ABSTRACT: British Columbia’s primary care landscape is increasingly focused on using blended virtual teams to coordinate and integrate patient journeys. Simply bringing multidisciplinary colleagues together does not guarantee effective team communication. With potentially depersonalized remote working environments, physicians need tools to support collaboration and enable staff to achieve a shared vision. Adapting daily huddle practices by using visual management tools during the COVID-19 pandemic has the potential to unite primary care staff. Reflecting on practice changes in my local clinical context, huddling has improved patient safety behaviors, job satisfaction, and leadership perception. Contextually targeted huddles are vital because there is no single approach that best suits all disciplines, rosters, and teams. Ideal huddle length, timing, and content must be adaptive and are of increasing importance due to the accelerated pace of health care change.
Huddling helps focus staff and improves teamwork, patient safety, job satisfaction, and leadership.
Across British Columbia, the primary care landscape continues to evolve as governments seek to establish effective models for the prevention of illness in pandemic and postpandemic environments. There is an increasing focus on using teams to support complex chronic conditions and coordinate and integrate care. As many physicians will be aware, simply bringing professionals together in teams does not guarantee collaboration. Iterative change to support collaboration is needed to enable staff to achieve their objectives.
The literature suggests that primary care staff can increase their situational awareness, decision making, workplace satisfaction, and access to care, and reduce human errors by huddling regularly. Huddles provide a scheduled venue for asking questions in real time and verbalizing concerns with colleagues. Despite little empirical evidence in Canadian practice, it is hypothesized that the introduction of huddles leads to increased staff efficiency, improved information sharing, increased accountability, feelings of empowerment, and a culture of collaboration.
The Institute for Healthcare Improvement studied 10 high-performing systems and noted that regular, standardized huddles involving frontline and mid-level managers were part of an excellent health care management system. In 2017, 3412 huddles were observed to evaluate their effect on team problem solving and information sharing over 3 months. Due to increased staff accountability, more than 92% of problems identified were resolved through the huddle process. But has this been our experience in BC?
Research has shown that a whiteboard outlining a small number of visual performance measures updated daily is a key tool in supporting team success and strengthening a culture of patient safety.[5,6] This has been translated into practice in some community health centres across the Lower Mainland.
Huddles are short 5- to 15-minute briefings designed to give staff opportunities to plan daily tasks and roles, stay informed, review events, and share plans to ensure well-coordinated patient care. The huddles can function as a venue for highlighting patient concerns, sharing information, celebrating success, and reinforcing common goals.[2,3,5,7,8]
Prior to the outbreak of COVID-19, my primary care community health centre team began a project on developing updated, relevant daily huddle content and capturing it on a large whiteboard in a high-traffic area. The purpose of this was to help better support mandated complex clients via brief multidisciplinary intervention planning. This created a psychologically safe space, improved daily visibility regarding workflow and equipment concerns, and allowed teams to keep abreast of health authority policy changes. Staff could anonymously submit kudos and “client voices” to celebrate examples of aspirational teamwork and patient journeys, and to connect meaning to daily work.
When COVID-19 arrived in Vancouver, the team pivoted huddling in a number of ways to help improve staff well-being and patient safety. Virtual conference technology was installed at the huddle board to allow providers working from home to remain engaged. Nursing staff improved pharmacovigilance and opioid agonist therapy processes by seeking team input at daily huddles. When combined with pandemic prescribing, this helped prevent overdose deaths and the spread of respiratory viruses. Performance indicators evolved, and useful clinical metrics were updated to reflect shifting workflows and staffing levels. Intensive housing outreach intakes opened, and new teams were created. As time progressed, daily huddles continued as a pivotal communication tool. Staff have taken ownership of the huddles and continually review their content.
Other successful huddling techniques include building clinical themes across a defined period. This encourages reflective practice, reorients groups to unseen biases, and builds new strategic capabilities. One example of a theme has been a weekly focus on exploring underused electronic medical record functionality, which has led to improved group practice entering interventions such as cervical screening recalls.
If staff experience uncertainty about specific, high-relevance topics, such as the use and availability of personal protective equipment during COVID-19, huddling is a perfect vehicle for immediately highlighting concerns. We found that direct clinician feedback was more likely to be heard and operationalized through interactive daily huddles than through large policy documents. This style of engagement provides local leaders with multiple touch points with staff, which fosters reliability and trust if done well.
In my practice, daily visual huddles throughout the pandemic have improved care team perception and understanding of the clinic’s shifting priority goals. Staff connections with each other, including those in remote arrangements, have also improved. This has allowed for deeper understanding and analysis of relevant issues. Staff have noted improved self-reflective practice, job satisfaction, and reduced burnout as a result of peer-led daily visual huddles.
There have also been numerous care benefits for patients, including prevention of emergency department presentations, successful outreach to de-escalate social and medical crises, a reduction in missed doses of opioid agonist therapy and mental health medications, coordinated recalls of at-risk patients, and improved communication with inpatient teams while community health centre patients are admitted.
Challenges and areas of growth
Optimizing huddle length remains a challenge, but there is no single approach that best suits all disciplines, rosters, and teams. Staff suggested that huddling twice a day would help our team remain patient focused during discussions but have found this challenging in practice.
Creating effective meaning for all staff remains challenging because it is easy for group discussions to get derailed. Knowing how to appropriately scale and close the loop on complicated open action items remains difficult. By potentially minimizing opportunities to fully explore issues, there is a risk of some staff feeling unsupported or psychologically unsafe. This is best dealt with by investment in communication and leadership training.
Rotation of voluntary huddle lead roles helps individuals gain an understanding of how side conversations and time delays can reduce the effectiveness of huddles. We found that taking important detailed discussions offline into smaller focus groups for a few minutes immediately after huddling was an effective way to maintain flow during the formal team engagement time.
With the adoption of virtual primary care environments and with workforce shortages, the importance of teamwork, goal setting, and job satisfaction will increase. Facilitating digital huddles requires the provision and adoption of compliant confidential technology solutions. An even greater focus on making daily briefings time appropriate to produce meaning for all disciplines is needed with virtual or hybrid huddling. Keeping to time is more important than ever, and virtual breakout rooms can be useful tools for smaller discussions. However, as privacy regulations evolve, a burden may be placed on smaller fee-for-service clinics that are required to self-fund videoconferencing solutions. This may prohibit huddling and the various benefits it confers in these environments.
Primary care huddles have an increasing role to play in developing strong, purposeful teams that provide quality patient care. As busy physicians, our time with colleagues is extremely precious. It is more important than ever for us to connect despite barriers faced in implementing and assessing huddles. There is evidence that these brief daily professional connections provide positive communication, patient safety, and teamwork and leadership benefits. As in many aspects of clinical practice, we must remain flexible and adaptive when we huddle. There is no one-size-fits-all solution, and it is up to us to support and facilitate these meaningful multidisciplinary encounters.
BC health authorities are investing in team-based primary care; tools to support staff collaboration are needed. Huddling is most useful when the process is peer designed and led. Visual huddling tools help focus staff and improve teamwork, patient safety behaviors, job satisfaction, and leadership perception. Optimizing huddles requires a targeted approach using videoconferencing technology for remote workers and focusing on the most important topics, performance metrics, and themes that are directly relevant to current daily clinical practice.
This article has been peer reviewed.
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5. Scoville R, Little K, Rakover J, et al. Sustaining improvement [IHI white paper]. Cambridge, MA: Institute for Healthcare Improvement; 2016. Accessed 3 February 2021. www.ihi.org/resources/Pages/IHIWhitePapers/Sustaining-Improvement.aspx.
8. Mate K, Rakover K. The answer to culture change: Everyday management tactics. NEJM Catalyst 2019. Accessed 3 February 2021. https://catalyst.nejm.org/doi/abs/10.1056/CAT.19.0004.
9. Canadian Medical Protective Association. Telehealth and virtual care. Accessed 2 March 2022. www.cmpa-acpm.ca/en/covid19/telehealth-and-virtual-care.
Dr van Bockxmeer is a family physician working across a number of community and hospital sites.
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