5 Tips to Improve Huddles (11 mins)

Is it possible that one of our top safety interventions could increase the risk of patient harm? Why do some huddles seem so fruitful while others fall short? This episode shares 5 pitfalls of the typical staff huddle with tips on how to improve their productivity without increasing the risk for clinical errors.
Key Points:
-Reality is not like the research
-The unforgiving med pass
-Opportunities for engagement

References:
-Pimentel, CB; Snow, AL; Carnes, SL; Shah, NR; Loup, JR, Vallejo-Luces, TM; Madrigal, C, Hartmann, CW (Sept. 2021). Huddles and their effectiveness at the frontlines of clinical care: a scoping review. J Gen Intern Med, 36(9): 2772-2873. DOI: 10.1007/s11606-021-06632-9. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8390736/.
-Greenberg, M (Jan. 14, 2014). Feeling Deprived Can Lead to Some Illogical Behavior. Psychology Today. https://www.psychologytoday.com/us/blog/the-mindful-self-express/201401/feeling-deprived-can-lead-some-illogical-behavior.

Transcript

I keep seeing people share that hospitals should make sure they do huddles because they are so important to safety. There were studies to back that up, where the huddle was modeled somewhat on the idea of gembarounds. These huddles opened a feedback loop for staff to casually mention safety concerns to leadership in a safe and non-punitive environment while standing around in a circle at the nurse’s station. 

It’s one of those methods that people either love or hate, and regardless of the side they are on, they are passionate about their position. It is one of the most polarizing issues that no one talks about anymore – we only share our ingrained positions on the matter, but discussion and further innovation stalled out a long time ago.

I’d like to change that. For one thing, I think huddles have become a safety hazard rather than a safety intervention and that saddens me because the idea isn’t a bad one. And while I know that some of you are already crying out at the apostasy of these statements, others are nodding their heads because in their personal experience, it becomes apparent that these promotional studies are not based in reality. Something is clearly missing from the real-life huddle experience and the fairy tale study experience. There must be some magic element that is missing that makes our huddles far less fruitful than the ones in the storybook medical journals. But they could be great, I do believe in the theory of it, and that’s why I am bothering to point out the flaws and opportunities of this favorite intervention that administration likes to brag about while clinical staff roll their eyes and try to find excuses to skip.

You see, we don’t live in a research bubble where people have time to listen to us casually mention safety concerns. In real life, leadership is haggard from trying to find someone to work night shift, worried that they’ll have to work the shift themselves if they can’t find anyone, and they’re drinking their 5th cup of coffee while they wipe the exhaustion from their reddened eyes. In real life, staff are afraid to be identified as troublemakers who always bring problems to their overworked leaders. In real life, if nobody’s going to die from the problem right now, it’s not a priority. These huddles are nonproductive at best, and potentially damaging at worst. So I’ve created a Top-Five list of reasons why huddles fail, with tips on how to make them better.

The first problem with huddles is that they are typically a one-way street. They are touted as a great way to get in touch with the frontline workers, but that is not reality. Huddles are not a feedback loop or even an outlet for staff, but they are more like rushed department meetings where policies and expectations are thrown out verbally and the expectation is that we will apply the change immediately and remember forever.

A lot of research on huddles occurs in an environment that is not blind – what I mean by this is that generally, everyone in the study is aware that the team is trying to see what difference a huddle can make and is trying to do the best possible huddle for the duration of the study. To have this attitude, these study participants are already luxurious elites in the world of healthcare, because most healthcare workers re so burned-out they are focused on survival rather than doing their best work in a thriving moment of self-actualization.

What we might learn from these studies is that focusing on something in healthcare – whether it be fall reduction, safe surgeries, infection prevention, or huddles – and then trying to do it really well, has a positive effect for the duration of the study, which is usually around three months or so.

I know that frontline huddles are not the same species as the ones measured in studies that show them to be fruitful in patient safety because the number one stated reason for huddles is actually staff engagement,[1] but staff engagement is not something that occurs in a majority of real-life huddles.

The second reason why huddles fail is that these rapid lectures are often forced on staff at the worst time of the day – during meals and med passes. And this scheduling issue is national – if you think about it, everyone across the country, the world even – eats, takes their medications, and checks their blood sugar at the same time. Despite this well-known fact, most huddles occur during meals and med passes, to the consternation of the nursing staff. 

So while PT is getting your patient up to the chair to eat, you half-listen to the vital information shared in your huddle while watching for the breakfast trays to arrive. You know that if you don’t get their blood sugar checked before that breakfast tray goes in, that you’ll never get them to wait. You know that they need their metformin before their meals as well and you still haven’t finished report on your seventh patient, who just arrived at shift change. For a 12-hour shift, we could schedule huddles at 3pm when staff can pause from the patient’s schedule and pay attention, and I’m telling you, that alone would make a world of difference.

Because of this poor scheduling, huddles today are guilty of provoking a scarcity mindset. We don’t have enough time, enough resources, hurry up and be perfect is often the message of huddles today. Coming off of a pandemic, getting rushed at the nurse’s station triggers a host of stressors and bad memories of never having enough, of not being enough, and wishing there was time to rest. Dr Greeberg, in an article in Psychology Today, explains the effect of scarcity: “Dealing with extremely limited resources increases the problems and barriers that we have to deal with, resulting in mental fatigue and cognitive overload.”[2]

We need to schedule wisely so that time and careful listening does not have to be a scare resource on the clinical floor. We need it, but our patients need it even more. That is a recipe for safety and engagement, and it all begins with a simple schedule change.

Third, instead of throwing out policy changes like verbal graffiti, try to actually foster feedback loops that someone slightly less sleep-deprived could monitor – I’m not just talking about a neglected suggestion box by the elevator, but a legitimate form that goes to quality analysts, or an IT innovation lab website that allows staff to provide feedback on the EHR tools. Anything that would allow staff to place requests at a time that’s convenient for them and their patients. When you huddle or host a department meeting, it might help to ask the same question or questions each time – maybe ask every week for an example of something that’s working well, something that could be improved, and something that could be a solution to an old problem. That routine of asking the same question each week will help staff plan what they would like to share and it puts a little bit more power in the hands of staff to share and not be penalized – it is encouraging to be asked a specific open question. The usual modus operandi is that information is shared rapidly and then the leader asks if anyone has any questions while they look at their watch and nonverbally discourage any staff comments as an interruption.

And speaking of feedback loops, those policy updates are important. No one wants to be the one who was distracted by a patient tray and missed the fact that we just changed our heparin policy.

Instead, number four is to try sharing policy updates using education and marketing principles. The folks in the advertising business have spent a ton of money figuring out exactly how to reach people with a message and we could learn a lot from them in the healthcare industry. For example, in advertising the general rule is to share the message at least 5 times in different ways, maybe using visual tools, stories, video, and plenty of repetition. This means a new heparin policy might be sent by email, shared verbally, posted with a memorable meme on the announcement board, shared as a video on the department’s internal website, and included as a flyer with every heparin order from the pharmacy. I can’t actually think of any institutions that do such a thing, but it sure would be nice for our tired brains to have some repetition and an acknowledgement of different learning styles. 

Number five, a lot of huddles are actually just care coordination rounds that don’t move past the nurse’s station and fail to include the patient. Rather than manage throughput in a large group, keep it focused with the charge nurse, and then craft a purposeful discharge rounding protocol to address patient needs in advance before the day of their discharge.

So if you just want to check off “huddles” on a list of recommended practices, then just keep doing what’s been done all along, but please realize that it is probably increasing risk and preventing safety practices due to the methods and scheduling used at most facilities. But if you were hoping to improve safety and help patient outcomes get better and inspire staff to do their best at work, then consider using these 5 tips and remember to get some help from other departments to receive and process the staff suggestions that roll in when you find a communication pattern that is truly open to frontline staff ideas.

[1] Pimentel, CB; Snow, AL; Carnes, SL; Shah, NR; Loup, JR, Vallejo-Luces, TM; Madrigal, C, Hartmann, CW (Sept. 2021). Huddles and their effectiveness at the frontlines of clinical care: a scoping review. J Gen Intern Med, 36(9): 2772-2873. DOI: 10.1007/s11606-021-06632-9. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8390736/.
[2] Greenberg, M (Jan. 14, 2014). Feeling Deprived Can Lead to Some Illogical Behavior. Psychology Today. https://www.psychologytoday.com/us/blog/the-mindful-self-express/201401/feeling-deprived-can-lead-some-illogical-behavior.