Huddle in Plastic Surgery

During the IHI IDCOP collaborative, many primary care practices adapted the military crew resource management concept of "huddles" to their own practice to take advantage of the benefits of huddles, such as preplanning for the day and review of roles, processes, and updates, to name a few benefits.

The design of the huddle was adapted from the IDCOP (idealized design of clinical office practices) literature on primary care huddles and the benefits of huddles to the practice and patients. Drawing from that experience the lead team in the Plastic Surgery Section designed a huddle process to pilot with Dr. Ryan, the lead physician.

Dr. Ryan instituted two huddles for her practice. One was a fifteen- to twenty-minute weekly huddle with a nurse, a clinic appointment scheduler, and a surgical scheduler. The substance of their meeting was to review the upcoming appointments and surgeries projected for the next two weeks in order to identify potential errors in scheduling (such as overbooking or underbooking) and to determine the specific information that needed to be gathered on patients prior to their visit. These huddles enabled timely action and learning—allowing everyone on the team to do his or her job better because they increased everyone's understanding of the challenges of the roles played by others.

The second huddle was held daily, taking five to ten minutes and involving Dr. Ryan and her nurse and the LNA (licensed nurse assistant) team assigned to her that day. The aim of this huddle was to preview the coming day's activities and anticipate needs for that single day.

Success of the Pilot Huddles

The huddles resulted in improved communication, decreased work stress, and increased opportunities for teaching, planning the day's work, adjusting the schedules, and thinking ahead to meet patients' needs while improving efficiency.

Given this success, the huddles were replicated with all the providers and their clinical teams in the section.

Benefits

All the clinicians in the Plastic Surgery Section now conduct interdisciplinary huddles. Here are some of the observed benefits:

• Efficiency is built into the system; work is now done mindfully, in advance, rather than under pressure on the day of a patient's visit.

• Teaching of future physicians is done by modeling the need and benefits of interdisciplinary teamwork.

• Better knowledge and improved communication are achieved because staff understand the work of other team members and they see how their actions affect the whole patient experience.

• Stronger relationships are built among team members, which contributes to greater worklife satisfaction.

• Scheduling errors are reduced and information gathering is improved, resulting in a decline of required tasks per huddle, from five or six down to one or two.

Key Learnings Noticed

• Huddles educate the staff—both newcomers needing orientation and long-time members needing continued learning.

• Huddles offer an easy way to make a significant difference in the staff's daily work and to craft a team approach to patient care.

• Huddles strengthen team health—team members have better communications, an understanding of one another's roles, more respect for and appreciation of what each contributes to the care of the patients.

• Huddles promote interdisciplinary communication on a regular, structured basis.

• Huddles generate flow—the sense of smooth and coordinated service delivery.

Inside-Out Planning. A microsystem's attention is often focused on market-driven service lines or traditional departments—which reflect the strategic plan and the organization chart—rather than on meeting patients' needs through an array of superlative services. Yet focusing attention first and foremost on the patient and family and how they present their health needs to the system, makes it relatively easy to identify the microsystems that provide services and to determine how the best services can be designed within each microsystem and how these services can be best linked together.

The staff in many microsystems work in a complex environment characterized by competing interests, inefficiencies, hassles, and frustrations due to poorly operating processes. They may feel helpless or that they cannot make the system work correctly because the system is run by outsiders. This feeling can be counteracted by working from the inside out, meaning that staff learn about their own patients and their microsystem—and then make improvements—as they go about their work, rather than being told what to do by those outside the microsystem.

Interdependency and Involvement. It is rare for staff to realize that they are part of a microsystem that renders identifiable care to subpopulations of patients and that they are fully interdependent with one another and the patients. The whole of the practice can be only as good as its individual components. Staff are often so busy trying to do "the job" that they have no time to reflect on the work they do, how they do it, and what the outcomes of their efforts are. Involvement of all members of the microsystem is essential to render the best patient services.

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