A practice team caring for complex patients must communicate and coordinate efforts among its members on a regular basis. Implementation of brief, in-person, scheduled meetings once or twice a day with relevant team members helps to ensure an efficient clinic day with fewer surprises. Huddles provide an opportunity to anticipate patient needs and prepare for changes in staffing and logistics so the day runs more smoothly. Over time, they can serve as a platform for additional practice improvement and role expansion. Robust, routine huddles contribute to an interdependent team culture, improved relationships and the delivery of safe and reliable patient care.
Why should we huddle?
Huddles can be implemented quickly by any practice and are an effective way to:
- Align the team at the start of a clinic session
- Build team culture and improve communication for a more engaged workforce
- Prospectively plan for patients who require extra time and assistance
- Prepare for staff, provider or equipment changes
When the team comes together to plan care on a regular basis, we become more high-functioning and efficient and accomplish so much more with our patients.
Three steps for effective huddles
- Establish the routine
- Develop relationships and designate roles
- Evolve and improve over time
Establish the routine
There are many ways to have effective huddles, but a consistent presence from key players is essential to making them rewarding and useful.
AInvolve the right people
Consider the purpose of the huddle in your practice and how it could be most useful for your team. This can be as simple as the provider and medical assistant (MA)/clinical support dyad discussing point-of-care needs for incoming patients that day.
Some practices find that including team members such as case managers, social workers, behaviorists, nursing supervisors and front-desk staff can offer valuable input to clinic flow and patient needs. These practices include the entire practice for a few minutes of daily announcements before breaking into smaller teams, or teamlets. Ideally, all team members who are involved with the practice unit should be invited and included.
BSchedule a time before clinic sessions start
- Last about five to 15 minutes, maximum. Many clinics meet just once in the morning
- Start at a consistent time that integrates smoothly into the practice’s workflow, such before morning clinic hours or before the afternoon clinic session
Initial experimentation with times may be necessary. It is okay if your team finds that the scheduled time does not actually work well for the team. Remember to be flexible as you find the perfect time. Even while you are figuring out the best time to meet, always start and end the huddle on time to ensure consistency and to evaluate whether the time frame works for your team.
CDetermine the team’s huddle location
The ideal location for a huddle is a convenient spot where everyone can fit comfortably and talk freely about patients. If patients have not yet entered the clinic’s working area, a nurses’ station or work room may work. Some practices will project the day’s schedule on a screen or wall so the team can review patients and available openings. The person who is leading the discussion should have access to a computer to walk the team through important patient issues that they can expect to encounter during the clinic session. It is okay for people to be standing during a huddle; in fact, this can help maintain focus and encourage efficiency during the meeting.
What are some ways to include team members who are shared across teams or teamlets?
Resources shared across teams or teamlets, such as case managers, pharmacists and behavioralists, can rotate among huddling teamlets to quickly touch base on issues for patients that day.
How can we make time for this new process?
The beauty of huddles is that they are short yet effective. A strong commitment to starting and ending on time will help make them a success. Many practices find that the time investment is more than made up for by improved clinic operations. However, it is important to establish a consistent time that integrates well into the clinic workflow. The team may struggle if huddles are considered to be an added obligation that falls outside of work hours or occurs while patients are waiting.
Develop relationships and designate roles
ADevelop relationships and designate roles
Distinguishing roles in the huddles helps to ensure that they will run smoothly. Physicians and practice leaders can serve as role models and reinforce the right attitude: focused, timely and present.
BDesignate a huddle leader
This can be a rotating or permanent role. Practices have found success designating a nurse or MA to champion huddles. This provides continuity and can be a great tool for building a strong culture of teamwork among the team or teamlet members. Conversely, if there are multiple MAs or nurses who are involved on the team, rotating leaders may help make everyone feel more involved. As a result, the entire team is more likely to take ownership of providing the best care to patients throughout the day. It leads to an “all-hands” culture where patients truly are cared for by a whole team of people.
The leader role can evolve over time. Leaders should ensure that the gathering starts and ends on time and should give other team members the opportunity to speak up when necessary. For example, a patient with a history of depression may have an appointment scheduled that day. If the behavioral health specialist is at the morning huddle, she may want to give a brief update or indicate that she plans to be available during the patient’s appointment. Huddle leaders should keep huddles short and focused, perhaps by putting bigger issues in a “parking lot” until they can be discussed at a different forum or meeting.
CUse a checklist or template
As the practice begins implementation, a checklist or template may be especially useful. Huddles can become more organic over time but may benefit from a set structure, at least during the first few meetings. The leader can use the template to keep the conversation concise and focused. Five to 15 minutes pass quickly when you have a day’s worth of patients to discuss!
How should we create our huddle checklist?
The checklist should include the items that the practice aims to discuss. Several practices have created helpful huddle checklists. The VA uses this checklist. The checklist that we have included in this document is a hybrid version of several checklists that have been found useful in different practices. Remember that your huddles, which will meet the needs of your practice and patients, will likely develop over time. Your checklist should evolve to meet these changing needs.
Identify and define additional roles. Consider what each person will prepare for the huddle based on team member roles and the agenda. Preparation is essential to make huddles useful as well as to engage team members. Here are some useful roles for different members of the team:
- The nurse manager or administrator can review staffing needs and absences for the day and reallocate accordingly
- Physicians, nurses and MAs can review their schedules for complex patients and flag any advance preparation required, including:
- Scheduling interpreters
- Procedure setup
- Allocating more time
- Behavioral health, pharmacy or case-management referrals
- Diabetes or other health education
- Updates about recent patient events, such as a hospitalizations, emergency room visits, consults or surgery
- Schedulers can note available clinic capacity that day and make the team aware of any same-day openings and urgent or cancelled visits
- MAs can flag preventive and chronic care needs
Communicating these items to the team ensures that everyone is aware and works collaboratively to meet each patient’s needs. Anticipating a call to an interpreter or coordinating a visit from behavioral health will ensure that the team is providing the best possible care to its patients. Anticipating procedure setups, such as a Pap smear or suture removal, reduces the number of trips out of the room during a visit, decreasing interruptions and increasing practice efficiency.
How can the information exchanged in a huddle benefit the team?
Team members may use this information to prioritize and allocate their work based on patient and team needs throughout the day. For example, an MA may offer to assist with phone calls or cover another provider on a day that his physician is not seeing as many patients. With everyone anticipating and planning together, the team becomes more flexible and adaptive during times when the practice is handling high patient volume and acuity.
DDevelop a strong team culture
Develop a strong team culture. Practices include a quick check-in at the beginning of the huddle to center the team and get everyone on the same page. A shout-out to a teammate (“Lori jumped in to pick up phones yesterday when we were really backed up.”) or a story about great care that was provided to a patient (“Mrs. Price’s cancer screening came back positive; it’s a good thing that Evan placed the order while she was being roomed, so we were able to catch it early.”) reminds everyone on the team how valuable they are. It is also a great opportunity to start the day on a positive note.
To remain on schedule, limit how many stories can be shared, or draw a single shout-out or patient compliment from a submission box. Huddles can end with a unifying team cheer or the team’s statement of purpose. Then the team begins their busy day on the same page about what their priorities will be for the upcoming clinic session.
How is a huddle different from a team meeting?
Huddles are brief, daily discussions that focus on the action plan of the day, rather than solving underlying process problems or broader workflow issues. Opportunities for improvement that the team identifies in a huddle can be saved for more in-depth discussion in longer team meetings. Huddles that exceed the allotted time due to extended discussions may benefit from a designated facilitator and indicate the need for additional forums for team members to communicate about these larger issues.
Evolve and improve over time
The team will remain enthusiastic about huddles if they continue to provide value. Focus on improving them so that they provide clear benefits to the team and patients. Practice leaders can round on team members and ask, “How can huddles be more useful for you and our patients?” Particularly when implementing in the practice, make huddles a standing agenda item at team meetings. As huddles evolve, the checklist can be adjusted.
AUse coaches to develop more meaningful huddles
Team members may benefit from having an impartial person review the checklist and provide feedback on aspects such as communication, teamwork and facilitation skills. Coaches can also assess time management in the huddle. Coaches are usually not involved in that day’s clinical operations and can be either internally-trained champions or external experts, hired for a discrete period of time. A good coach should be able to provide positive, constructive feedback to all members of the team.
BContinue to increase team engagement
When huddles are brief and high-yield for all involved, participants are more likely to engage. Explore barriers to participation, perceived or real, and always consider ways to make them more valuable. Use different tactics to encourage huddles as they become part of the practice’s culture:
- Teamlet competitions (e.g., publicizing which teamlets huddled the most)
- Incentives (e.g., lunch, snacks or notes of appreciation for pods that huddle >90 percent of the time)
- Positive reinforcement or coaching during individual performance discussions
- Visual indicators of huddle success, such as:
- Green sticker: team successfully huddled
- Yellow sticker: incomplete or missing people
- Red sticker: did not occur
Involvement in huddles also strengthens engagement. If the participants are not engaged, try rotating the role of leader so everyone can more actively participate.
Finally, show the results of huddles. Are patients being seen more efficiently? Is the team better prepared for more complex patients? Is the team better able to address patient health concerns because they collectively and proactively anticipate patient needs? Maybe more behavioral health visits are being made or more follow-up care is being coordinated or performed while the patient is at the office for their visit. Sharing positive results will help the team see the value of the huddles, and team members will become more engaged when they see the difference that it is making for their patients and in the team’s level of cohesion.
Leader engagement is important as well. Successful huddles need time, space and constructive feedback to become truly effective. Clinic leaders can model being on-time, engaged and prepared. They can also work with huddle leaders to help develop their new skill set.
Incorporate important announcements or quality improvement check-ins
Because huddles are the team’s daily opportunity to communicate about patients and formulate the plan for the day, they can be used to circulate other important information. If the team is focusing on decreasing patient wait time or increasing referrals to the diabetes educator, the huddle can be used to remind the team and reinforce these initiatives at the beginning of the day. Announcements, such as a scheduled downtime in the electronic health record (EHR) system, can also be made during this dedicated time.
If the team is struggling with timing, assign time limits for checklist items
As you would in a scheduled meeting, assign brief time limits to specific checklist items, and stick to them to keep the huddle on time and efficient. If the leader has a hard time getting through the checklist and watching the time, have another member of the team watch the time and keep the team on track and on time. A leader or coach could also observe and help the team develop efficiency to get through the necessary items in a timely manner.
Save time during the day, improve office culture and provide better care by having a daily team huddle #STEPSforward
The huddle can provide a forum where the team can connect with each other before a clinic session. Huddles give the team the opportunity to provide the best care possible to their patients through proactively and efficiently working together throughout the day. This module can help your team get started with this simple but impactful practice.
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- Rodriguez HP, Meredith LS, Hamilton AB, Yano EM, Rubenstein LV. Huddle up!: the adoption and use of structured team communication for VA medical home implementation. Health Care Manage Rev. 2014 Jul 15. [Epub ahead of print].
- Helfrich CD, Dolan ED, Simonetti J, et al. Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees. J Gen Intern Med. 2014;29(Suppl 2):S659-S666.
- Provost SM, Lanham HJ, Leykum LK, McDaniel RR Jr, Pugh J. Health care huddles: managing complexity to achieve high reliability. Health Care Manage Rev. 2015;40(1):2-12.
- Shunk R, Dulay M, Chou CL, Janson S, O'Brien BC. Huddle-coaching: a dynamic intervention for trainees and staff to support team-based care. Acad Med. 2014;89(2):244-250.
- Dingley C, Daugherty K, Derieg MK, Persing R. Improving patient safety through provider communication strategy enhancements. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches, Vol. 3: Performance and Tools. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
- Fogarty CT, Schultz S. Team huddles: the role of the primary care educator. Clin Teach. 2010;7(3):157-160.
- Stewart EE, Johnson BC. Huddles: improve office efficiency in mere minutes. Fam Pract Manag. 2007;14(6):27-29.
- Stout S, Klucznik C, Chevalier A, et al; Cambridge Health Alliance Team-Based Care Leadership Team. Implementation Guide and Toolkit. http://www.safetynetmedicalhome.org/sites/default/files/CHA-Teams-Guide.pdf. Accessed July 11, 2015.
- Kaiser Permanante. Huddle Power. https://www.youtube.com/watch?v=vvEiGPEFBLE. Accessed July 11, 2015.
- UC Davis Health System Team Huddles Patient Experience Model. https://www.youtube.com/watch?v=VxdG2_nZ2fc. Accessed July 11, 2015.
- Schutzbank A. Martin’s Point Health Care, Evergreen Woods Practice, Bangor ME. http://www.abimfoundation.org/~/media/Foundation/Initiatives/Primary%20Care/Martins%20Point.ashx?la=en. Accessed July 11, 2015.
- UCSF Center for Excellence in Primary Care. Spotlight on Huddles. http://cepc.ucsf.edu/sites/cepc.ucsf.edu/files/Spotlight_on_Huddles_12-1226.pdf. Published June 5, 2012. Accessed July 11, 2015.
- UCSF Center for Excellence in Primary Care. Healthy Huddles. http://cepc.ucsf.edu/healthy-huddles. Accessed July 11, 2015.
STEPS in practice
How’s it working in San Francisco, CA?
At Maxine Hall Health Center, a public health primary care clinic in San Francisco, huddles were not an immediate success. When the clinic sessions continued to be chaotic, leadership decided to reinvigorate the practice’s huddle efforts. It took more than a year for the huddles to become routine and impactful, as leaders worked with the team to identify the huddle format and timing that produced the highest value. Now, there is a clinic-wide sense that “if you missed huddle, you missed important information for your day,” says Catherine James, MD, part-time medical director and CMO for Pirmary Care at Maxine Hall Health Center.
Huddles start at 8:00 a.m. in a central team room where providers and MA teammates are co-located. The huddle is called and led by the nurse manager. The entire clinic staff is encouraged to attend, including behavioral health clinicians, nutritionist, pharmacists, specialists, scribes, front-desk staff, nurses and volunteers.
The huddle checklist
Huddles start with staffing and logistical information, followed by quick reminders about ongoing clinic quality-improvement work, such as a depression-screening initiative. Then two critical pieces of scheduling information are discussed. The first is available appointment capacity that day, and the second is each provider’s next available appointment. This includes nurses, pharmacists and behaviorists—anyone who offers appointments to patients. Identifying the next available appointment was added to the huddle checklist as huddles evolved and has greatly improved patient-care coordination among the team. For example, if Dr. James needs a patient to be seen for hypertension follow-up in six weeks, but knows she does not have an available appointment for seven weeks, she might schedule an interim follow-up appointment with one of the pharmacists that she knows has availability in three weeks. The five-minute huddle concludes with general announcements and shout-outs.
Subsequent teamlet huddle
After the large team huddle, teamlets spend an additional two to three minutes to coordinate their scheduled patients for the day. Four years into huddling, they run organically without reference to a checklist, although one was used initially to structure the huddles.
Making huddles a success
Dr. James recalls several other techniques that helped the team show up on time and ready to huddle regularly. First, clinic leadership committed to serving as models for appropriate huddle behavior, including being punctual and present. Second, the team used enthusiastic, positive reinforcement when people demonstrated good huddling behavior, both publicly and privately during performance reviews. Finally, an invested leader, the charge nurse in this case, was designated to call the huddle each day so everyone arrived at the correct time. Since making the decision to commit to regular team huddles, Maxine Hall Health Center has seen improvements in teamwork, preparation and the ability to coordinate care for their patients.
How’s it working in Denver, CO?
At Clinica Family Health, a federally qualified health center in Denver/Boulder metro area, huddles occur twice a day, in the morning and after lunch. The first twenty minutes of each clinic session are blocked off for huddles. Care teams at Clinica (called Pods) have found this a worthwhile time investment, allowing them to prepare for each patient’s visit. Karen Funk, MD, MPP, Vice President of Clinical Services and a practicing family physician at Clinica, justifies the time used for huddles in this way: “When the team comes together to plan care on a regular basis, we become more high-functioning and efficient and accomplish so much more with our patients.” Clinica has a very low rate of no-shows due to advanced-access scheduling, ensuring that this preparation pays off.
Huddles take place in the pod workstation where the provider and MA are co-located and work together regularly. When huddles started 10 years ago, this teamlet would pull each chart and review relevant clinical issues together. Now, they have an EHR with embedded tools that prints a one-page visit-prep checklist for each patient. This care planner was developed by Clinica to flag guideline-concordant preventive and chronic disease care including immunizations, diagnostic and laboratory testing and referrals. The provider-MA teamlet reviews the care planner together so that arrangements can be made to address those issues proactively during the visit. Other pre-visit preparation or paperwork is done side-by-side during this time. Extended team members, including a nurse care manager, behaviorist and referral case manager, make rounds on each teamlet to discuss patients as well. For example, the care manager may flag a complex care patient who is arriving that day and ask the MA to find her when the provider is finished for a post-visit meeting. Likewise, the provider may ask the care manager to see an additional patient on her schedule that day who may benefit from her services.
Huddle time at Clinica is also used to reinforce data-driven quality-improvement efforts on a daily basis. Team members will gather at the data board regularly to review their pod-level performance data and discuss plans of attack for lagging indicators. This sends the message that the entire team is responsible for patient health and is another way that Clinica creates exceptional team culture and performance.
How’s it working in Bangor, ME?
At Martin’s Point Healthcare in Bangor, Maine, huddles started as informal meetings between a single clinician and his clinical support staff to improve communication. Ten years later, that simple meeting has evolved into a 10 to 15 minute high-energy meeting at the beginning of each clinic day where the entire practice arrives ready to discuss to the day’s plan. Paula Eaton, the clinic’s administrator, has been a key champion of driving this evolution. She recalls, “At the first official huddle, even the doctor didn’t show up. I had to keep asking, ‘How can we make this useful to the team?’” She cites this question as critically important to developing the level of engagement seen in their daily team huddles. She describes huddles as “what we are doing today and how that is moving us closer to our goals. Every day is an opportunity to make improvements.”
Martin’s Point Healthcare huddles are held first thing in the morning, prior to the start of the clinic session but after everyone has arrived at work. The huddle agenda is determined by a written template that undergoes revision approximately every three months. The minutes for each huddle are recorded electronically and emailed to the team. Huddles start with an understanding of capacity: how many appointment slots are open, what the staffing levels are, and who is working with whom. This is summarized in the huddle minutes as “today’s constraints.” For example, the minutes might indicate that one provider is out for the day, and there are no acute-care openings.
This is followed briefly by patient complaints or concerns from the previous day, such as a patient who was unhappy with a delayed appointment. This allows the team to quickly delegate a team member to address service recovery and maintain patient satisfaction scores. The team then shares “WOWs,” or shout-outs about those who have made a notable contribution (e.g., Jill thanking Laurie for covering for her while she tracked down a missing lab result). Paula notes that the team highly values WOWs. They make a noticeable impact on teamwork, appreciation and culture. The team moved WOWs to the end of the huddle, so they did not impact the other important items on the huddle checklist.
The huddle model at Martin’s Point Healthcare has met challenges over the years. A meeting facilitator role was created to keep huddles on track, by tabling and recording issues that required longer discussions for team meetings. Paula says, “Huddles are not really meetings; the team makes the plan, then off we go.” When huddles drag on, the team found that people lose interest and focus. Initially, the huddle leader role rotated between team members, but the team has become comfortable with one patient-service representative taking on this role.
Paula shares, “Huddles can be as simple or complex as you want them to be. If people find huddles useful, the time will be there. Time is always a constraint; it’s how we utilize it that gets people to go. Making huddles ‘mandatory’ is beside the point.”
How’s it working in San Francisco, CA?
The hepatology clinic at University of California, San Francisco is an outpatient practice that serves patients with complex hepatic conditions, including patients who have undergone liver transplantation. The busy academic practice books approximately 6,500 patient visits a year.
Clinic leaders initiated daily team huddles as a component of a broader Lean implementation, triggered in part by persistently low patient satisfaction scores. Facilitated by the practice manager, the team huddles are held each day at 9:30 AM and include the entire care team—attending physicians, fellows, nurse practitioners, physician assistants, and administrative staff. The team comes together for 15 minutes to discuss the agenda for the day. They identify any potential issues, such as a provider being out sick, and develop plans to minimize any negative effects, such as longer wait times for patients.
During the huddles, the team also reviews a status report for the previous day, which the practice manager generates each morning from the electronic medical record. The report includes four pieces of data that relate to the overall goals for the clinic:
- Number of new and return patient visits
- Number of “no shows” and the reasons for them (the staff contacts patients to inquire about the cause of missed appointments)
- Average visit time
- Number and status of referrals received, both internal and external
During the huddles, team members also identify any ongoing issues that are adversely affecting their daily work, such as inefficient patient rooming practices, difficulties consistently collecting copays, or delays in obtaining diagnostic tests. Once a problem is identified, team members suggest a potential solution to test, an individual is identified who will be accountable for implementing the solution, and a timeline for the change is determined. These staff-initiated solutions have resulted in rapid improvements to problems that contribute to delays for patients and frustration among care providers. If a problem cannot be solved by the team, it is escalated to the clinic leaders, who address the problem or bring it to the attention of medical center leaders.
The huddle also serves as an opportunity to recognize staff and care providers for their positive contributions to the clinic. The practice manager reads emails and comments from patients and shares results from the week’s patient survey. According to Bilal Hameed, MD, associate chief of the clinic, the team huddles have resulted in many improvements that have boosted morale and job satisfaction among clinic staff and care providers, as well as among patients. “Our clinic staff has been empowered to identify problems and test solutions. Now they feel heard, respected, and an important part of the team. Providers get what they need for their patients and are less frustrated. It doesn’t take six months or a year to fix a problem that affects their daily work. It’s solved right away.”
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Downloadable toolsGo to Resource Library
The tools and resources here can offer implementation support for your practice. You can download and modify them to fit your specific needs.
Implementing a daily team huddle module
Download a printable PDF version of this module.
PDF, 496 KBPreview
Implementing a daily team huddle PowerPoint
Use this PowerPoint presentation to review this module with your team.
PPT, 114 MBPreview
Sample huddle checklist
Use this checklist to guide your team through efficient, effective huddles at the beginning of the clinic day or session.
MS WORD, 37 KBPreview
Huddle evaluation form
Evaluate how huddles are going in your practice, and identify opportunities for improvement.
MS WORD, 44 KBPreview
Visit prep checklist
Use this checklist to compile a list of screening and immunization needs to be addressed during the next patient visit.
MS WORD, 52 KBPreview
This document provides a definition of huddles as well as some best practices for huddles.
PDF, 156 KBPreview
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