As leaders, we like to think we have all the information we need to address issues effectively and efficiently; but in reality, the information we have is often lagging, coming to us in post-problem, aggregated reports. The information that leaders really need is at the front lines and in real time; and, in just 15 minutes each day, leaders can communicate and align the organization to what is most important.
A significant amount of any health system’s knowledge lives in the heads of its caregivers; providing them with a fast and convenient way to escalate that information to leadership can have lasting impacts on response times and critical action plans that resolve safety, practice, access, and stewardship issues.
That communication channel can also build a culture of respect and value within an organization and bridge the age-old “does management care?” gap by showing caregivers that leadership is listening to them and addressing issues proactively.
Intermountain Healthcare learned early on that it is not enough to escalate issues and ideas from front line to manager; there are items that must be escalated even further up the chain of command, including up to the executive level. So the health system has implemented daily, tiered escalation huddles that start with frontline caregivers (Tier 1) and end with the executive leadership team (Tier 6) — all occurring before 10:30 each morning.
15 Minutes a Day at Tier 6
The huddles are brief meetings in which the participants stand around huddle boards — whiteboards divided into sections, showing dashboard metrics, charts, lists of new ideas, and other information. In Tier 1, frontline caregivers convene to review safety events and other KPIs, as well as the resources needed to complete their daily tasks or implement new ideas.
Relevant metrics and issues are then reported up through additional tiers based on escalation protocols involving different levels of management, until the most critical information — matters needing system-level attention — reaches the most senior executives in Tier 6. Through this process, Intermountain is able to get data and issues to the CEO within 24 hours, ensuring that leaders are aware of problems and able to resolve them in a timely way.
At the Tier 6 huddle — scheduled for just 15 minutes each day — the executive leadership team stands before its system-level huddle board and receives reports on issues from group leaders, hospital CEOs, and central functions such as information systems, legal, and communications. Some participants are present in person and others call in. The reports concern matters that need the immediate and collective attention of the top executives, with a particular focus on removing barriers that interfere with caregiving.
Leaders then write action plans and give follow-up reports in subsequent Tier 6 huddles to close the loop on escalated items. The escalation items and the process itself are reviewed quarterly to ensure that the program addresses key organizational priorities and facilitates the ability to adapt to the trends discovered through the escalation process that require additional transparency or focus.
One of the most important benefits of this process is the early identification of trends — which allows for speedy interventions, sometimes leading to an initial corrective action within 24 to 48 hours. Hospital-acquired infections, downtime of information systems or equipment, power outages, caregiver injuries, patient falls, capacity and access issues, and other performance indicators are tracked continuously. For example, senior leaders can address capacity issues at one facility by coordinating diversions to other facilities, keeping patients within the Intermountain system. Safety events can be investigated immediately, with system-wide alerts sent to prevent similar events. Caregivers can detect and quickly address epidemiological issues such as E. coli outbreaks.
Intermountain’s process helps operations “return to green” much more rapidly compared to the older process in which information came to management’s attention on a slower periodic basis, sometimes weeks or even months after events. Issues can be addressed and resolved without reaching the Tier 6 level. For a period of nearly 10 months (April 17, 2017, through January 30, 2018), the program has assigned and closed 305 actions at the Tier 6 level.
The Tier 6 huddle also performs an important secondary function: It allows leaders from across the system to collaborate on issues they might have previously thought they alone were experiencing. Sharing practices that are working well — and those that are not effective — leads to improved consistency, transparency, and performance system wide. Often, great ideas developed in one area can be rapidly replicated in other areas, improving outcomes and reducing inappropriate variation in quality and cost.
After less than 1 year of daily Tier 6 huddles, the gains are measurable, and participants have faster response times, better awareness, and stronger collaboration in solving problems and preventing new problems. Intermountain is addressing safety issues more effectively. Patient and customer service issues are identified and resolved faster. Leaders see capacity more clearly, which allows for more control over transfers out of the system and hospital diversions.
Examples of Success
One of the most compelling examples of the benefit of the escalation huddles is an improvement in the downtime of imaging equipment. The huddles revealed a pattern of delays in repairs to MRI, CT scan, and other imaging devices, and Intermountain discovered the delays were often caused by international shipping processes, where the parts were coming from abroad and were delayed going through customs.
Intermountain discussed the problem with the device manufacturers, who were able to streamline their international shipping processes. The result was significantly faster arrival of needed parts and significantly reduced equipment downtime. And all customers of these suppliers benefited — not just Intermountain.
Other improvements include:
> Capacity improvement: We receive daily reports on units at capacity and transfers out of the system. Early in the process, it was evident that we transferred a number of patients out of our system due to capacity issues for behavioral health needs. This led us to: 1) report where we had capacity, to help reduce transfers out of the system; and, 2) analyze the out-of-network service requests and approvals our insurance company, SelectHealth, was receiving, as well as the behavioral health network of providers. For example, out-of-network Service Approval Requests declined from 400+ in January 2017 to 147 in August 2017, as access/availability of contracted providers increased.
> Patient safety: Rapid training on new bedside rail equipment was implemented system wide when a caregiver experienced a safety issue with patient.
> Safety alerts: Safety events are communicated up through the huddles and a safety alert is communicated back down through the organizations for initial corrective action within 24 to 48 hours. Dozens of actions have been communicated through this process, including initiating a number of national recalls.
> Staff concerns: Grievances received in the C-suite were down 25% from a year ago after only 3 months into the Tier 6 huddle process.
> Information alerts: Pharmacy shortages and alerts are sent out immediately enterprise wide.
> Patient access: Medical group clinics reported marked improvements within 3 months; phone access (8-5, M-F) was available at 99% of clinics, up from 53%; appointment availability reached 86%, up from 53%; and extended clinic hours were available at 83% of clinics, up from 49%.
> Best practices: Utah Valley Hospital NICU implemented the UCLA Medical Center NICU safety protocol after learning of it from a grandfather visiting the UVU NICU.
Intermountain continues to develop its tiered escalation huddle process; for example, leaders continue to refine the list of key performance indicators that should be reviewed in Tier 6. But the benefits of the process are already clear: faster response, better sharing of best practices, enhanced esprit de corps, and improved safety, quality, access, and efficiency.
It all adds up to better care and service for patients. In just 15 minutes a day, health system leaders can know what frontline caregivers know and how they can support the people who do the work. That may be the most powerful information to have in health care.