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Huddles

Tip Sheet


WHAT IT IS:
A Huddle is a quick meeting to share and discuss important information. There are several kinds of huddles.

  • Shift Huddle is a gathering of the nurses and CNAs working together in one area. Start of Shift and End of Shift Huddles provide ways to share information about each resident as everyone starts work and to recap and pass along to the next shift any new information. Huddles can be done in a stand-up meeting or as room-to-room walking rounds with the charge nurse and CNAs together checking on each resident. CNAs lead the sharing about each resident, with nurses and others adding relevant information. Many homes also include other staff who can benefit from and/or contribute needed information and ideas. Start and end of shift huddles normally take about 15 minutes.

Shift huddle is best done with staff from both shifts. If there is not a shift overlap, at the end of the shift, CNAs share information for each resident on their assignment. The nurse then shares that information in her report to the next shift. At the start of shift, nurses give information provided by CNAs and nursing from the previous shift's end of shift report. Other staff may add relevant information about that resident. Make a deliberate effort to ensure that shift report huddles are truly a conversation with all team having an equal voice, and not just another name for a "traditional shift report" with the nurse as the only or primary speaker.

Huddles can occur at other times, such as before staff go on break, when a new resident arrives, or as an issue arises that needs the team to come together. Another type of huddle is called Everyone Stands Up Together, in which members of the management or clinical team huddle with staff closest to the resident. With practice, these huddles can usually be completed in 5 – 15 minutes but may take longer when they are first used, depending on how prompt and focused staff are.
  • New Resident Huddles let staff know about new residents before they arrive and check in with staff about how new residents are doing in the first few days. Areas to cover include any areas of risk, goals, customary routines, social history, family situation, mood, appetite, and functional abilities. In addition to the CNAs and nurses, a new resident huddle can include housekeeping, social work, activities, clinical nurses, and therapy.
  • QI Huddles focus on a particular resident or topic to analyze what is happening, why is it happening, and what can be done about it. In these huddles, staff closest to the resident come together with other clinical and operations staff to share perspectives, conduct a root cause analysis, develop a game plan, and evaluate the effectiveness of their action. QI huddles can be used to discuss "at risk" residents or to review an adverse event such as why someone fell. They can be used as part of QAPI Performance Improvement Projects (PIPs) such as removing alarms, reducing antipsychotic medications, or trouble-shooting other areas of concern, such as wounds or weight loss. Beyond the CNAs and nurses, a QI huddle can include housekeeping, social work, activities, clinical nurses, and therapy. QI huddles can be held at any time when other departments can participate, without interfering with the crunch of care. (See Tip Sheet on QI Huddles Closest to the Resident)
  • Everyone Stands Up Together takes the management team's morning stand-up or daily clinical meeting out to staff closest to the resident so that CNAs, nurses, and managers share and discuss, at the same time together, information needed by everyone. Review of the 24 hour report requires conversation with CNAs and nurses to learn what happened, share information, and problem solve. By "standing up together," issues are resolved in one conversation between the management team and the CNA's and charge nurses involved. When everyone stands-up together, the management and clinical team joins with nurses and CNAs so that operational or clinical issues can be addressed on the spot. This type of management stand-up with staff works best when it is done early enough to be able to act on items identified. Consider a "stand-down" huddle with staff in the afternoon to close the loop on action items. An everyone stands up together huddle should last about 15 minutes in each area of the home.

WHY IT IS IMPORTANT:
Communication of essential information cannot be left to chance. When it is shared in a group through a huddle of the shift or with the management team, everyone hears EXACTLY the same information and can share what they know. The group can problem-solve any issues on the spot. Staff closest to the resident know the resident best. They have vital information and effective ideas. When they understand the problem and shape the solution, they have the best chance to implement it well.

Organizations are most effective when they use systems to foster timely, accurate, problem-solving communication that provides equal voice, shared knowledge and shared goals. When staff problem solve together every day, they have the structures and skills in place to problem solve on a larger systems scale as needed for effective Performance Improvement Projects (PIPs) under Quality Assurance & Performance Improvement (QAPI).

A shift huddle reinforces teamwork and allows everyone to hear about residents so staff can help residents not on their assignment.

HOW TO DO IT:
The four foundational practices are each strengthened by the others. Huddles are most effective when staff are consistently assigned and know their residents well. Daily huddles help staff incorporate critical thinking and collaborative problem solving into their daily practice, which improves their participation in care plan meetings and QI huddles. When management huddles with staff closest to the resident and makes the necessary accommodations, staff can meet residents' needs. When staff then capture this information in the assessment, care plan, and daily work processes, every one is on the same page. These huddles are mutually reinforcing and provide the foundation for continuous improvement.

  • Keep it constructive: This is a positive exchange of information needed to care for each resident. Develop staff's competency in constructive problem solving. If staff slip into blame or negativity, refocus the discussion on constructive action that addresses the concerns raised. Keep on topic and redirect staff who digress by letting them know their point can be addressed later so that the group can return to the focus at hand. Probe to generate critical thinking about the root causes of a situation and the most effective responses. Thank people for their contributions.
  • Work with a regular agenda: Agenda Items for a shift huddle or everyone standing up together may include:
    • Resident-by-resident report by exception, focused on risks and opportunities, including quality of life and quality of care, using MDS areas of functional status, mood, and customary routines as a guide. For example if someone is at risk for pressure ulcers, discussion will include anything unusual about how well they ate and drank, and any positioning issues. If someone has been depressed, the discussion will include their interactions and participation in activities. If a resident does not seem to be herself that day, this is noted and discussed. INTERACTII Stop and Watch is an excellent tool to focus the end of shift exchange.
    • "At risk" residents, including people in the 24 hour report, residents being watched for issues such as wounds, falls, antipsychotic medications, weight, mood, any new residents and any residents in the midst of a change in condition.
    • Anyone being evaluated for a Change in Condition assessment or due for their annual or quarterly assessment and care plan meeting (in their Assessment Reference Date - ARD)
    • Changes in census – people coming in or leaving
    • Information about new residents, including social history, family information, medical needs, goals, areas of risk, customary routines and special needs
    • Reportable events, incidents, accidents for any resident 
    • Concerns and compliments from any resident
    • Follow-up on any issues raised for which the loop needs to be closed
    • Any clinical area that is being worked on or is the focus of a QAPI Performance Improvement Project (e.g., antipsychotic reduction)
    • News from any department requiring staff knowledge or coordination
    • Introduction of and check-in with new employees
  • Facilitate a good group process in QI huddles:
    • Provide information staff need.
    • Bring the white board and write down all the ideas
    • Prompt people who are less likely to jump in
    • Set rules for "no blame" to keep it positive and constructive
    • Enhance problem-solving competence by using teachable moments in the discussion. Stay with it. Everyone will get better at it with practice.
  • Pilot test to implement: Try out huddles with your strongest charge nurse and CNA team. Learn the best time for the huddle and how to do it. As the huddle gets solid, pilot teams can share with peers.
  • Be on time: This is a short meeting. It needs to start and end on time. Everyone needs to be there on time and be prepared to share.
  • Provide Coverage So Staff Can Attend: Have management answer lights and meet residents' needs while CNAs and the charge nurse are rounding or having stand-up so that they can have uninterrupted time.
  • Teach critical thinking: To be successful, huddles have to be valuable to the participants. These are not rote reports. They are opportunities for critical thinking and problem-solving together to ensure the best care for each resident. The exchange is an opportunity for "just-in-time" teachable moments. For example, when CNAs describe ways that a resident is not herself, as the nurse probes the issue, she can explain the medical concerns and what to look for in monitoring the situation.
  • Teach constructive participation: Provide mentoring and role model how to facilitate and participate constructively.
CAUTION: For staff to engage in huddles, they must see that what they bring up is valued by being followed up on. If they bring up ideas or concerns and don't see them taken seriously, they will stop participating.

RESOURCES:
Pioneer Network
  • Pioneer Network's website provides links to many affiliate resource organizations.
  • Pioneer Network National Learning Collaborative Webinars all contain examples of staff huddles to provide high quality individualized care. They are available for a fee for five on-demand viewings of each webinar. All 12 webinars are also available for purchase as a set of discs, at a discounted rate. To purchase viewings of one or more of the webinars, or the entire package of 12 webinars, go to Pioneer Network store.
  • This tip sheet is from the Pioneer Network Starter Toolkit: Engaging Staff in Individualizing Care. The entire toolkit, with additional tip sheets, starter exercise and resources, is available at www.pioneernetwork.net/Providers/StarterToolkit
Advancing Excellence in America's Nursing Homes www.nhqualitycampaign.org
Data collection can help determine whether the changes being made are working, and continue to work. The Advancing Excellence in America's Nursing Homes campaign has the tools and excel sheets for collecting data on consistent assignment (are we REALLY doing this?) and on Person Centered Care (are the wishes and preferences of the residents actually being delivered, and are the direct care workers attending and participating in the care plan meetings?), as well as other organizational and clinical goals. www.nhqualitycampaign.org

B&F Consulting www.BandFConsultingInc.com
Short videos available under free resources at www.BandFConsultingInc.com and www.BandFConsultingInc.com/WhatYouDoMatters

Stop and Watch, a nursing home communication tool, at www.interact2.net


Download Huddles Tip Sheet (PDF)

Starter Toolkit Home          Step One          Step Two          Step Three          Self-Assessment
Prepared by B&F Consulting for Pioneer Network's National Learning Collaborative on Using the MDS as the Engine for High Quality Individualized Care. Funded by The Retirement Research Foundation.
All webinars in this series are available as archived recordings at
http://eo2.commpartners.com/users/pioneerlive/all_series.php.
In addition, the full series is available as packaged DVD set in the Pioneer Network store.