Should Daily Tiered Huddles Be Held Every Single Day in Healthcare Settings?

A while back, I got an email from a Lean process improvement facilitator at a U.S. hospital. Her question was about the practice of "daily huddles" in her organization. More specifically, they use "daily tiered huddles," as many would describe them.

"Tiered huddles" are a common practice within the context of a Lean Management System. 

1. Frontline teams huddle early in the morning, often before their shift
2. The managers of those frontline teams then come together to huddle (those managers reporting to the same director, usually)
3. The directors who report to the same VP then huddle
4. The vice presidents then huddle with their C-suite leader
5. The C-suite executive team (CEO, CMO, CNO, etc.) huddle

Depending on the size and complexity of the organization, you might have fewer tiers (or more tiers).

As we go through the huddles, groups are encouraged to solve as many problems as they can (being empowered and educated on how best to do so). There are, however, some problems, issues, or questions that need to be escalated to the next tier. Widespread, often systemic problems, might be escalated all the way to the C-suite huddle, when their input or help is needed, or to keep them informed.

One trap or pitfall to guard against is a tendency to either escalate nothing (which might be a sign that their sense of psychological safety is not high enough), or a tendency to escalate everything (which might be another symptom of low psychological safety, or a lack of confidence in their own problem-solving skills).

Does "Daily" Really Mean Seven Days a Week?

So, back to the question from the hospital Lean facilitator.

She saw how daily huddles were effective, with the short and quick cycles of communication up and down the chain. However, the "daily" huddles were only being held on weekdays, Monday through Friday.

She noted how they aren't called "weekday huddles." Good point.

The email asked about how many organizations do "daily" huddles, meaning seven days a week. If there was an urgent issue identified on a Saturday (given that it's a 24/7 operation), could it really wait until Monday? Should they consider daily huddles being every single day, even if they were phone calls or virtual meetings?

How did other organizations address weekend issues that were urgent?

She was also a bit frustrated that her executive team wouldn't even discuss the possibility of weekend huddles (or other countermeasures that could address weekend issues).

Surveying Others

I asked around -- some of the Value Capture team and some healthcare leaders in my network. I'll share their thoughts here, all anonymized.

What I asked them was this, regarding huddles, does "daily" mean:

"1) Daily means M-F 

2) Daily means M-F, but during peak pandemic times, also do Sat/Sun

3) Daily always means Sat/Sun

Follow up question - if there are no weekend huddles, do issues accumulate until Monday? 

Can leaders be pulled on, during the weekend, on an exception or as needed basis?"

No Weekend Huddles

One system VP of continuous improvement said:

"Each hospital has a daily Safety Huddle Monday through Friday. They do not do it on night shift or the weekend, which I believe they should do. That information also gets reported to corporate and the corporate system does a system Safety Huddle every Monday."

It's interesting that he sees a similar challenge or opportunity. If huddles are effective on weekdays, and they are time sensitive, why not also do them on weekends? The downside is that weekend huddles might affect leaders' work/life balance — but hospitals are 24x7x365 operations, so what else can we do?

Are They Really Tiered?

Another senior level improvement leader brought up a different challenge: are the huddles properly tiered? Are the huddles covering the right topics?

"On the surface, our huddles are tiered. The departments are to huddle before 9:30, then bring any items to that huddle, which then feeds an admin huddle at 10 or 10:30. 

It’s rare that anyone has something to report and if they do, it's a communication item such as, 'The CT scanner is down blah blah blah.'

If someone should bring an issue, feedback is rare.

We’ve snuck into some department huddles and they are (except the ones we are coaching) operational only."

Effective huddles cover, in a short period of time:

• Immediate tactical or operational issues (who is out sick, for example)
• Problems, harms, errors, near-misses, or unsafe conditions
• Improvement opportunities and ideas.

This health system reports a few issues with the huddles:

• People rarely bring up problems or ideas for escalation
• Communication up the chain does lead to feedback (or action?)

If people aren't speaking up, don't blame them for that. It all starts with leadership, at the senior level. If people are going through the motions with huddles, or if they're not reaching their potential for other reasons, senior leaders need to step in to lead the problem solving on this front.

An "Administrator on Call"

A physician leader with deep experience in continuous improvement also replied, back to the original question at hand:

"Great question. The “Formal” construct is Monday through Friday for all the tiers.

For Tier 1 in areas that are open on the weekends (some of our business, outpatient, and certain clinical areas are not), those teams still huddle (for instance – our inpatient teams huddle at shift change twice a day – that would be “tier 1”).

There is also an “Administrator on Call” at each location every weekend and holiday who is the “first call” for addressing issues that need to be addressed on the weekend. The issues would typically also be shared at the huddles on Monday if still relevant, or if relevant to others (for learning, awareness, etc).

Definitely, our leaders can be and are pulled on for their teams – at any time. Depending on the area – the frequency and nature of those issues varies widely."

Huddles Aren't About Control

One of my Value Capture colleagues said this:

"Mark, my experience, and what I have observed.

Of course, the purpose of tiered huddles in healthcare can vary greatly based on the organization from:

1. Power and control under disguise (bad disguise): “Tell me your numbers from yesterday”
2. Ensuring the frontline teams will be successful in meeting the commitments made to patients and customers"

They said that daily "always means Saturday and Sunday" with the caveat that the huddles "stop at Tier 3 – hospital level with limited leaders.

Escalation above Tier 3 is based on exceptions with designated senior leader on call if criteria are met. Yes, leaders can be pulled on, by exception, on the weekends as needed"

Daily Tier 1 Huddles

Another Value Capture colleague added this about a current client organization:

"In the learning lab (pilot area), the Tier 1 huddle happens seven days a week and the other leadership huddles are Monday through Friday."

Similar thoughts came from another colleague:

"What I have seen is Daily Tiered huddles happen Monday through Friday. The front-line huddles still happen on Saturday and Sunday but not the Tiers. Any escalation required out of the daily huddle on the weekend goes to the Executive On Call (EOC)."

It Depends on the Circumstances

Another Value Capture team member wrote:

Every place I have been so far…

• Daily huddles mean Monday through Friday, sometimes 1x per day, sometimes 2x per day
  • • • • • • Sometimes that matches business hours, not so in acute settings
• Incident Command means 7 days a week, multiple times per day
• If tiered huddles have been incorporated to include some incident/pandemic management, then tiered huddles will increase to 7 days per week and/or multiple times per day during periods of highest need

They Should be Every Day

From another Value Capture colleague:

"My experience is all of the above [from the three options on when "daily" huddles occur].

My coaching is that huddles support the operation and should be held every day that the operation operates. So most hospital departments should have weekend huddles. Sometimes, departments will combine huddles on the weekends or nights for scale purposes, but at least there would be a huddle covering every worker. 

Some organizations that I've worked with went there right away, some eventually, some never. For the 'nevers,' issues would build up over the weekend, creating built-in unevenness. 

And leaders are pulled according to the defined help chain. It can be defined differently for off shifts but should be defined. Again, that said, our coaching is not always followed nor always well executed."

Podcast Mentions

Daily huddles and tiered huddles often come up in episodes of our Habitual Excellence podcast.

You can click here to see transcript search results across all of our episodes. Clicking on the results will play those relevant portions of the episodes.

Those episodes in full are (click on the title for the episode page):

Alyson Gordon on Developing Everyone, Every Day to See, Solve, and Share Problems

A partial transcript of what was shared, more generally on huddles, by Alyson Gordon of Duke University Health System:

"So I think some practical things that we did was that we set up tiered huddles to allow people a way to call out problems and we helped people talk a lot about problems maybe that we weren't used to seeing and did some things to help teach us to see problems better. Like we regularly did Gemba rounds and safety walks. And I think really talked about problems in a new way that we were seeing and experiencing and starting to call each other out better when we were maybe using old ways to solve problems and challenge each other to say, well, how might we think of this differently?

And I think even the practice of using open-ended questions, learning more about our behaviors and how our behaviors really influence our outcomes in a way that we don't always think about when we think about different safety and things like that. So I think the things that stand out to me that were most impactful were doing Gemba rounds and going to where the work was, was really helpful to help us see problems differently. And then we can kind of go back and work with the coach to say, okay, now what does that tell us? And what do we do differently as a result?"

Aravind Chandrasekaran on Continuous Improvement & Psychological Safety

The professor from the Ohio State University has researched huddles. Here is one of his articles:

Optimizing huddle engagement through leadership and problem-solving within primary care: A study protocol for a cluster randomized trial

From the podcast, he said, in part:

"So in one study we wanted to study daily huddles. So we wanted to study daily huddles, which we always talk about, are they really effective? And when I say effective, is it really influencing psychological safety? Is it really improving team morale?

And more importantly, it is helping, does it really help in terms of getting a patient seen better, especially in a primary care kind of setting? So we wanted to study this question.

So we ended up doing a randomized controlled experiment in a big healthcare institution. We had about 50 different primary care sites. We randomized them. We in a randomized controlled experiment, you give an intervention to one and it's kind of a placebo to the other, that you weren't really giving them program intervention." 

You can read more about his conclusions or, again, listen to the podcast with Aravind. 

Dr. Lisa Yerian on Patients First at Cleveland Clinic

In her episode, Dr. Yerian shared, in part:

"Tiered daily huddles is something that occurs every day at all levels of the organization. They start with the tier one, which is your closest to the patient and that would be the bedside nurse or the, you know, a bedside pharmacist, the person who's closest to the patient at the bedside, ah, and then first tier huddle is with that team and their manager.

And then those managers who are peers come together and huddle with their director, then the directors who are peers come together and huddle with, you know, whoever their leader is. And there are six layers of huddles that tier. So the information cascades in a very timely and accessible way to the tier six huddle. And the tier six huddles is run by our CEO and our executive team members.

Those huddles are structured with a standard agenda and the first item on everybody's agenda, its safety. So we have four commitments:

• caring for our patients,
• caring for our caregivers,
• caring for our organization and
• caring for our community.

So the structure of the agenda for every huddle was based on that. Now, what are those specific items are, are probably going to vary with what your specific work is, right?

But you know, safety is always our first topic. Are there any serious safety events, one or a potential serious safety events? They have to go through a review to see if they are classified as a serious safety event... do you have any safety event at all for Patients that we identified? How is the quality of care? Did we miss any opportunities to deliver high quality care and then carrying for our care givers, you know, any caregiver, safety issues or concerns?

And then we move on to caring for the organization, do we have appropriate staffing, things like that. And then caring for the community is something that doesn't typically show up on a daily basis because that happens typically over a longer time horizon.

But that's the standard agenda and that information flows in a consistent, structured way throughout the organization. And really the idea is that we bring forth problems, information, opportunities that we can then solve within that huddle.

Or we escalate to the next tier, if we need to convey information, if we need help, we have to ask you a question for whatever reason and, and the information flows then in all directions. So we can very rapidly communicate while at the same time, fostering this environment.

We want to know about problems. We wanna talk about them. And so we did do a lot of coaching and training of our leaders when we started to say, right, when somebody brings you a problem, you can respond in a way that says, 'thank you. I'm so glad you did that.' That's really important. And, and honors and respects it. Or you can do it in a way that says, 'I'd really rather you not bring that up the next time because I'm tired or busy. I'm not happy about it' or whatever. So they're gonna work through some of those things.

And that's been a powerful system for us to drive and permanently foster the culture, and also the behaviors, that we need to support our mission.
...

So, the system that we've put into place around problem solving, or tiered huddles, everybody has the responsibility and the ability to raise problems. So I think a lot of the continuous improvement work does help us achieve the, the things that Paul O'Neill was talking about."

Applying Lessons from Autoliv (Manufacturing) to Intermountain Healthcare: Scott Saxton

Scott said, in part:

One of the things that we did at Autoliv was daily tiered escalation huddles. And so it would start at the frontline team leader and quality issues, safety issues, cost issues, supplier issues, all of those different things would escalate right up to the senior leadership team for the day.

And then we would discuss it. And if it was actionable, we would record it and, and respond to it at the right level of leadership.

So we introduced that to Intermountain. And I remember several leaders saying 'we don't need that, Scott, we, we already have good systems in place.' 

I said, 'can we just try it out?' And so we had a leader at McKay Dee that saw the value in this, and we just started with three simple things, McKay Dee Hospital in Ogden.

And we started with three simple things.

1. What are our serious safety events?
2. What are our medication errors?
3. And I can't remember the other one right now off the top of my head.

But we just started with simple three things. And what, what we ended up doing is we having an escalation and we started inviting the leaders to participate in that.

And I remember one of our chief nursing officers at the time, her eyes getting really big as the information was told each day. And she had no idea the number of defects that we were having in that hospital, because we thought we had good systems. And it was very eye-opening to them.

And it was, it gave us the ability to respond more appropriately. We used to gather all of our problems and discussing in a weekly team meeting, you know, an executive team meeting. Well, now we have the ability on a daily basis within a 24-hour period to respond appropriately to the needs of what's going on in the front line."

How Do We Engage Leaders in a Conversation?

We got a lot of great input from Value Capture team members and healthcare leaders. My friend who asked the question wasn't alone in trying to figure out the answers to these questions.

When we asked how to get leaders to talk about the idea of weekend huddle coverage (or another countermeasure like an Executive On Call), my suggestion is to not lead with the solution.

Instead of asking, "Can we talk about doing weekend huddles?" (where the answer might be a quick no, even to the discussion, maybe another question that frames the need or the challenge might be more engaging.

"Can we talk about how we provide support to frontline team members who identify urgent issues, especially safety concerns or problems, on weekends?"

Whatever the idea is, "can we just try it out?" as Scott Saxton suggested?

What do you think? Please scroll down and leave a comment, below.