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Improvement Tools/Methods
Limitations / Lessons Learned
Background Improvement Model
Process Improvement
Kimberly Albers, SN Jennifer Barnett, SN Kevin Devine, SN
The focus of this quality improvement
project is to improve patient safety,
outcomes, quality of care, and
communication through the
implementation pre-shift huddles.

According to the Joint Commission on Accreditation of
Health Care Organization, over 70% of all sentinel
events are due to failures in communication (Setaro et
al., 2011). Research shows that in numerous instances,
implementation of team huddles has coincided with
improved patient safety, overall patient care, employee
satisfaction, and staff retention (Goldenhar et al., 2012).

Bayfront Health has undergone multiple changes in
ownership. Along with the changes in ownership came
changes in policy, staff turnover, and an overall culture
of uncertainty. As a result, staff confidence about core
measures, quality indicators, and other policies has
declined, and necessary information is not always being
effectively communicated.
Limit each huddle to a maximum of 15 minutes
Have each member of the huddle stand throughout to
ensure the huddles are brief.
Meet at the same central location and time
Expect all staff to attend the huddle each shift to
promote cohesiveness
All staff members should have the opportunity to
express their ideas, comments, and concerns they may
Respect all members of the huddle
Keep the tone light and professional
Designate a huddle leader to summarize main concepts
and re-emphasize patient safety
Emphasis on communication and making sure all team
members know what is happening within the unit
(Morrison & Saunders, 2011)

Staff resistance related to clocking in 10 minutes earlier
for shift.
Staff buy-in will decrease the effectiveness of the

Trauma ICU, PCU, CCU Bayfront Health
Plan-Do-Study-Act improvement method:

P- Is implementing pre-shift staff huddles an effective
method of improving patient satisfaction with care, staff
communication, teamwork, and satisfaction with work
D- Assess patient satisfaction of care received and
employee satisfaction with communication, teamwork, and
work environment utilizing questionnaires prior to
implementing huddles. Implement team huddles among
all RNs, PCTs, and charge nurses 10 minutes prior to each
change of shift to discuss any newly implemented policies
or procedures, evaluate unit performance, discuss special
needs of patients on the floor, hold team building
exercises, or provide a platform for the staff to make
announcements. Redistribute the questionnaires to
patients and staff six months after huddles have been
S- Compare the responses in the questionnaires prior to
the implementation of team huddles and six months post-
implementation and assess for any improvement in patient
reported satisfaction with received care, staff satisfaction
with work environment, teamwork, or teamwork.
A- If the questionnaires reveal a significant improvement
in any of the area in question, team huddles should be
implemented throughout the hospital.


Goldenhar, L.M., Brady, P.W., Sutcliffe, K.M., Muething,
S.E. (2012). Huddling for high reliability and situational
awareness. Cincinnati Children’s Hospital Medical
Center, 22, 899-906. doi: 10.1136/bmjqs-2012-001467
 Morrison, D., & Sanders, C. (2011). Huddling for optimal
care outcomes. Nursing 2011, 12, 22-
24. doi: 10.1097/01.NURSE. 0000407682.12130.f3
Sentinel event data- Root causes by event type 2004-2Q
2012 (2014). The Joint Commission. Retrieved from
Setaro, J., & Connolly, M. (2011). Safety huddles in the
PACU: when a patient self-medicates. Journal of
PeriAnesthesia Nursing, 26(2), 96-102.
“I pushed for team huddles on our unit
because they promote patient safety
and teamwork on the unit. Everyone is
aware of what is happening unit wide.”
-ICU Nurse 1

Team Members

 RN and PCT attendance is necessary to support implementation.
 Charge nurses from a.m. and p.m. shifts must collaborate to run
huddles at shift change.
Nurse managers attend, when available, to discuss policy and
process changes.
Staff should be held accountable to attend the huddles to ensure

To assess the effectiveness of pre-shift huddles, patient
and staff satisfaction questionnaires will be distributed
and analyzed for alterations in perception of quality of
care received, work environment satisfaction,
communication, and teamwork among the staff.
 Long term comparison of sentinel events, incident
reports, and near misses prior to and after implementing
team huddles.

Pre-Shift Huddles
Discuss Issues
on Unit

Assign Staff to
Communication &
Teamwork on the Unit
Improved Patient
Care & Safety
“Pre shift huddles have
increased communication on
the unit and encouraged better
-ICU Nurse 2
“The team huddles have helped to identify the patients who will need extra
assistance throughout the shift. I’ve been able to better manage my time,
and assist nurses who will need extra help during their shift.”
-ICU Tech
Bayfront’s ICU Staff Perception of Team Huddles Since
Implementation in June 2014
Root Causes of Sentinel Events Reviewed by The Joint
Commission by Year