation began, but before the huddles were embedded. In addition, staff were reluctant to complete the evaluation surveys such as the TSC, leading to small response rates at times and the need to aggregate data.
Implications for Practice
Overall, the findings suggest that PSHs are feasible and effective for improving teamwork and safety culture in a busy, ever-changing hospital context, particularly for nursing staff. Huddles do not lead to an overall increase in ward workload and the cost of supporting the huddle are small compared to the savings per harm (see Crosswaite et al 2018 (8) for a ROI analysis). However, all nine huddle criteria, as originally described by the implementation team, may not be essential to achieve the described positive changes. These findings have three possible implications, one is that huddles could be adapted to include only the most relevant criteria as deemed by frontline staff. Such changes could capitalise on the observed improvements in TSC, producing a larger change both within and across TSC items. Secondly, the TSC may not be appropriate for all clinical areas. The fact that critical care wards felt that they were frequently unable to express disagreement may be a symptom of the organisational structure rather than a genuine barrier for patient safety. Thirdly, PSHs may be particularly appealing and beneficial for nurses as it gives them a regular multi-disciplinary forum for shared communication, reporting and feedback. However, while change in TSC may be facilitated by PSHs, huddles that neglect certain criteria may be insufficient for doctors to recognise the changes in TSC; TSC may raise awareness of poor ward characteristics and therefore further or longer intervention of PSHs may be required. Future work should explore whether the TSC should be specialised for different clinical areas and staff roles or if there is scope for change in communication practices.