December 9, 2008 Huddles in Healthcare
Seems we’ve been doing a lot of sports analogies lately! Actually, since we’ve recently been spending time on ways to improve communication in healthcare (handoffs, briefings, debriefings, checklists, etc.), it is logical that we look at the tools other “teams” use to promote teamwork. The football “huddle” is one of the most obvious.
What is the purpose of the huddle? It is to get all the players on the same page. They all develop a mental image of what the play should look like and what their role in that play is. They all need to understand what count the ball will be snapped on. They develop an understanding of the goal of the play (“we’re trying to get 7 yards for the first down” or “we’re going to fake it and go for the bomb”). They discuss contingencies (“here’s what we will do instead if the defense is in a specific formation”) and how the quarterback will let them know to change the play at the line of scrimmage (the “audible”). And sometimes they even discuss a second play they may run without a second huddle. Though one person, the quarterback, usually leads the huddle, a good leader takes feedback from other team members (eg. one of the lineman says the defense is likely to do something that may interfere with the play called, or the wide receiver says “I think I can beat the safety on a post pattern”). And they even discuss safety issues (“if I can’t see a receiver open by the time I count 3, I’ll just throw the ball out of bounds because we can’t risk a quarterback sack here”). And body language plays a role in huddles – like when you see fear in the eyes of your 180-lb. running back who just realized he has to block the 320-lb. defensive end by himself! There are huddles on defense, too. They discuss what type of defensive pattern to be in, whether they will blitz the quarterback, what they will do if the offense comes out in a certain formation, etc. The defensive captain also goes through his own mental checklist, which includes counting the number of men his team has on the field.
The huddle is not unique to sports. Pilots do a “huddle” before every flight, facilitated by a checklist. The executive team of a business usually does a huddle before presenting at a shareholders’ meeting (unless you are automotive executives presenting to Congress!). Even a rock band does huddles between songs (“let’s play this, and we need to pick up the tempo a little, and a little less volume on that bass guitar”)!
Huddles are also practiced over and over again. That practice and repetition helps everyone understand how their teammates are likely to act in certain situations, so that when there is no time for a huddle (the “2-minute drill” in football), the team members can use visual or quick verbal signals to help coordinate what they do.
And sometimes you need to huddle after a play is over (“why didn’t that play work?”, “what should we do differently next time?”, etc.).
So why not huddles in healthcare? They already are used. Sometimes they go by different names, eg. the pre-op “briefing”, the “timeout”, the post-incident “debriefing”, etc.
The surgical timeout is a prime example of a huddle. Though the timeout is best recognized for its function for final verification of patient and site of surgery, the timeout has many more potential uses. Nundy and colleagues at Johns Hopkins (Nundy 2008) used a very simple format for pre-operative briefings that led to a 31% reduction in unexpected delays in the OR and a 19% reduction in communication breakdowns that lead to delays. The tool they used was simple and consisted of 5 key items:
We’ve long been advocates of using the surgical timeouts for far more than originally intended. In our April 9, 2007 Patient Safety Tip of the Week “Make Your Surgical Timeouts More Useful” we advocated using either the pre-surgical timeout and/or the final verification timeout to also focus on some of the more common complications you wish to avoid. For example, use the timeout to ask questions such as following:
But one of the unsaid messages in the Nundy paper is the KISS (“Keep It Simple, Stupid”) principle. Anticipate things and try to discuss the most serious things that might happen, but don’t make the process so complex and long that team members lose their attention.
Using a checklist to facilitate the huddle makes a lot of sense. There’s nothing wrong with using a checklist to help you remember things to do. Even the best quarterbacks in football keep a list of plays on a plastic wristband to help them remember during a game. In our discussion on handoffs, we noted Lingard et al ( ) used a checklist to structure short team briefings and documented both reduction in the number of communication failures and other utility of the intervention. And remember, the 2009 Joint Commission National Patient Safety Goals now include a requirement for use of a checklist in the preprocedure verification process. That checklist should include elements such as the H&P, anesthesia assessment, completed informed consent, appropriate diagnostic and imaging reports or images, and any required implants, devices, special equipment or blood products that will be needed. Note that such a checklist would also be expected to reduce unnecessary delays.
So what are you other opportunities to “huddle up”? The following list names just a few:
You’ve heard us rave about the freeas a great resource on communication and teamwork developed by the Department of Defense (DoD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ). It covers huddles as a specific topic. The TeamSTEPPS™ resources include presentation modules, great videos of bad and good team interactions and communications, implementation and action planning tools, evaluation tools, a pocket guide and posters. Many of the resources are available online and others are provided on CD/DVD’s. Topics covered include developing teams, use of briefs, brief checklists, huddles, debriefing, situation monitoring, cross monitoring, SBAR, handoffs, and others.
The huddle is a simple concept and can take place in just a few minutes. Like the checklist, simple but powerful.
Nundy S, Mukherjee A, Sexton JB, Pronovost PJ, Andrew Knight A, Rowen LC, Duncan M, Syin D, Makary MA. Impact of Preoperative Briefings on Operating Room Delays: A Preliminary Report. Arch Surg 2008; 143(11):1068-1072
Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17