May 31, 2019/Nursing/Quality

Tiered Huddles Bring Interdisciplinary Teams Together

A close-up on one of the six tiered huddles improving quality system-wide


Last year, Cleveland Clinic instituted daily tiered huddles to expose and elevate operational information across the system. The huddles include six levels, from Tier 1 (unit level caregivers and their managers/supervisors) to Tier 6 (the CEO and Operations Council). At first glance, it may seem that having a series of huddles would take time away from patient care. But each tier has a purpose, and a closer look at one of them – Tier 2 huddles for managers and directors – reveals their importance.


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“When we started Tier 2 huddles, many people were skeptical and thought, ‘Wow! It’s just another meeting,’” says Kathy Saffron, MSN, RN, NE-BC, Nurse Director of Emergency Services and Critical Care at Cleveland Clinic Hillcrest Hospital. She participates in Tier 2 huddles that include emergency services, the ICU, the cardiac/surgical ICU and the coronary care ICU. “After we did them for just a short time, we recognized that we’re coming together as more of a team. Having a full understanding of what’s going on in all of our units has been very helpful.”

Standardization is key to huddles

Most Tier 2 huddles happen between 8 a.m. and 9:30 a.m., depending on the needs of the specific area, and they last approximately 20 to 30 minutes. Participants use a standardized template to review topics, including potential serious safety events, hospital-acquired infections, falls, codes, bed management, patient length of stay and staffing. “The template provides a defined focus,” says Saffron. “Instead of people coming to huddles and not knowing what to talk about, we have agenda items.”

Shannon Pengel, MSN, RN, NE-BC, ACNO at Cleveland Clinic’s main campus, cites another benefit: “Using standardized questions has helped our managers to all think in a similar fashion,” she says. As a clinical nursing director with the Nursing Institute, Pengel leads a Tier 2 huddle for the areas she is responsible for. “When we started this process, our ICU nurse managers had a better handle on how to look at hospital-acquired infections. But now, because we are all looking at each occurrence the same way, our step-down and floor managers are equally as knowledgeable as our ICU nurse managers,” says Pengel.


Interdisciplinary approach yields results

In addition to standardization, there’s another key component of most Tier 2 huddles: They are typically interdisciplinary. The emergency services and critical care huddles at Hillcrest Hospital often include nurse managers, a clinical nurse specialist, the nursing operations manager, emergency service providers and a representative from both the ICU intensivist group and the respiratory group.

Bringing everyone together allows the team to identify and rectify issues early on. For example, at the Tier 2 huddle, Samantha Connelly, BSN, RN, Nurse Manager of the ICU at Hillcrest Hospital, reports out on everyone who is intubated. “We noticed we had an opportunity to lighten the sedation of intubated patients and try to get them off ventilators,” says Connelly. “There hadn’t been efficient communication between nursing, respiratory and the doctors before.” Since focusing on this issue in the huddles, the ICU has seen improvement in their spontaneous breathing trials (SBTs) and spontaneous awakening trials (SATs), as well as the number of days on the ventilator.

Advantages of Tier 2 huddles

Nursing professionals at Cleveland Clinic cite several advantages of the Tier 2 huddles:

  • Accurate assessment of units/clinical areas. “It increases everyone’s understanding of what our current state is and what we can expect for the day,” says Kimberly Hunter, DNP, MBA, RN, NEA-BC, ACNO of Cleveland Clinic’s main campus and a nursing director in the Nursing Institute. For instance, it provides a projection on patient census and room capacity. “Will we be right on track, are we going to have extra beds open, or does it look like we’re going to have a deficit of beds?” says Hunter. “That helps us understand if we need to take action to improve the situation.”
  • Opportunity for problem-solving. “If there’s a particular piece of equipment that malfunctioned or a unit that is short of certain supplies, it provides an opportunity for people to step up and say, ‘I’ve got a solution for that,’” says Hunter. For example, at a perioperative Tier 2 huddle on main campus earlier this year, a nurse mentioned that her team needed a specialized surgical table for an afternoon case. A nurse manager chimed in that she knew where to find one and she called the OR to deliver it. Instead of making several phone calls, the problem was solved in less than a minute.
  • Communication up and down the chain of command. Information flows between all six tiered huddles as needed. Prior to attending the Tier 2 huddle, Connelly participates in a Tier 1 huddle with her night shift nurses. She takes information from that meeting into the Tier 2 huddle and then reports back to her clinical nurses at the twice-daily Tier 1 unit huddles. “It’s really a 360-degree touchpoint several times a day,” says Connelly.
  • Strengthening of bonds between colleagues. “Being in the Tier 2 huddle provides a subtle – but very real – sense of teamwork,” says Hunter. “We are in this together, understanding what people are dealing with and caring about each other.”

When caregivers are “in this together,” it achieves the ultimate goal – providing quality patient care. “I love the interdisciplinary huddle approach because it brings everyone together with the same goal,” says Saffron. “It puts the patients first.”

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