Four Headers, Zero Metrics: An Empty Huddle Board in the ICU Hallway

A close family member spent time in a hospital ICU recently. The clinical care, as far as I could tell, was excellent. The nurses were attentive. The physicians explained things clearly, and more than once. I'm grateful, and I don't take any of it for granted.

I also walked past a bulletin board in a public hallway, several times a day, for days. It was a huddle board. Or it had been one.

Four headers ran across the top:

• Patient Safety
• Quality
• Patient Satisfaction
• Financial Stewardship

Under the headers were a flyer about an employee appreciation event, a notice about parking, and a memo I didn't read closely. Useful things. Things a team should know.

Metrics posted: zero.

What I Know and What I Don't

I was a visitor, not a consultant, and I want to be careful about how much weight one bulletin board can hold.

I don't know whether that hallway board is where the team actually huddles. Maybe the real board is behind a badge-access door, updated every morning, and the hallway version is a leftover. I've also heard, secondhand, that this health system once ran a serious Lean management system, and that much of it has fallen away. I can't verify that from a hallway. The board is consistent with the story I've heard. It isn't proof of it.

Here's what I can say with confidence. At some point, somebody in that organization printed four headers and put them on a wall in public view. Somebody decided those were the four things that mattered on that unit. And at some later point, somebody stopped putting anything under them. Or they never posted metrics.

The headers stayed.

This isn't the only hospital where I've seen this situation.

A Board Is Not Visual Management

I've written before about the difference between visuals and visual management. A chart on a wall is a visual. Visual management is closer to what Fujio Cho described:

“Know normal from abnormal, right now.”

An empty board fails that test in a specific way. It tells me nothing about whether patient safety on that unit is normal or abnormal today. It does tell me something about the management system, which is that an abnormal condition has been sitting in a public hallway long enough to become part of the wallpaper.

A few years ago, I visited a hospital in June and found the safety cross for April still hanging on the board. Days from the 10th to the 14th were never filled in. I wasn't there to judge anyone. I did wonder what message a stale board sends to the person walking past it on their way to a twelve-hour shift.

You don't need Lean to expect that a hospital unit shows how it's doing on safety and quality. Plenty of organizations do that and have never used the word kaizen.

Boards Don't Go Quiet on Their Own

A board doesn't go blank because the staff got lazy. Something upstream changed. If I were the manager, I'd want to know what.

Maybe the person who owned the board left and it was never reassigned. Maybe reporting got centralized into an electronic dashboard, so the metrics still exist, just nowhere near the people doing the work. Maybe an improvement office was cut in a budget cycle and nobody connected that decision to the boards downstream of it. Maybe leaders stopped asking about the board during rounds, and once nobody asks, updating it becomes unpaid work.

Or maybe somebody posted a real number, it was red, and the response they got made them wish they hadn't.

That last possibility deserves more attention than it usually gets. If posting an honest metric leads to being questioned, defended against, or made an example of, then not posting is the rational choice. The empty board would be a countermeasure. It would be working exactly as designed.

The Contradiction on the Wall

What struck me was the gap between the top of the board and the middle of it.

The headers make a claim: we measure these four things, and we show them to you. The empty space underneath says something else. Every patient, family member, and staff member who walks past reads both messages at the same time, whether or not they'd put it in those words.

I'll admit I stared at “Financial Stewardship” for a while and wondered what a family member sitting outside an ICU makes of that header. Probably nothing. Probably they walk right past. I didn't.

None of this is the staff's fault. They were doing hard work and doing it well. That's the leadership question.

If You Managed That Unit

So what would you do?

One option is to take the headers down. Leaving them up is a small daily contradiction that everyone can see. A blank wall is at least honest.

The counterargument is that the headers are a reminder of a standard, and once you remove them, it gets easier to forget the standard ever existed.

My instinct is that I'd rather work for the manager who takes them down and says, out loud, “We stopped doing this. Here's what got in the way. Here's what I want to restart, and when.” Admitting you stopped is a starting point. Pretending you didn't is not.

And if restarting all four is unrealistic right now, restart one. Pick the metric closest to the actual work, something the team can track by hand, daily, without waiting six weeks for a report. In Lean Hospitals, Theresa Moore from ThedaCare told me there was “not a published standard” for their tracking center boards, and that “more important is the coaching approach more so than the board itself.” A slightly messy board that a team uses beats a beautiful one that nobody touches.

There's a version of the fix that's worse than doing nothing, which is to fill the board back in the week before an accreditation survey. Everyone on that unit would know exactly what happened. So would the surveyors, probably.

Back to the Hallway

I want to say again that the care was excellent. This post could read as ingratitude, and it isn't. Those nurses were good at their jobs.

Whether anyone outside that unit knew how good, in any measurable way, on any given day, I couldn't tell from where I was standing.

If you walked past a board like that in your own building tomorrow, would you notice it, and who would you tell?