Faced with the daunting challenge of opening a new hospital and simultaneously going live with a new electronic health record (EHR) system in 2013, the leaders of Baylor Scott & White Medical Center in College Station, Texas, created a daily “safety huddle” involving dozens of representatives from nearly all clinical and other areas of the facility. The meetings helped bring to the fore EHR-related quality and safety concerns that could be rapidly addressed to protect patients.
“We knew these changes would pose significant safety issues because you had new employees, a new hospital and a new EHR,” the hospital’s chief medical officer, William L. Rayburn, MD, told AMA Wire®. “We knew there would be potential safety opportunities and issues, and that we needed to defuse them as quickly as possible.”
That is where the safety huddle came in. As many as 40 leadership roles and departments were represented in the daily, 20-minute gathering, ranging from the CEO to staff services. One of the questions opened to the floor: “Have there been any quality or safety issues in the last 24 hours?” As physicians, nurses and others spoke up, a recurring theme emerged: problems with the EHR. They fell into these six categories derived from a sociotechnical model developed by Hardeep Singh, MD, MPH, and Dean Sittig, PhD. Among the examples of problems that cropped up:
- Hardware: Device incompatibility made obtaining computed tomography results difficult
- Software: An unexpected design issue made preadmission orders inaccessible
- Clinical content: The EHR misplaced the renal protocol with infusion protocols
- People: A prescription for blood-pressure medication was filled incorrectly; the error went undetected through four steps and the medication was received by the patient
- Workflow and communication: The EHR and the laboratory were not able to process orders of discharged patients as outpatients
- Human-computer interface: Orders for patients transferred to other units were not visible on the new unit
When EHRs do not work
The leading cause of EHR-related safety problems was that the system was working incorrectly. That happened in 42 percent of the issues reported in the daily safety huddles, according to data published by Dr. Rayburn and his colleagues in a Dec. 28, 2016, online-first article in the Journal of the American Medical Informatics Association. Thirty-two percent of the concerns had to do with some element of the EHR technology was missing or linked to user mistakes. In approximately 26 percent of the safety concerns identified, some element of the EHR technology was not working at all.
Over the course of huddles held during the hospital’s first year, about one EHR-related safety or quality concern arose per meeting. Previous research, relying on incident reporting or other methods of gathering information about EHR safety concerns, garnered far fewer reports of EHR problems.
Dr. Rayburn and his colleagues attribute that to the huddles themselves, which “can increase various team members’ situational awareness about EHR-related safety, facilitating identification of concerns and development of plans to mitigate those concerns.”
“What the safety huddle did for us was to allow us to immediately identify issues that we needed to address,” Dr. Rayburn said. “As opposed to the traditional IT approach, which was to put a ticket in. That silos the problem and you don’t see, ‘Oh, my gosh, the ED is having this problem, and so is the ICU, or the med-surg floors.”
Aside from encouraging clinicians and others to attend the daily huddles, leaders at the Baylor Scott & White Medical Center in College Station also rewarded those who made “great catches” on EHR or other quality and safety problems. A single “great catch” of a problem could earn the health professional who spotted it a $25 reward, Dr. Rayburn said. “The supervisor then approves it,” he added. “So the person who made the great catch gets a small amount of money, but most importantly, they get recognition by [their] supervisor.”
It is not yet possible to definitively establish how frequently EHR-related quality and safety problems happen, and Dr. Rayburn argued it would be misleading to infer that the JAMIA study establishes that EHRs are more dangerous than previously believed. That is because the differences in how the problems were reported and addressed confounds any apples-to-apples comparison.
“We are not trying to say that EHRs are dangerous,” he said. “That’s for other people to study. We know that safety and error problems have always been underreported and the EHR begins to really allow us to look at these things. It’s not an indictment of the EHR. We were trying to mitigate the safety and quality issues that invariably will occur when you go live with a new EHR.”
The power of huddling
One of the JAMIA article co-authors is Dr. Singh, chief of the health policy, quality and informatics program at the VA Research Center of Innovation and associate professor at Baylor College of Medicine in Houston.
Dr. Singh lauded the College Station hospital’s approach to using the huddle as a patient safety tool.
“I don’t think a lot of places are taking huddles as seriously as this one,” Dr. Singh said. “It is quite an achievement to bring everybody together to the same table and have an open discussion on what needs to be fixed with the EHR. Very few health care organization leaders are using such proactive methods to understand EHR-related safety problems and implementing improvements based on what they learned ... That’s where the patient safety field needs to go.”
Huddles are also used in the ambulatory care clinics at Baylor Scott & White, Dr. Rayburn said.
“We feel so strongly that bringing people together socially to talk about the day and concerns they have—including quality and safety issues—that it’s extremely positive,” he said.
Learn more about implementing daily team huddles with this AMA STEPS Forward™ educational module. At the 2016 Interim Meeting, the AMA House of Delegates voted to support implementation of a national health IT safety center to “minimize EHR-related patient safety risks through collection, aggregation and analysis of data reported from EHR-related adverse patient safety events and near misses.”
The daily team huddle is just one idea that can help health care organizations improve care. Others will be explored in April at the Collaborate in Practice Conference at the Sheraton Grand Hotel in Chicago. The conference, held by the AMA and the Medical Group Management Association, honors physicians and administrators as partners in leading medical practices to enhance patient experience, improve population health, cut costs and improve the work life of health professionals.
