Use of Daily Interdisciplinary Huddles to Improve Communication and Collaboration

Staci Wuchner Tyler Wysong

Alessa Quinones

Objectives

• Overview of high-reliability organizations and accountable care organizations

• Overview of importance for daily communication

• Review of scholarly article• Review of methods and findings from

field exploration• Recommendations

Introduction

• Healthcare providers’ goal is to provide efficient, cost-effective, quality care to patients

• High-Reliability Organizations (HRO) seek to provide this type of care, with zero defects

• Accountable Care Organizations/ Units (ACOs/ACUs) assist with achieving the goals of becoming HROs

Introduction

• Within ACUs, interdisciplinary groups come together to provide coordinated, high quality care to patients

• The Institute of Medicine recommends that interdisciplinary teams be established to improve communication and coordination among the team members.

Background• Interdisciplinary collaboration improves patient

outcomes and decreases healthcare costs – Poor interdisciplinary communication and

collaboration is linked to significant patient harm

– The changing context of healthcare necessitates personalized care:•Diverse and aging populations•Staffing shortages•Rising healthcare costs•Complex organizations

Background

• According to Zwarenstein et al. (2013), “many problems of coordination and communication may arise from lack of a common cross-team understanding of the care priorities for a specific patient at a specific time and the resulting failure of individual team members to align their activities to those priorities, rather than simple miscommunication” (p. 2).

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Background• Lack of coordination can lead to:

– Team confusion– Dissatisfaction by patients and families– Discharge delays– Readmissions– Adverse events (falls, infections, etc)

• Deliberate face-to-face communication is better able to facilitate “common understanding of patient needs and alignment of professional priorities” (Zwarenstein et al., 2013, p. 2) rather than asynchronous electronic communication methods.

Background• Systemic, organizational, and interactional

components will determine the success of interdisciplinary collaboration

• Huddles must be integrated into the daily workflow

• For effective team work, members must:– Work together closely– Have regular and timely meetings– Have frequent communications with each

other in order to provide optimal patient care

Background• Daily interdisciplinary huddles have been

established in many institutions to improve interdisciplinary communication• Allows information sharing and aids in

reaching consensus regarding the patient’s treatment plan and discharge goals

• Recent article in Modern Healthcare:• One New York University medical center

improved communication and decreased hospital length of stay by instituting daily interdisciplinary huddles

Scholarly Article

• Health care huddles: Managing complexity to achieve high reliability (2015)– Complex Adaptive Systems (CAS)

framework guided the study•Emphasized conversations, relationships,

culture– Study used literature review, direct

observation, and semi-structured interviews to understand HOW and WHY huddles have been useful in healthcare.

Provost, S.M., Lanham, H.J., Leykum, L.K., McDaniel, R.R., & Pugh, J. (2015). Health care huddles: Managing complexity to achieve high reliability. Health Care Management Review, 40(1), 2-12.

Scholarly ArticleHuddles

ObservedParticipants

Internal medicine clinic morning huddle

• Medical director• Clinicians,• Administrative staff

Pediatric hospital inpatient morning/afternoon huddle

• Manager of patient services

• Safety officer• Interdepartmental

representationDaily operations brief

• Manager of patient services

• Safety officer• Administrator• Employees

Operating room huddle

• OR clinicians• Staff

Pharmacy huddle • Head pharmacists • Rotating residents

Scholarly Article

• Themes from observations and interviews

Conversation•Topics that might not otherwise be discussed•Conversations between individuals who may not otherwise communicate•Opportunities for conversations that span boundaries and hierarchies

Relationships•Relationships among individuals who might not otherwise interact•Newly trained clinicians can foster new shared understandings of work to be done

Culture•The repetition and consistency become part of the fabric of the organization•Diverse group of care providers assess events both routine and unexpected, leading to new shared understandings

Implications from Scholarly Article• Huddles provide a venue for meaningful

interaction where participants polish communication and relational skills

• How can managers maximize the likelihood of effective huddles?– Exhibit expectations for all individuals to

contribute during huddles by modeling this behavior

– Commending generative behaviors during huddles

– Setting expectations for reporting and praising transparency initiatives

– Build into the daily-work routine by having huddles at regular intervals (daily)

Methods• To improve interdisciplinary communication

and collaboration, IU Health Methodist Hospital utilized the Transformation Team to restructure the healthcare provider’s work design– The daily huddle solution was rendered during

a week-long Rapid Improvement Event (RIE)• To better understand the interdisciplinary

dynamics found within the daily huddles, our group observed several daily huddles and interviewed different disciplines. – This project was approved/supported by the

Director of Nursing Practice & Quality and the Transformation Office leader

Methods• Huddles observed:

– A4North Trauma floor– A2/3North Cardiovascular floor– A5North/South Neuroscience Progressive Care Unit

and floor– A6N Pulmonary floor

• The huddle observation forms included questions such as:– Who was the huddle facilitator?– In what order were the patients discussed?– What was the overall flow of the huddle?– What was the overall feel of the culture/climate of

the huddle?– Did you identify any weaknesses, issues, or

concerns during the huddle process?– What were the strengths of the huddle?

Findings: Huddle Observations• Process variations:

– Two facilitated by providers; two facilitated by charge nurse

– Most discussed patients by room number; one discussed each patient by provider

• White boards:– Information on these white boards included:

– White board physically moved for each huddle on one unit

• Patient’s Initials • Actual Length of Stay • Estimated Discharge Date• Room Number • Estimated Length of Stay • PT Ordered• Provider Team • Disposition • Discharge Orders/Barriers to

Discharge

Findings: Huddle Observations• Overall climate of the huddles:

– Laid back and open– Members allowed to speak freely– No hierarchy or tension

• Flow of the huddles:– Somewhat disjointed– Not all providers were present, leading to

“skipping around” to different patients– Most conversation between provider and

case management about length of stay

Methods• Disciplines interviewed:

– Direct care charge nurse– Physician– Nursing manager– Case manager– Clinical Nurse Specialists

• Questions related to the daily huddles included: – Tell me about your huddle process. What do you

like (strengths) /dislike (weaknesses) about this process?

– If you could change anything about the huddle process, what would it be?

• Qualitative data analysis findings were shared with some of the interviewed participants to see if our themes were an accurate representation

Findings: Interview Questions

• Likes/ strengths of the huddles Interdisciplinary

involvement“The people; it’s so important to have multiple providers represented, such as ortho[pedics], trauma, hospitalists, as well as nursing, case management, and social work.”

Engagement/communication“All team members have an opportunity to connect. There is great information sharing between the disciplines.”

Action-oriented“The daily huddles hold people accountable and responsible for follow up. I like it when the various disciplines are present so they are able to help solve problems in the moment.”

Effective and timely process

“We have a very good process and hit the things we need to hit in a timely manner. The huddle keeps the team focused and is vital to patient outcomes.”

Findings: Interview Questions

• Dislikes/ weaknesses of the huddles:Inefficiencies in the huddle

process“Many huddles occur at the same times and prevents the physicians/providers from attending all huddles on units where their patients are located. It’s hard to make sure we are making efficient us of the time without wasting time on people waiting.”

Variations in the huddle facilitation

“Different charge nurses facilitate the huddles differently. Some talk about unnecessary things, or spend too much time on issues that aren’t pertinent, like psychosocial problems. We need to follow the standard work that was created from the RIE.”

Lack of focus on quality“We are too focused on length of stay; we could introduce other things to the huddle that we could impact, like lines, foleys [indwelling urinary catheters], and falls.”

Not all of the necessary disciplines are present

“Not all providers are able to come to the huddles; hospitalists are good about coming, but Cardiology isn’t always present, and sometimes they are the only providers following certain patients.”

Findings: Interview Questions

• What participants would change about the huddles (opportunities):Engagement from all

providers“We need to have more provider engagements so they are more proactive instead of reactive.”

More focus on patient quality

“We are at a point in the process where we could begin to introduce more quality information. We should be able to introduce other things with the group that could be impacted with the members that are present.”

Follow standard work processes to decrease

variations“We should make sure facilitators of huddles are following a script for what needs to be discussed so they stay on task; there are currently too much extraneous, irrelevant discussions.”

Inclusion of bedside nurses“I wish we could improve the relational coordination and interdisciplinary communication between providers and nursing. We need a way to include RNs because they could glean and give a lot of information to the conversation.”

Recommendations• Electronic white board provided to every

unit – Decrease the need to physically move the

white board– Ability to add other columns for new initiatives– Easier readability– Improve communication between the huddle

and the bedside nurses

Current White Boards

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Electronic White Board

Recommendations• Revive the use of standard script developed

in RIE– Reiterate importance of all facilitators using

script– Revise/update script with current huddle

participants to ensure all necessary topics are included, and to add any quality points

– The script will assist the facilitator with staying on track, finishing in a timely manner, and focus on all of the necessary information

Recommendations

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Recommendations

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Recommendations• Develop a process for getting information from and

back to the bedside nurses– One unit makes copies of their “dot” sheet and

passes them out to bedside nurses after huddle– A similar process could be developed for gathering

information prior to the huddle.• Ensure all providers (or a designee) are present for

all huddles– Stagger huddle times so they are not overlapping– Develop a process where physicians/practitioners

can provide information to the charge nurse if unable to attend huddles

– Communicate with upper leadership the need for all providers to be present at huddles; garner their support of and accountability for the daily huddles

Recommendations• To motivate participants in the interdisciplinary

huddles, it may be beneficial to set goals with measureable outcomes that can be communicated back to the group – Goal Setting Theory:

• Setting the goal• Obtaining goal commitment• Providing support elements

• The huddle’s infrastructure should support these goals by tailoring the huddles to ensure timely and effective communication

• Team building workshops may help to improve the relational coordination, effectiveness, and cohesiveness between members of the interdisciplinary huddle participants

Recommendations

• This presentation, including recommendations, will be presented to the Medical/Surgical Value Stream Analysis Team for knowledge dissemination and possible implementation

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Questions?

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