High Reliability in Action — A Closer Look at Unit-Based Quality Rounds

Change, even the most ambitious, organization-wide change, begins with a small group of thoughtful and committed individuals coming together. At 11 a.m. on a recent Wednesday, the caregivers on Massachusetts General Hospital’s Blake 8 Cardiac Surgical ICU gathered around a nurses’ station in the center of their unit for a 15-minute huddle that will help Mass General Brigham become the leading health system for quality in the country.

“We’re creating a new process and I’m so proud of all of you because what you have accomplished so far has been amazing,” Nursing Director Vivian Donahue, RN, said at the opening of the huddle with just over 20 physicians, nurses, advance practice providers (APPs), unit staff and hospital and system senior leaders in attendance, including Thor Sundt, MD, chief of Cardiac Surgery for Mass General Brigham.

Blake 8 is the first Mass General Brigham unit to launch unit-based quality rounds, holding their first regular huddle in late October. Since then, the huddle has produced two impactful process improvement initiatives, driven by multidisciplinary collaboration, that are benefiting patients and improving quality. 

The rounds are an on-the-ground extension of Mass General Brigham’s For Every Patient unified quality strategy and a key component of our system’s work to become a High Reliability Organization (HRO) that optimizes our ability to identify and assess risk, provides a structure for reviewing lapses, and ensures individuals feel comfortable speaking up if they spot a potential risk. Rounds have since been rolled out across four additional Cardiac Surgery units — two more at Massachusetts General Hospital and two units at Brigham and Women’s Hospital. The goal is to identify and address risks across a series of metrics that are key to improving patient outcomes, experience, equity and the overall care we provide.

Blake 8’s quality rounds huddle currently takes place every other Wednesday but will eventually move to a weekly session. At the Dec. 11 huddle, Donahue spoke to her colleagues as she stood beside a posterboard displaying Blake 8’s “scorecard.” The scorecard captures near real-time, unit-specific data around key quality domains (Effectiveness, Safety and Efficiency) and associated metrics, including the unit’s performance as it relates to mortality, catheter-associated urinary tract infection (CAUTI) events and length of stay, for example.

“One thing that I want to focus on a little bit this week is how we’re in the red (below target). This is intentional,” Donahue said. “Mass General Brigham has selected our opportunities for improvement, so we expected to be red to start. Our goal is to move toward green.”

Enabling collaboration, innovation and improvement

Compiled by the Office of the Chief Medical Officer, the scorecard provides targeted performance measurement and timely access to relevant and actionable data. Prior to the initiation of quality rounds, Blake 8 would review unit-specific data only on a quarterly (every three months) basis, which hindered the unit’s ability to quickly identify challenges and develop, test and refine interventions to enhance care and increase efficiency, Donahue said.

At the unit’s first huddle in October, a conversation about the availability of hospice care generated a new referral process that connects patients receiving end-of-life care and their families to hospice services and ongoing emotional support for those coping with the passing of a loved one. At the Dec. 11 huddle, Donahue reported that the unit had provided this welcome, deeply appreciated additional support to five patients and their families.

In November, the huddle sparked a collaboration between the unit’s APPs and nurses who together focused on eliminating persistent delays in transferring patients to step-down units. The teams established a new workflow that added nightly, cross-team communication to help identify and prep patients who were ready to have chest tubes and wires removed. Their work is facilitating the early-morning removal of these tubes and wires and preparing eligible patients for transfer by 9 a.m. each day.

The increased efficiency is helping to progress patients faster, reducing their length of stay, and creating capacity to accommodate more cases in the Operating Room or admissions from the Emergency Department.

“Thank you so much to all of you for doing a lot of hard work on this,” Megan Tibbetts, CNP, who is leading the process improvement initiative, said during the huddle. “I know there have been challenges as we adjust to a new workflow. I appreciate your continued feedback so we can collaborate together to make this new process work as best as it possibly can for all of us but, most of all, for our patients.”

The value of the huddle, Tibbetts said after the Dec. 11 session adjourned, is that it enables team members to “put faces to names” and gain a better understanding of the work being done across role groups. The multidisciplinary huddle provides the opportunity to rally the unit around common goals and create connections, strengthened by pre- and post-huddle interactions, that help advance the work being done to achieve those goals.

All in to improve quality

Leadership is playing a critical role in shepherding process improvement initiatives from idea to implementation. Through their participation in the huddle, leaders are expediting improvement efforts by addressing potential roadblocks and engaging key stakeholders across units and disciplines who are needed to operationalize proposed changes.

“We know that there will be bumps in the road as we work through a new process. But because leadership is here with us, we can bring forward a challenge and benefit from an immediate response. That is what makes this work,” Donahue said.

Direct leadership involvement is making a difference in breaking down barriers, said Ken Shelton, MD, chief of Critical Care, Department of Anesthesia, for Mass General Brigham. “This is the first time that we’ve had hospital leadership together at rounds, and it is helping to prevent any perceived disconnect between executive leadership and the bedside staff,” he said.

Everyone who participates in the huddle is encouraged and empowered to speak up when they see a potential risk to the team’s ability to make progress within the identified domains. Frontline clinicians know their patients best and the goal of unit-based quality rounds is to harness their expertise to identify risks and drive improvements quickly.

“It gives everyone a voice and requires leaders to be engaged and responsive,” Sundt said. “We’re all in this with the same purpose – to deliver the highest quality, exceptional care to our patients.”

Mass General Brigham will gradually expand the adoption of quality rounds throughout our academic medical centers as well as our specialty and community hospitals over the next year and beyond. Meanwhile, teams across the system will continue to participate in HRO training that will help us deploy the high reliability model systemwide.

After the huddle on Blake 8 finished, Donahue drafted a meeting summary that she emailed to the unit’s 140 team members to ensure all are kept aware of the progress and initiatives underway.

“I’m impressed with all of you,” she said at the huddle. “You’re so invested in this work. You know that it’s important to our patients and you’re doing everything you can to move us forward.”