Tiered Huddles Improve Quality Across the System

Empowering leadership through focused discussions

In a culture of continuous improvement, empowering caregivers at all levels to provide the highest quality patient care is taken to a new level at Cleveland Clinic through tiered huddles.

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Tiered huddles are a series of brief, focused conversations that take place every morning across the hospital system, opening the lines of communication from our nursing staff all the way through executive management. The most critical issues are escalated to senior levels within hours through different tiers; thereby, identifying concerns needing hospital and enterprise-level attention.

The framework

Items brought to huddle are typically issues that cannot be resolved at the point of service, or involve system or process issues that need to be reviewed generally.

“Between 7 a.m. and 11 a.m., anything that happened to a patient or caregiver in the hospital in the last 24 hours is reported to the top level of the hospital system,” says Shannon Pengel, MSN, RN, NE-BC, ACNO and Clinical Nursing Director, Heart & Vascular Institute and Critical Care. She adds, tiered huddles allow concerns from the bedside to be escalated the same day, with many issues resolved within 24 hours.

Tiered huddles were piloted at Cleveland Clinic’s main campus in January 2018, followed by Cleveland Clinic Hillcrest Hospital in February. Since then, huddles have been rolled out to all regional hospitals with a goal of bringing family health centers and institutes into the fold in the coming months.

“It’s a huge win for our teams,” Pengel says. “Caregivers are getting their concerns heard, but managers also feel a sense of empowerment in resolving issues quickly. From a leadership perspective, it’s a time saver.”

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Focus on safety

“There is now a laser focus on safety, as every day we hear through these huddles what didn’t work well and what we could do better,” says Sue Collier, DNP, RN, NEA-BC, Vice President, Nursing, and Chief Nursing Officer at Hillcrest Hospital. “Issues are shared transparently, with the goal to quickly learn from each other. This really puts the focus onto what we are doing clinically to support our patients and caregivers to provide the best quality care.”


Pengel says tired huddles create a different way to lead.

“I’m not constantly trying to follow up on issues. Everyone is bringing issues to one forum,” she says. “As a leader in a room with 10-15 managers, it forces me to delegate to make the follow-up happen. For some new leaders, observing an expert leader delegate responsibilities to others during huddles provides a model they can replicate; it may be a growth opportunity in their leadership journey.

“Delegation in problem solving forces accountability. The next day we ask managers and leaders for follow up. The tiered huddle process empowers leaders who are peers and colleagues to perform at the top of their scope,” says Pengel.

She explains that Cleveland Clinic is continuing to refine the process, including the questions asked. An early discovery was that events have to be analyzed the same way at all levels to make an impact on quality and safety.

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“We’re in the process of hardwiring those questions we ask each time to drill down to a root cause,” she says.

Tiered Huddle Structure

All huddles follow the same priorities:

  • Care for Patients focuses on potential serious safety events, central line-associated bloodstream infection, catheter-associated urinary tract infection, clostridium difficile, falls, clinical/non-clinical codes, other safety risks and patient experience.
  • Care for Caregivers focuses on the caregiver experience.
  • Care for Organization looks at occupancy rate, operating room volume/target, emergency department volume/target, transfers/target, crucial staffing issues, sitter cases and environmental safety.

Tier Participants

  • Tiers 1-4 focus on hospitals:
    • Tier 1: Caregivers at the unit level and managers/supervisors
    • Tier 2: Managers and directors
    • Tier 3: Nursing directors and ACNO/CNO and Operations President, COO
    • Tier 4: President, COO, ACNO/CNO
  • Tiers 5 and 6 focus on the enterprise:
    • Tier 5: Hospital system presidents, COOs, CNOs and ECNO
    • Tier 6: CEO and Operations Council