Health care huddles: Managing complexity to achieve high reliability

[Note: this is an update and repost of a REALLY old summary]

ABSTRACT

Background: Health care huddles are increasingly employed in a range of formats but theoretical mechanisms underlying huddles remain relatively uncharted. Purpose: A complexity science view implies that essential managerial strategies for high-performing health care organizations include meaningful conversations, enhanced relationships, and a learning culture. These three dimensions informed our approach to studying huddles. We explore new theories for how and why huddles have been useful in health care organizations.

Methods: We used a study design incorporating literature review, direct observation, and semistructured interviews. A complexity science framework guided data collection in three health care settings; we also incorporated theories on high-reliability organizations to analyze our observations and interpret huddle participants’ perspectives.

Findings: We identify theoretical paths that could link huddles to improvement in patient safety outcomes. Huddles create time and space for conversations, enhance relationships, and strengthen a culture of safety. Huddles can be of particular value to health care organizations seeking or sustaining high reliability.

Practice Implications: Achieving high reliability, the organizational capacity to deliver what is intended to be delivered every time is difficult in complex systems. Managers have potential to create conditions from which huddle outcomes that support high reliability are more likely to emerge. Huddles support efforts to improve patient safety when they afford opportunities for heedful interactions to take place among individuals caring for patients and embed mindfulness into the organization.

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From the full-text paper:

This explored the huddle (focused gatherings of functional groups). Huddles can take many forms. Although this study looks at healthcare, the findings are broadly applicable elsewhere (e.g. prestarts in construction etc.)

The drew on theory from complex adaptive systems (CAS) and highly reliable organising (HRO). Healthcare systems are considered CAS and the uncertainty inherent in these systems “unfold in perpetual novelty and that providers must respond effectively in unfamiliar situations” and “Health care providers in CAS are always vulnerable to one of Weick’s ‘‘cosmology episodes,’’ a sudden and profound sense that the universe is neither rational nor orderly” (p3).

Huddles are said to promote interpersonal relationships and communication.

It’s said less time should be spent trying to found out what we should do and more time learning in the moment; less time making decisions and more time creating meaning through dialog, interpretation and observation. “We should spend less time memorizing facts and more time exploring relationships (p3)

Further, “learning is a social act, it thrives on opportunities for interaction and a climate of openness” (p3). Huddles should focus less on conveying “know what” and more time unpacking “know how” and “know why”.

Results

An extract of some findings from the paper are shown in the below image.

Huddles:

·????????Serving as opportunities to highlight timely and specific institutional improvement targets (e.g. increasing skin assessments)

·????????Affording opportunities for conservations that span boundaries and hierarchies

·????????Inclusion of newly trained clinicians in the huddle can foster new shared understandings of work to be done

·????????The repetition and consistency of the huddle become part of the fabric of the organization

·????????Huddles create space for a diverse group of care providers to assess events both routine and unexpected, leading to new shared understandings

·????????Face-to-face huddles were seen to convey “signals, cues, and sequencing in addition to information,?leading to the development of shared assumptions and expectations” (p8)

·????????Huddles were argued to facilitate storytelling, which is seen as a way to enhance reliability

·????????Huddles helped to facilitate opportunities for people to interact who may not have otherwise interacted and may “help to combat the perpetuation of unconstructive communication norms” such as combatting the “fallacy of centrality: the assumption that someone in a central or senior position will be aware of or informed about any significant occurrences” (p8)

·????????Huddles may also enhance the opportunities for interactions between stakeholders. Although frequency of interactions doesn’t automatically increase quality, aspects of conversation that huddles are suggested to improve are: trust, responsive interaction, disciplined debate, intimate exchange and creative dialogue

·????????Because huddles enhance relationships as people get to know each other, this enhances interpersonal skills (which are seen to be equally as important to technical skills)

·????????Huddles may also allow breakdowns of hierarchical power gradients, such as providing people other than physicians and surgeons to theorise about what is or could happen. This may result in greater professional heterogeneity, e.g. requisite variety, improving collective learning etc

·????????Huddles may also result in changes to “cultural dynamics” related to transparency and reporting without blame or punishment also breaking down knowledge that is trapped within individual and unit silos; psychological safety is discussed at length within the context of huddles & HRO

·????????Further, huddles can be seen as a type of organisational microcosm, where management “can model the kind of culture that they want their organization to exhibit” (p9)

·????????While some practices can be codified in rules, much of health care “includes large tacit components. In addition to strengthening social ties, the huddle can support strategies for tacit knowledge transfer” (p9)

·????????Huddles and other means could also have undesired effects. For instance they could reinforce existing feedback looks that are one-sided and route information exchanges, and power imbalances and the like

·????????The types of huddles that allow groups to collectively create meaning through reflections on the current state of the system and speculations on the future state “interactions are unlikely to happen of their own accord unless huddle leaders model appropriate interactive behaviors in ways that are positive and highly observable to participants” (p9)

·????????On the above, huddles can also become stale and “mindless”; and simply reinforcing undesired system variability.

Link in comments.

Authors: Provost, S.M., Lanham, H.J., Leykum, L.K., McDaniel, R.R. Jr, & Pugh, J. (2015). Health Care Manage Rev., 40(1), 2-12.