Background

Communication failures among healthcare personnel are significant contributors to medical errors and patient harm.¹ When used consistently, huddles – a technique to enhance team communication – are an effective and efficient way for healthcare teams to share information, review their performance, proactively flag safety concerns, increase accountability, and ensure that safety interventions are hardwired into the system.^2-4 Huddles empower and engage frontline staff in problem identification and build a culture of collaboration and quality, thereby enhancing the ability to deliver safer care.^2,3,5

Huddles have been shown to improve patient safety in a range of areas such as wrong-site surgery, medication errors, poor hand hygiene, unrecognized clinical deterioration, serious safety events, and near misses.^2,3 Huddles increase individual and collective accountability for patient safety, designate a fixed time during the workday or shift to focus on care coordination, facilitate immediate face-to-face clarification of issues, result in fewer interruptions during the rest of the workday, and foster a culture of empowerment and collaboration in healthcare teams.^2,3,5

Definition

A safety huddle, in the context of healthcare delivery, is a short meeting involving interdisciplinary healthcare team members– no more than 10-15 minutes in duration – that proactively enables teams to focus on patient safety, thereby facilitating team communication.⁶ The overall goal of the safety huddle is to review the previous day’s work to identify safety issues as well as to proactively identify safety concerns for patients to be seen on the current day. The purpose of the huddle is to share information and highlight concerns to be followed up – not solve issues. Ideally, concerns raised during huddles are then directed to the appropriate person or groups for resolution, such as supervisors or patient safety committees.⁷ Safety huddles are also called daily safety briefings, daily check-ins, or daily safety calls.

Structure

A huddle typically occurs at a consistent time and location at the beginning of the workday in outpatient settings, and at the beginning of each major shift in ambulatory surgery and inpatient units.⁶ The huddle process is most efficient if team members stand in front of a visual management board that provides information on the agenda for the huddle, current safety issues and performance on safety metrics. The expectation that participants remain standing increases the likelihood that the huddle will remain brief. It is important to ensure that the location of huddles and visual management boards complies with patient privacy standards in each healthcare organization.⁶

The huddle leader gives every team member the opportunity to contribute by going around the group and inviting each individual to share one positive observation and one concern about patient safety from the previous day. The team leader encourages others to listen and to avoid interrupting the person speaking. Issues with non-functional or defective equipment, or concerns about patient rooms are included in these discussions. TeamSTEPPS recommends the “Concern-Uncomfortable-Safety Event” (CUS) technique to minimize ambiguity in communicating the seriousness of patient safety issues.⁷ This communication technique uses escalating levels of assertive statements such as "I am concerned", "I am uncomfortable" or "this is a safety issue" to clearly convey the gravity of the event to the listener.⁸

A designated team member notes issues that need to be followed up and the individual responsible for this follow up on the visual management board. The advantage of tracking follow-up items on the visual management board is that team members can indicate and share, in real time, how and when safety issues have been followed up and resolved.

Following a review of the previous day, the next step is for a designated team member to preview selected patients to be seen that day who may be at risk for potential patient safety issues and to outline plans to prevent and address those issues. Examples include patients who may be on medications that could increase their risk of falls or bleeding, patients with indwelling central venous or urinary catheters, or patients with similar names. An efficient way to record and track these discussions is to use a visual management board that has a table to list patients and safety issues.

The huddle leader provides updates on recent or upcoming relevant patient safety announcements and initiatives, such as changes to high-alert medications and adherence to standardized checklists, which are ideally posted for future reference on the visual management board.⁶ The leader then thanks attendees and announces that the huddle has concluded, which clearly signals to staff that they can now move on to their next task. Ideally, patient safety leaders in the organization are invited to attend huddles periodically to keep them updated on the huddle process and current and emerging safety issues across the organization.

Figure 1: Pocket card with patient safety huddle agenda

Context

High reliability organizations (HROs), such as the aviation and the nuclear power industries, are designed to perform safely and reliability despite their intrinsic complexity and unpredictability.⁹ Huddles are employed in HROs to enable frontline staff to proactively share safety concerns. Huddles illustrate the application of the five key principles of HROs, namely, actively tracking unexpected events and near misses (preoccupation with failure), identifying root causes of safety incidents (reluctance to simplify), recognizing the complex and unpredictable nature of healthcare (sensitively to operations), promptly addressing issues that are raised (commitment to resilience), and recognizing that frontline staff are well-positioned to recognize potential failures and opportunities for improvement (deference to expertise).⁹

The Agency for Healthcare Research and Quality and the Department of Defense developed TeamSTEPPS 2.0 as a methodology to improve teamwork and communication between healthcare teams and to foster a culture of patient safety.  Huddles are recommended as a teambuilding tool in TeamSTEPPS to increase situational awareness-- the ability of individuals to monitor and identify cues in their environment that enhance their likelihood of recognizing aberrations and their influence on patient safety.^7,8

When planning the implementation of a huddles in new setting, attention needs to be paid to mitigating potential challenges, which include constraints in time, personnel, workload, and the possibility of reinforcement of hierarchies if the active involvement of junior team members is not emphasized at the outset.^3,4

Although this primer focuses on huddles as a mechanism to ensure patient safety in health care organizations, huddles can be used in any setting to improve information exchange, review workflow, and share patient care plans with the goal of ensuring high quality care and optimizing team communication.¹⁰ For example, huddles can be used in the outpatient clinic setting to identify preventative care gaps and chronic disease management needs in patients scheduled for appointments that day, or to announce the availability of seasonal influenza vaccines or new point-of-care tests in the clinic. Huddles are an efficient communication technique to allow teams to share information, identify concerns, collaborate, and effectively engage interdisciplinary team members.¹

Ulfat Shaikh, MD, MPH, MS
Professor of Pediatrics University of California Davis School of Medicine
Clinical Quality Officer, UC Davis Medical Group

References

1. CRICO Strategies. Malpractice risk in communication failures. Boston, MA. 2015.
2. Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics. 2013;131(1):e298-308. [Free full text]
3. Goldenhar LM, Brady PW, Sutcliffe KM,et al. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22(11):899-906. [Free full text]
4. Stapley E, Sharples E, Lachman P, et al. Factors to consider in the introduction of huddles on clinical wards: perceptions of staff on the SAFE programme. Int J Qual Health Care. 2018;30(1):44-49. [Free full text]
5. Dingley C, Daugherty K, Derieg MK, et al. Improving Patient Safety Through Provider Communication Strategy Enhancements. In: Henriksen K BJ, Keyes MA, Grady ML, ed. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville, MD: Agency for Healthcare Research and Quality; 2008. [Free full text]
6. Institute for Healthcare Improvement. Patient Safety Toolkit Essentials: Huddles. Cambridge, MA. 2019. [Available at]
7. Daily Huddle Component Kit. Content last reviewed June 2017. Agency for Healthcare Research and Quality, Rockville, MD. [Available at]
8. TeamSTEPPS 2.0 Fundamentals. Content last reviewed June 2019. Agency for Healthcare Research and Quality, Rockville, MD.[Free full text] Accessed January 2020
9. Weick KE, Sutcliffe KM. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. 2nd ed. San Francisco: Jossey-Bass; 2007.
10. Rodriguez HP, Meredith LS, Hamilton AB, et al. Huddle up!: The adoption and use of structured team communication for VA medical home implementation. Health Care Manage Rev. 2015;40(4):286-299. [Available at]