1. McCain, Natalia BSN, RN, ACRP-CP
  2. Ferguson, Tysa DNP, RN, CNML
  3. Barry Hultquist, Teresa PhD, RN, PHCNS-BC, NE-BC
  4. Wahl, Carol DNP, RN, MBA, NEA-BC, FACHE
  5. Struwe, Leeza PhD, RN


Background: Literature shows that interdisciplinary huddles help promote clear communication and proactive reporting of potential errors.


Local Problem: High reliability organization (HRO) and just culture models were implemented, yet fragmented team communication about patient safety remained. Huddles were implemented to identify and address patient safety issues.


Methods: A pre/postintervention design was used. Near-miss and actual event safety metrics, patient satisfaction, and employee satisfaction/work group perceptions were measured at 3 time points over 1 year.


Interventions: Daily interdisciplinary huddles were implemented to improve communication, reduce errors, and improve patient and employee satisfaction.


Results: Near-miss reporting increased across time points. Patient satisfaction with how the staff worked together to provide care significantly increased over time. Employee satisfaction and perception of work group communication, collaboration, and psychological safety scores improved, however, were not statistically significant.


Conclusion: Implementing huddles demonstrated improved outcomes in patient safety, patient satisfaction, and employee satisfaction/work group perceptions.


Article Content

It has been 20 years since the publication of To Err Is Human and yet medical errors continue to be the third leading cause of death in the United States.1 While there have been efforts to address this safety concern, health care organizations struggle to sustain results due to complex structures and rigorous efforts and extensive costs needed to implement changes.2 Other patient populations, including those with psychiatric conditions, have unique patient safety issues, such as risks of self-harm, restraint injuries, or violence that may be preventable if organizational safety strategies are employed.3-5 In the United States, 115 out of every 1000 hospitalizations result in a preventable safety event, with a cost to payers averaging $8000 per admission.6 A systematic review and meta-analysis across a range of health care settings globally estimated that about one in 20 patients experience preventable harm related to health care.7 Actual and potential (near miss) patient safety risks typically result from a combination of individual failings, systematic weaknesses, and environmental factors; all need to be recognized and addressed since root causes are likely similar.8 Near misses, defined as reporting of unsafe situations even if no harm has occurred, are often underreported and become a missed opportunity to build a better safety culture.8,9


Hospitals persist in quality improvement (QI) efforts to improve patient safety but continue to experience challenges in reducing patient harm.1 The Joint Commission Center for Transforming Healthcare found that poor communication is a major contributor to 80% of medical errors.10 Lack of transparency in communication, fragmented team dynamics, and fear of retribution make it difficult to identify errors and take appropriate action to mitigate potential harm.9,10 To address potential and actual patient safety and medical errors, many organizations have adopted the high reliability organization (HRO) and just culture models that target improved patient safety and reduced errors through a culture of transparency in reporting.1-3,9


Nurses at the bedside are in a position to observe and report unsafe conditions before they become adverse events, yet many events remain unreported because of concerns about being blamed for the situation.9 Just culture's contribution to HRO implementation occurs with accountability (system or individual) for near misses and actual adverse events, as well as addressing flaws in system design rather than blaming individuals for an error.1,9 For example, McFarland and Doucette9 provided nurses with education on HROs and just culture, which led to a 14.7% increase in adverse event and near-miss reporting.9 Findings also showed that nurses felt confident, comfortable, and safe reporting variations in standard processes and incorporated safety behaviors and prevention tools as part of daily practices.9 The HRO and just culture approach encourages clear communication, enhanced collaboration and teamwork, and improved system design and balances accountability between individuals and organizations for patient safety reporting without retribution.1,9,11


Huddles have been underrecognized in literature but repeatedly praised for their results in teamwork operations and links to improvements in patient safety.12 Huddles are a communication strategy between team members to promote situational awareness about concerns in the organizational environment, catch near misses, encourage collaboration and teamwork, learn from other's experiences, and encourage employees to speak up about potential problems and issues before events occur.3,11-13 Although huddles are dynamic and evolving based on the needs of the team, key characteristics for huddles include a short, regular planned checkpoint and feedback loop to identify, discuss, and track individual, system, or environmental concerns that might lead to near misses or adverse patient safety events.12,14 Huddles foster relationships among employees who might not otherwise regularly interact, allow time for discussions, and provide a venue for developing adaptations that address identified risks-both near misses and actual events.12 Through these interactions, huddles empower employees and create space for shared understandings and decision-making vital to developing trust and encouraging team excellence.9 The ability to use a safe, supportive place to articulate concerns is essential to build high expectations and standards within a culture of transparent error disclosure so that safe health care can be provided.9,15 For example, Sullivan et al4 found an 8% to 16.6% reduction in physical and nonphysical violent incidents in psychiatric wards over 2 years after implementing collaborative learning and huddles.


These approaches (HRO, just culture, and use of huddles) support development of an organizational culture that can also contribute to patient and employee satisfaction in a variety of health care settings. An evaluation of huddle implementation showed improvements in patient experience and satisfaction in inpatient units3 and emergency departments (EDs).16 After implementing huddles, staff satisfaction improved in the ED by 5% to 30%.16 Acute adult psychiatric ward staff perceived huddles had a positive impact on staff well-being (feeling safe, prepared for day, and empowered).17 Venkataraman et al10 found improvements in staff satisfaction after huddles were implemented, as staff perceived huddles improved teamwork, enhanced communication, and helped identify deteriorating patients. Farley et al13 found huddles improved nurse engagement, from 39% to 78%, 2 years after huddle implementation.


An HRO model encourages staff to strive toward high reliability where harm prevention and process improvement are expectations.9,15 By emphasizing just culture and a focus on safety through huddles, employees are enabled to create a culture of accountability and reliability.11,15 Huddles engage employees, improve communication, identify and improve processes, improve patient and employee satisfaction, and ultimately are designed to prevent harm.1,3,12,16,17



The purpose of this project was to evaluate the implementation of team huddles as part of HRO development in the organization. The aims of this project were to assess the implementation of huddles as measured by (1) patient safety near-miss and actual event reporting (using the Joint Patient Safety Report [JPSR]), (2) patient satisfaction (using 2 selected Patient Satisfaction Press Ganey questions), and (3) employee satisfaction and work group perceptions (using 4 selected All Employee Satisfaction [AES] questions).




The QI project used the implementation framework RE-AIM to extend the foundational HRO work. RE-AIM is used to translate research evidence into practice, assist with program planning, and improve program success through implementation and effectiveness measures.18 This project was designed to improve unit safety culture and communication using the RE-AIM framework by (a) reach, involving all multidisciplinary members in planning and implementation; (b) adoption, through Interdisciplinary Department Meetings (IDT) members and frontline nursing staff attending huddles; (c) implementation, using huddle boards as a vehicle for team communication and collaboration to discuss safety issues; and (d) effectiveness, through evaluating patient safety near misses and actual events, patient satisfaction, and employee satisfaction and work group outcomes.


This QI project used a pre/post intervention design. Data collection included 3 time points. Time point 1 (T1) occurred October-December 2020, before HRO training education and the huddle intervention. Time point 2 (T2) occurred April-June 2021, before the huddle intervention. Time point 3 (T3) occurred July-September 2021 to collect postintervention data. The AES survey was completed in November 2021 after the intervention was complete. This study was classified as a QI project by the organization and was not considered human subjects research as deemed by the university's and organization's institutional review boards and Office of Regulatory Affairs, respectively.


Organization context

The local organization consists of a larger health care enterprise whose goal is to focus on an enterprise-wide culture of safety, resulting in greater reliability and zero harm.19 In February 2019, the health care enterprise teamed with the Institute for Healthcare Improvement to implement HRO principles across the system, including HRO education and huddles.20 The organization completed the first launch of HRO 101 training in 2020, with a 95% staff/supervisor completion rate. HRO 201 for staff/supervisors was completed December 31, 2021, with a 92% completion rate. The HRO subcommittee provided a bidirectional flow of metric data from executive leadership to frontline staff.


Building a just culture included the following: (1) performing an organization assessment; (2) creating awareness; (3) developing an implementation plan; (4) implementing training; (5) sustaining through organizational practices; (6) measuring success; and (7) celebrating success.21 The organization undertook this work by creating a project mission statement for just culture in the organization and implementing tiered huddles to improve communication. Tiered huddles were implemented at a unit/department level, at the middle manager level, and at the executive leadership level as noted by Croke.14 Improved communication within and between these levels was viewed as paramount to building a just culture environment and an HRO system.


Organizational unit/department communication and huddle formation

The unit/department-level project to implement huddles was completed on a 12-bed psychiatric inpatient unit with 22 nursing staff and 7 multidisciplinary team members. Prior to use of huddles, 2 separate communication approaches were used, one for frontline nursing staff and one for multidisciplinary members. Frontline nursing staff used a routine 5- to 10-minute handoff that highlighted the continuity of care plans for patient assignments. The IDT with the multidisciplinary team occurred weekday mornings at 7:30 AM. The multidisciplinary team consisted of physicians, psychology, pharmacy, the charge nurse, peer support, recreational therapy, and social workers. The IDT was a collaborative opportunity for this unit to develop a plan of care and provide ongoing transparency between the multidisciplinary team members. These communication approaches continued, but an additional communication strategy (huddles) was added to address individual, environmental, and system issues that might lead to near misses or actual safety issues/events.


Huddle formation was designed with employee input and was modeled after the 2 leadership-level huddles (middle manager and executive). Huddles added an additional layer of communication to promote transparency, incorporating all staff members in a brief discussion about patient and unit safety concerns following the IDT. Visual huddle boards were used, which are efficient for tracking and reporting patient safety issues. The department used a dedicated monitor display, which included sections such as a problem list, communication items, and key performance areas (see Supplemental Digital Content, Table 1, available at:,22 Completed items on the huddle boards were downloaded, saved, and used for data collection and evaluation.

Table. Joint Patient... - Click to enlarge in new windowTable. Joint Patient Safety Report (JPSR) Near Misses and Actual Adverse Events Reporting Changes

The team used the huddle board template during implementation, with 3 adaptations occurring to fit evolving needs and identify additional patient safety issues. First, because of electricity issues, the electronic monitor was changed to a whiteboard. Data were captured on the whiteboard and subsequently entered into the electronic system on an operational computer. Second, because of needs from the ongoing pandemic, COVID-19 results and protocol compliance were added to the daily huddle discussion. Finally, a psychiatric patient eloped from a medical/surgical unit due to psychiatric unit bed unavailability. Because of this event, the inpatient psychiatric team began identifying psychiatric patients on medical/surgical units during the safety huddles, expediting the provision of needed psychiatric services and support. A section prioritizing psychiatric admissions to other units was added to the daily huddle board.


Measures and outcomes

Patient safety was measured using the JPSR reporting of near misses or actual safety events. When a near miss or actual event occurred, involved staff entered data in the JPSR reporting system, events were discussed during huddles, and the involved department(s) and leadership reviewed the situation and took appropriate action steps. Aggregate JPSR reports were used to measure changes over time in near misses and actual events. Changes in near misses and events were assessed with Fisher's exact tests.


Patient satisfaction was measured using 2 questions from the 37-item Press Ganey Patient Satisfaction survey. Questions used included the patient's perception of (1) overall assessment of how well the staff worked together to care for you, and (2) overall rating of care given at this facility. This tool used a 5-point Likert scale for responses ranging from 1 (very poor) to 5 (very good). Changes were assessed with an independent t test using summary data.


Employee satisfaction was measured using 4 questions from the organization's AES. This 64-item survey was developed by the organization, completed yearly, and gathered employee perceptions and satisfaction with the organization, work group, and job. Items used included the employee's (1) overall satisfaction: considering everything, how satisfied are you with your job; (2) work group collaboration: work groups collaborate to accomplish shared objectives; (3) work group communication: members of my work group communicate well with each other; and (4) work group psychological safety: members in my work group are able to bring up problems and tough issues. The tool had a 5-point Likert scale for responses ranging from 1 (very dissatisfied) to 5 (very satisfied); a "not applicable" response was also available. Descriptive statistics were used to analyze the data, as only summary data (mean and response rate) were available for each question.



All unit disciplines participated in development and implementation and consistently attended the Monday through Friday huddles, with the physicians and charge nurse most frequently represented. Huddles occurred 98% (n = 59/60) of the time during the 3-month period. Huddle meeting times averaged 4 minutes (median = 4 minutes; range, 2-6 minutes).


There was a significant decrease in the number of near misses reported, from 7 (T1) to 1 (T2) (P = .0231), and a significant increase from 1 (T2) to 9 (T3) (P = .0183) (Table). There were no other significant differences in near misses or actual events, although the number of actual events reported did increase in T3 (7 events) compared with T1 and T2 (4 events each).


For patient satisfaction, only one question and time period showed a significant change, how well the staff worked together to care for you increased from mean = 87.5 in T1 to mean = 97.4 in T3 (t86 = 2.790, P = .01) (see Supplemental Digital Content Table 2, available at: Patient satisfaction related to overall care given at the facility increased from mean = 91.2 (T1) to mean = 96.7 (T3); however, this was not statistically significant (t72 = 0.092, P = .92).


For employee satisfaction, the mean satisfaction increased for 3 of 4 items from T1 to T3, including overall satisfaction (increased from 3.6 to 4.3), work group communication (increased from 3.9 to 4.2), and work group psychological safety (increased from 3.5 to 4.4) (see Supplemental Digital Content Table 3, available at:



This QI project found a significant increase in near-miss reporting from T2 to T3, with no significant increase in actual safety events. McFarland and Doucette9 similarly found an increase in reporting near misses and actual events after implementing huddles, which the authors attributed to the organization's focus on HRO and just culture, which created a conducive environment where staff felt more comfortable reporting safety events.11 Brass et al3 indicated huddles contributed to improvement in safety metrics over 2 years, and Sullivan et al4 attained reductions in incidents over 2 years. These results might signify that longer use of huddles would have more impact on reporting of events.


A statistically significant difference in patient satisfaction results was noted for staff working together to care for the patient from T1 to T3 and a nonsignificant increase in overall rating of care. Increased communication and collaboration due to huddles could have positively influenced the patient satisfaction results, similar to other findings in the literature.3,16


Employee satisfaction improved between T1 and T3. Review of the huddle board showed that employees participated in huddles throughout the project. Previous literature has shown that the use of huddles encourages team building and improves communication16; increases staff perceptions of teamwork and support, communication, and identifying deteriorating patients10; and increases employee engagement.13 Sullivan et al4 and Provost et al12 found that staff perceived huddles to be a safe space that supported communication, collaboration, teamwork, and strengthened a culture of safety. Increases in positive employee responses show that huddles may help improve employee satisfaction and perceptions of collaboration, communication, and safety.


Nursing implications

System leaders can create a trusting environment and model meaningful interactions and adaptations to address routine and rare patient safety events through huddles.9,12,14 To create sustainable practices and validate the value of huddles, nursing leadership must model transformational leadership and support interprofessional team communication and time for collaboration.9,12 In this organization, the leadership team advanced the HRO culture of safety as described by Provost et al12 and Croke14 through committee structure, resource deployment, physical presence, streamlined communication, and a tiered huddle approach. System leadership supported adaptions of HRO processes and huddles for improved efficiency and effectiveness.


At a unit level, nursing leadership was a key catalyst for implementation of huddles. Huddle processes need to be dynamic, visual, and adaptable to fit the needs of each team and unit (such as unique needs of psychiatric units) to effectively address safety issues.3,10,12,16,22 As noted in McFarland and Doucette,9 unit nursing leaders have oversight of unit operations and are in a pivotal position to encourage adoption and sustainability. Nurses were key in connecting members of the multidisciplinary team; as such, their involvement and engagement in huddles for addressing safety concerns are of paramount importance.


While the electronic huddle board facilitated the collection of huddle information, the team found that a whiteboard guided the huddle most efficiently, with information entered electronically after the huddle. This occurred because the electronic huddle board required a dedicated computer, which decreased flexibility for meeting spaces and could have created confidentiality issues. Nursing staff found use and adaptations of huddles provided the venue for consistent communication of issues and ideas for resolution that made for easier implementation of changes, similar to findings by Provost et al.12 As a result, communication was consistent, proactive actions were taken to mitigate risks, and patients and employees remained safe. In fact, nursing staff felt the huddles were so valuable they expanded the project by implementing daily huddles over weekends and holidays to enhance communication, coordination, and facilitation of safe care. The project is being extended to other inpatient care units to fulfill the commitments of an HRO.



Results may not be transferrable to other units or organizations due to the small size of this unit, patient diagnoses served in the unit, supportive governance structures, and high IDT involvement. In addition, the short duration of a 3-month huddle intervention may have limited the significance of outcomes. More longitudinal data collection could be included in future project expansion.



While few statistically significant findings were achieved within this project time frame, positive practice changes occurred with the implementation of huddles. HRO baseline training provided the educational foundation of a safety culture, which became a major driver in project acceptance and influence. The principles of HRO and just culture incorporated with huddle consistency were focal points of this project. These findings support the use of huddles to advance an HRO model and may contribute to the goal of zero harm in health care.




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adverse event reports; high reliability; just culture; patient safety