Exploratory Study on Evaluating the Effectiveness of Implementing the Culture of Huddling in Ambulatory Care

Friday, 28 July 2017

Carol Bloch, PhD, MAEd, BA
Carolyn Bloch, PhD, MAEd, BA
Ambulatory Care Services, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA

Purpose:  This follow-up study measured if huddles were occurring in ambulatory clinics post-didactic education to nursing staff. Interrelating Dr. Madeleine Leininger’s cultural care theory with the definition of culture of safety from the Centers for Disease Control and Prevention National Institute for Occupational Safety and Health Education and Information Division in the healthcare setting, the two concepts were explored for commonality and clarification. Although the concept of sharing and reviewing patients prior to clinic staff beginning care is not new, huddle was new terminology for clinic staff. Instruction for entire ambulatory nursing staff in both primary and specialty clinics was provided to clarify and demystify what a huddle is and what team members’ responsibilities would be regarding this new concept.

Methods:  A follow-up survey of 173 staff was conducted over 3 days to evaluate the effectiveness of huddles in ambulatory care clinics. The survey included direct questions about implementation of huddles in clinics and open-ended questions regarding feelings, problems solved, likes, and dislikes of huddles.

Results:  Findings revealed the following: (a) Most clinics have daily huddles; (b) most are convened at the nurses’ station; (c) huddles contribute to interprofessional communication between attendings, residents, interns, and clerical staff; (d) there are designated leaders for the huddles; and (e) the majority of huddles are led by registered nurses. The top three topics for huddles were (a) team staff present or absent, (b) number of patients for the day, and (c) who is working with whom in the clinic. Huddles occurred verbally, written, or electronically, and there was no one way huddles are documented to have occurred for review or verification. A specific method for documenting a huddle occurred was called a Huddlegram. It is interesting that survey results indicated access to Huddlegrams on the intranet is limited to specialty clinics only, not primary clinics. Analysis of open-ended survey questions revealed that if one misses a huddle, there are (a) feelings of missing connectedness to clinic activities, (b) emotional milieu of being lost or empty, (c) other ways to get the information, and (d) indifference. Regarding problems solved by huddles, three themes were (a) daily planning of staff and workflow, (b) improved communication, and (c) daily topics involving teamwork, support, and awareness. Two themes emerged on how participants liked huddles: enhances clinic communication and group cohesiveness and team spirit. Likewise, two themes emerged about not liking huddles: interrupts clinic schedule and timeliness of topics and updates. The final survey question was, “How can huddles be useful for you and your patients?” (AMA, 2015). The two themes were (a) improves team communication and (b) better patient care.

Conclusion: There is evidence of team culture-building through communication in the huddle, and huddles have become routine in clinics. Huddles had a clear checklist for staff daily planning and workflow. Further evaluation is needed of huddles’ effectiveness in improving interprofessional connectedness. In combining Dr. Leininger’s definition and the CDC definition of culture, nurses learned, shared, transmitted, and influenced the communication culture by focusing on patient safety to ensure and improve effective communication among team members. Congruence was achieved by combining the two frameworks, in that communication among the team was improved based on elements of the concept of culture. Study limitations included (a) only nursing staff completed the survey even though it queried about interprofessional communication, and (b) not all interprofessional staff were surveyed. As noted in survey results, very few medical staff attend huddles, possibly because huddles focus on attendance issues vs. patient problems or issues. Implications include that further research is needed to identify how to encourage interprofessional staff to participate in huddles that have clinical relevance for all.