River Falls Area Hospital, 2025 Quality
Safety First: Enhancing patient and Staff Safety Through Tiered Huddles
River Falls Area Hospital has had a long history of a strong safety culture resulting in a limited number of preventable patient harm events. Coordinated efforts to develop a high reliability safety culture based in safety science began more than 10 years ago with the help of the Agency for Healthcare Research and Quality’s (AHRQ) TeamSTEPPS training and curriculum, focusing on the development of highly reliable safety processes in a critical access hospital environment.
Tiered safety huddles were successfully implemented in 2019 as Allina Health’s journey to zero preventable harm was initiated. Tiered safety huddles, starting at the unit level, promote the daily identification of safety risks as well as prompt follow-up on near miss or actual safety events. This, along with the use of high reliability skills, has contributed to a reduction in safety events, including the achievement of zero preventable serious safety events for extended periods of time.
When three safety events occurred between January 2023 and July 2023, an assessment of high reliability was promptly initiated. The assessment revealed that the tiered safety huddle process had drifted from the original standard work, contributing to an increase in safety events. Tiered safety huddle standard work was reviewed, revised, and implemented throughout the hospital and supported by senior leadership and safety and quality rounding with real-time coaching. A key focus area of both the standard work and coaching was ensuring teams could appropriately identify safety risks and follow the escalation process inherent to tiered huddles. Adherence to tiered huddle standard work exceeded the original goal of 70% and resulted in a reduction of safety events with harm, achieving the goal of zero preventable harm for a period of over one year after the improvement work began. Tiered safety huddles as part of a larger high reliability strategy continue to contribute to the success and sustainability of a positive culture of safety at River Falls Area Hospital.
Tiered safety huddles were successfully implemented in 2019 as Allina Health’s journey to zero preventable harm was initiated. Tiered safety huddles, starting at the unit level, promote the daily identification of safety risks as well as prompt follow-up on near miss or actual safety events. This, along with the use of high reliability skills, has contributed to a reduction in safety events, including the achievement of zero preventable serious safety events for extended periods of time.
When three safety events occurred between January 2023 and July 2023, an assessment of high reliability was promptly initiated. The assessment revealed that the tiered safety huddle process had drifted from the original standard work, contributing to an increase in safety events. Tiered safety huddle standard work was reviewed, revised, and implemented throughout the hospital and supported by senior leadership and safety and quality rounding with real-time coaching. A key focus area of both the standard work and coaching was ensuring teams could appropriately identify safety risks and follow the escalation process inherent to tiered huddles. Adherence to tiered huddle standard work exceeded the original goal of 70% and resulted in a reduction of safety events with harm, achieving the goal of zero preventable harm for a period of over one year after the improvement work began. Tiered safety huddles as part of a larger high reliability strategy continue to contribute to the success and sustainability of a positive culture of safety at River Falls Area Hospital.
