Twice-Daily Huddles Improves Collaborative Problem Solving in the Respiratory Care Department

Discussion

In this study, we demonstrate that daily huddles can be successfully adapted by a respiratory care department as part of a quality improvement program. This quality improvement program allowed for the identification of process improvement opportunities on average of once per day, with 88% of opportunities resolved within 1 week and 90.5% of opportunities managed with the resources of the respiratory care department and its multidisciplinary colleagues.

Lean business strategies (also known as Lean Production, Lean Enterprise, and Lean Thinking) originated within production industries to increase process quality and efficiency. The Lean methodology aims to implement process improvements by utilizing a coordinated set of principles that modify processes in a way that promotes efficiency and reduces waste. Lean methodology has evolved from its traditional application in manufacturing and has migrated into other settings, including finance, construction, and health care. Lean first started branching into health care in the late 1980s with initiatives like Continuous Quality Improvement.⁶ Health care scheduling and access are examples of issues that have been dealt with successfully in many health care organizations using Lean principles.⁷

Huddles are one of the many tools available in the Lean methodology. Team huddles have been shown to increase team processes when leaders reinforce principles of continuous improvement and collaboration.⁸ Huddles within health care align directly with the Affordable Care Act's emphasis on team-based care.^9,10 By collaborating as a team in a huddle prior to shift start, teams can become more cohesive and effective at problem solving. Gardner et al⁸ reviewed a huddle process at 5 Veteran Affairs medical centers as a conduit to improve primary care education for residents. In their model, huddles were focused around 4 core domains: shared decision-making, sustained relationships, interprofessional collaboration, and performance improvement. Primary participants were medical residents and their associated fellows and attendings. Gardner and his colleagues⁸ reported that huddles provided ample opportunities for learning within the workplace. Learning opportunities were related to relationship building, care coordination, and vital camaraderie that is necessary for team-based, patient-centered care. Overall, the authors noted that team huddles increased team mentality and positively affected team performance.

Cracknell and colleagues¹¹ tested safety huddles in a single, large, acute care hospital in 4 front-line teams. Huddles were organized to be led by senior clinicians, nonhierarchical, and succinct. A key metric in this study was a reduction in patient falls. The authors reported that falls were reduced from an average of 12.4 falls/week to 5 falls/week. Additionally, cultural surveys from participants showed improvement in 23 of 27 parameters, including overall safety on the units studied. The authors concluded that huddles are a key tool for decreasing harm to patients, increasing team empowerment, and improving safety culture.

In a study from an English pediatric hospital, Stapley et al¹² utilized staff interviews to explore staff perspectives and experiences with the Situational Awareness for Everyone (SAFE) program, which included huddles. Interviews from 76 staff members (nurses, physicians, leadership) across 4 wards were included in the qualitative study analysis, which occurred 4 months after the SAFE program was initiated. Positive feedback from interviewed staff related to huddles included increased awareness of important issues, improvement in communication, increased teamwork, increased efficiency, and improved forward thinking. Challenges raised by interviewed staff members included added pressure on staff work load, potential for junior nurses to be excluded, and potentially inadvertently reinforcing medical hierarchies. Overall, this study highlights the huddle process as a way of potentially identifying opportunities for improvement in employee working environments and in clinical practice.

In 2018, Johnson¹³ echoed the above studies, identifying that teams with poor communication often are unable to be organized, empowered, and responsive to a rapidly changing environment. Teams with poor communication also often lack a sense of safety and good team dynamics. Ultimately, poorly performing teams were directly associated with poor patient outcomes. From this article, the author suggests huddles as being the single, simplest tool aimed at improving communication and increasing employee satisfaction and patient outcomes.

To our knowledge, our study is the first to review a huddle process within a respiratory care department. Respiratory care departments vary greatly from other departments within the health care environment. Many times respiratory care departments are not located in patient care areas. Additionally, respiratory therapists may cover multiple units in a single shift and be responsible for a variety of patient populations. The general nature of respiratory care departments serving entire institutions increases the risk for poor communication, which could potentially translate into poor patient outcomes.

In our department, one of the main barriers to problem resolution is that we operate in many patient care areas and lack opportunities for group communication. Department huddles allow issues to be communicated in real time and ensure that there is an assigned party accountable for resolution. The use of a department huddle translates into effective situational awareness. This increased situational awareness can then translate into staff information gathering, realization of significance, and better understanding of the importance of addressing and rectifying opportunities for improvement by staff members. Twice-daily department huddles can also aid in improving communication between shifts in a round-the-clock operation.⁸

In the analysis of our huddle process, we found that process improvement opportunities were identified once daily on average, and the majority of these opportunities were resolved within a week. Nearly half of these resolutions only required resources already present in the respiratory care department, and < 10% of opportunities needed to be escalated to the organizational level. For department leaders, the breakdown of types of problems and need for interdisciplinary involvement and escalation can aid in the planning and implementation of the huddle process. Knowing that most opportunities for improvement that are surfaced in huddles can be solved quickly and within the department is a key factor in comprehending the relationship to problem-solving capacity and throughput, time management of problem owners to ensure transparency, and success of huddle item resolution.

We encountered several barriers to the successful implementation of the huddle process. One of these barriers was staff timeliness. We found that not all staff members arrived in the department prepared to start the huddle at designated times. This lack of timeliness can create confusion because staff members who show up late miss vital information. Staff are expected to be on time for huddle 100% of the time. Department and institutional policies for lateness can allow for up to 3 lateness occurrences before corrective action is taken. If tardiness extended beyond the acceptable allowance, it was addressed following the corrective action matrix, which includes a verbal warning and follows a step-wise approach ending with termination. We also saw a barrier with our off-shift employees. Staff who are not assigned to work shifts starting at either 06:45 or 18:45 were not able to attend the huddle. While information from the huddle is displayed and available to these staff members, the conversation around them is missed; thus, those personnel sometimes require separate conversations for information sharing. Additionally, lengthy huddles coupled with extensive patient shift report can delay the outgoing shift.

Staff ownership of huddle items is a component of the huddle audit with the aim to have more than half of huddle items owned by associates. Although staff ownership of issues is positive, our respiratory therapists utilize a block schedule where they may not work for several days. If they are a problem leader, then their report at huddle on a process improvement opportunity resolution might be delayed until their next scheduled shift. In these instances, if the staff member was not present on the due date to report out, the huddle leader would move the due date to the next day. This would occur until the owner was present for report out or another team member was assigned the responsibility of reporting the resolution.

Senior organizational leadership support was paramount to success in our journey throughout the huddle process. Because the huddle initiative was started as a trial with senior leadership departments, we received ample support to make this journey successful. Without support, the effectiveness and overall positive impact of huddles may have been impeded. One barrier that we encountered, which was resolved with the assistance of senior leadership, was a lack of staff engagement during huddles. Initially, staff were uncertain about huddle effectiveness and were not always forthcoming about raising process improvement opportunities during huddles. Additionally, huddle leaders (ie, respiratory therapy leadership and charge therapists) gave staff feedback to escalate concerns to respiratory care department huddles if they were brought up outside of the huddle forum. When items were escalated to huddles by respiratory care department staff, huddle leaders provided positive feedback and recognition in an effort to promote this behavior.