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• To enhance your awareness of the benefits of team huddles
• To learn about the effects of a service improvement project that involved the implementation of daily huddles and huddle boards
• To identify methods you could use to improve communication and teamwork in your area of practice
Instrument-processing staff work in a fast-paced, high-risk environment and errors in any of their processes can have a significant effect on patient safety. Effective communication is essential to the maintenance of complex processes such as the cleaning, disinfection and sterilisation of surgical instruments. This article details a service improvement project that aimed to evaluate staff members’ perceptions of teamwork and communication before and after the implementation of team huddles in an instrument-processing department. A questionnaire was used to survey staff perceptions of teamwork and communication before and after the implementation of team huddles. The huddles included the use of a huddle board to standardise their content.
While the survey did not identify any significant differences in staff perceptions before and after the implementation of the huddles, the department leaders noted significant improvements in the attitudes and engagement of staff members. The service improvement project demonstrated that structured team huddles can improve morale and efficiencies within departments through enhanced collaboration and communication.
Nursing Management. doi: 10.7748/nm.2020.e1958
Peer reviewThis article has been subject to external double-blind peer review and has been checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Loesche AH (2020) Using huddles to improve communication and teamwork in an instrument-processing department. Nursing Management. doi: 10.7748/nm.2020.e1958
Acknowledgements The author would like to thank the following individuals for their expertise and contribution to this manuscript: Alexandra Baker, Stephen Betins-Kinnamon, Tara Brigham, Corinne Cochran, Nathan Hans, Anne Lara, Mary Lois Lacey, Jake McHugh and Carolyn O’Brien
Published online: 16 November 2020
Communication failures are among the top three causes of reported adverse events in healthcare (The Joint Commission 2015). Effective communication is multifaceted and is affected by human factors such as interpersonal dynamics and system processes (Lee and Doran 2017). Teamwork can support effective communication and have a positive effect on staff engagement (Ogbonnaya et al 2018). For example, engaged staff are more likely to feel empowered, particularly when they feel they have a ‘voice’ in the daily functioning of a unit. Similarly, an empowered work environment can decrease staff ‘burnout’, increase job satisfaction and promote improved outcomes (Boamah et al 2017).
Ensuring a safe organisational culture is particularly important within instrument-processing departments because they are on the front line of patient safety. The effective cleaning, disinfection and sterilisation of surgical instruments can prevent the transmission of pathogenic organisms from these instruments to patients (Cowperthwaite and Holm 2015). Effective processing of surgical instrumentation is vital to the provision of safe operating rooms, while communication and safety are intricately linked (Institute of Medicine 2000, Spruce 2017). Failures at any stage of the instrument-processing procedure can compromise patient safety, and can also put healthcare organisations at risk of financial and reputational repercussions (The Center for Public Integrity 2014).
This article details a service improvement project that sought to determine if instrument-processing staff participating in daily huddles that used a huddle board had a positive effect on their communication and teamwork. This was assessed by collating scores from a TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) (Baker et al 2008) before and after a ten-week pilot that ran between February and April 2019.
A huddle is an evidence-based tool with demonstrated effectiveness in improving lean thinking (a decision-making process that aims to organise activities to benefit people and add value) and change management. A huddle board is a visual aid, typically a whiteboard, that provides a visual representation of various departmental aims such as key performance indicators, actionable items, recognition or ‘wins’ and other relevant metrics.
Huddles can assist teams to focus on meaningful results and are a proven method of improving teamwork, communication and staff satisfaction (Martin and Ciurzynski 2015, Van Duren et al 2015). Huddles were chosen as the core subject of this project because it has been demonstrated that they improve communication and outcomes within healthcare (Glymph et al 2015, Dutka 2016). Huddles can enhance accountability and a sense of community, improve the quality of information sharing, empower staff to raise safety concerns and support a collegiate culture (Goldenhar et al 2013, Agency for Healthcare Research and Quality 2017a).
• Huddles can assist teams to focus on meaningful results and are a proven method of improving teamwork, communication and staff satisfaction
• Results of a 2017 staff survey in the author’s organisation indicated that areas for improvement in the instrument-processing department included communication, trust and cooperation
• The action plan developed included the implementation of daily team huddles incorporating a huddle board
• While there were no significant differences in staff perceptions before and after the implementation of the huddles, the department leaders noted significant improvements in the attitudes and engagement of staff members
The author’s organisation surveys its staff annually using a workplace survey with the aim of understanding staff members’ experiences. The survey enables the organisation to identify strengths and challenging areas in individual departments. The author’s organisation requires department leaders to develop collaborative action plans based on the results of the survey. The strategic implementation and execution of these plans can enable staff members to feel that their voices matter. This demonstrates an organisational commitment to staff satisfaction, patient safety and the establishment of an environment that embraces change.
The 2017 survey results indicated that areas for improvement in the instrument-processing department included communication, trust and cooperation. The action plan developed included the implementation of daily team huddles incorporating a huddle board.
The implementation of daily huddles was regarded as a method of improving teamwork and communication. In the perioperative environment, teamwork and communication are essential elements in the promotion of patient safety, and the literature supports systematic processes such as huddles and training to enhance teamwork, communication and compliance with safety measures (Lyons and Popejoy 2014, Tibbs and Moss 2014, Franklin et al 2020).
The decision to use a huddle board as a central aspect of the daily team huddle was strategic. In addition to assisting in shift handovers by developing a specific framework for information sharing, the use of huddle boards supported team cohesion. Huddle boards also provide a visual representation of performance gaps, enabling improvement planning and the development of an enhanced safety culture (Franklin et al 2020). Huddle boards also support staff engagement with tasks, and develop teamwork and communication during a focused time frame when teams can share relevant and essential information (Goldenhar et al 2013, Bourgault et al 2018).
Communication is essential to enhancing workplace relationships and can also promote employee engagement; in healthcare, teamwork is the primary structure of workplace organisation and as such, comprehensive team-based interventions should be employed in an effort to enhance patient safety (Karanges et al 2015, Welp and Manser 2016). A focus on teamwork and communication can also have a direct effect on the safety culture within healthcare settings (Blegen et al 2010, Franklin et al 2020). Improving staff engagement should not be regarded simply as an altruistic aim but rather an essential element in any healthcare organisation. Staff engagement has a direct effect on employee performance as well as contributing to the advancement of professions such as nursing (Anitha 2014, Strumwasser and Virkstis 2015).
A literature review that focused on teamwork and communication within the field of instrument processing was completed to inform this service improvement project. The overall paucity of recent evidence on this topic meant that the author had to include several older peer-reviewed articles in the literature review. Melnyk and Fineout-Overholt’s (2011) levelling system, which assigns levels of evidence to studies based on research methodology, quality of design, validity and applicability, was used to evaluate the literature.
There is minimal literature on the effect of communication failures within an instrument-processing department specifically. However, there is evidence to suggest that many communication failures take place during handovers (Staggers and Blaz 2013, Ginsburg 2015). In any 24-hour period there are several shift changes that occur within an instrument-processing department. This means there are multiple opportunities for staff to omit essential information in handovers and to overlook processes that might streamline efficiencies and improve safety. Identifying where communication failures typically take place can support strategic planning to ensure safe care delivery.
There was also minimal literature focusing on quality improvement initiatives in instrument-processing departments. This may have been because of a lack of formalised evidence-based practice training within instrument-processing departments, or a lack of resources available for evidence-based practice projects. However, the literature review identified five themes: communication, engagement, quality, structure and ‘filling in the gaps’.
Effective communication is essential in the delivery of safe patient care. Communication failures remain a leading cause of adverse events (The Joint Commission 2015). Improved communication and handovers can reduce errors, prevent adverse events and enhance workflows (Starmer et al 2014, Tibbs and Moss 2014). Huddles provide an innovative forum for staff to report concerns regarding communication and contribute to a positive patient safety culture (Traynor 2015, Webb-Anderson 2016).
A systematic review by Glymph et al (2015) supported the use of huddles as an effective measure in enhancing safety culture, teamwork and communication. Huddles can be conducted briefly and adhere to efficient time frames, which can encourage leadership participation and engagement (Gorospe et al 2013, Davis 2015).
Huddles and huddle boards have been used to effectively support staff engagement, enhance interdisciplinary communication, and solicit ideas and feedback from staff (Griffiths-Turner and Stevenson 2005, Hayden et al 2008, Kylor et al 2016, Bourgault et al 2018). Engaging the workforce is one leadership strategy that can contribute to the prevention of patient harm (Sokol-Hessner et al 2018).
Lean initiatives have been used effectively to prevent errors by standardising workflows, increasing efficiencies, decreasing error rates and surfacing defects (a process of revealing defects and/or areas of opportunity in processes) (Bandari et al 2012, Blackmore et al 2013, Adrianzen et al 2014). Huddles and huddle boards can contribute to decreased harm, increased reporting of errors and near misses, and enhanced patient satisfaction scores (Davis 2015).
While instrument-processing staff do not undertake direct patient care, their work has a direct effect on the overall safety and outcomes of surgical procedures. Minimising instrument-processing errors can contribute to lower infection rates as well as reduced costs (Joint Commission 2013, Spruce 2017).
Schauer et al (2013) reported on one university hospital system’s quality improvement project that included daily huddles, with post-implementation data indicating a reduction of 82% in immediate-use steam sterilisation (IUSS) rates. IUSS is a technique designed to sterilise instruments for immediate use, but which should only be reserved for urgent situations; the convenience of IUSS may lead to abuse and a subsequent increased risk of surgical site infections. Furthermore, Campbell et al (2016) found that the use of visual boards in dental clinics was correlated with a 20% decrease in the number of contaminated instrument kits.
The effective implementation of initiatives such as huddle boards must have a definitive structure, because this supports sustainability. Plan, do, study, act (PDSA) cycles are a method of ensuring that complex needs are streamlined into effective initiatives (Nakayama et al 2010). PDSA cycles involve repeated evaluations of the initiative alongside real-time management and the flexibility to accommodate changing circumstances.
Patterson (2013) noted that supporting continuous improvement is essential in achieving effective sterile processing. Providing instrument-processing staff members with time to focus on quality data (for example, the number of instrument sets processed and hospital data such as the number of surgical procedures undertaken) can also serve to engage and empower them, while enhancing their practice and outcomes (Williamson 2012). Incorporating this type of quality data into a daily huddle can provide instrument-processing staff with an overall view of the effect of their work. Huddle boards can also support staff engagement and communication, provide a safe forum for staff to share ideas and feedback, and enable those in leadership positions to share outcome data (Bourgault et al 2018).
The aim of this service improvement project was to assess the effect of daily huddles on teamwork and communication in an instrument-processing department.
The implementation of team huddles in the instrument-processing department was planned strategically to ensure sustainability. In the past, implementation of huddles in the department had not been sustainable, and the department leaders were determined to develop a huddle structure that could be used reliably and on a daily basis. The daily huddle was to be implemented using PDSA cycles to ensure that stakeholders were engaged, implementation was critically evaluated and refinements could be made as the project unfolded. These are crucial components in quality implementation and sustainability (Leis and Shojania 2017).
The instrument-processing department has four separate areas that require handovers: decontamination, preparation and packing (where instruments are counted and placed in containers for sterilisation), sterilisation, and transport. Instrument-processing staff work throughout these areas on a non-specific schedule rotation, being randomly allocated to one of the four areas. Collaboration and reliable communication across these areas is essential to ensure efficiency and quality.
The author’s organisation states that departments must embrace stewardship (for example appropriately managing resources) and monitor expenses related to staff members’ attendance. Adding huddles to the daily workflow created the possibility that staff might be required to stay beyond their scheduled shifts. However, staff members were consulted on the ideal length of time for each huddle; an ideal huddle length of under ten minutes was agreed on.
Effective leadership is essential to the development of a transparent safety culture, and initiatives that strengthen teamwork and communication have a direct effect on safety culture (Joint Commission 2017). The Joint Commission (2017) also recommended that leaders should commit to effective handovers and standardise the handover process. Leadership support and participation were crucial to the planning and implementation of this service improvement project. The design and implementation of the huddles were championed by the instrument-processing department staff, while the department leaders (comprising the administrator, manager, instrument specialist, instrument-tracking coordinator and shift team leads), also supported the implementation of huddles, which enabled them to be embedded within the daily workflow.
The success of the project was dependent on stakeholder engagement. Primary stakeholders included the instrument-processing department manager, the coordinator of the instrument-tracking system, surgical instrument specialist, and front-line staff (instrument-processing technicians). The instrument-processing department operates several shifts. Each shift has a lead technician who was essential to the project’s success, because they decided whether to incorporate the huddles as a defined portion of the shift. Because the huddles took place over several shifts, this provided an opportunity for staff on each shift to engage in the project.
The project design followed the Institute for Healthcare Improvement (2018a) model for improvement. This model focuses on setting aims and then selecting measures that will determine if a change has resulted in improvement (Institute for Healthcare Improvement 2018a). The huddle board was a central element of this project, and the components were based on the Agency for Healthcare Research and Quality (2017b) Visual Management Board Component Kit, including the reinforcement of targets, key performance indicators, opportunities and action items.
PDSA was a central component of this service improvement project, and there were four PDSA cycles required over a ten-week period. The goal of the PDSA cycles was to continually identify areas for improvement. If aspects of a huddle needed to change, staff were encouraged to be flexible. The focus was to support positive change in the instrument-processing department in a methodical and sustainable way.
Measurement and monitoring are essential components of quality improvement projects (Portela et al 2015). Pre-intervention and post-intervention data from the T-TAQ (Baker et al 2008) were used to measure this project’s results.
The implementation of huddles included the use of a huddle board that incorporated key departmental metrics including quality, customer service, innovation, teamwork and finance. Huddles were initially driven and led by the department leaders, but eventually staff were also coached in leading and developing them. The instrument specialist and the instrument tracking coordinator were appointed as huddle ‘champions’.
Table 1 outlines the four PDSA cycles that provided the framework for this project. These cycles are based on the visual management boards of the Institute for Healthcare Improvement (2018b). This was a dynamic process and changes were made based on evaluation during each cycle. Table 1 shows the PDSA cycles used to implement huddles in the instrument-processing department, representing the various stages of the ten-week project. The PDSA cycles were arranged and administered by the author.
The evaluation involved participating staff completing the T-TAQ on two occasions: once in a two-week period before implementation of the huddles, and again during a period incorporating the fourth PDSA cycle and up until approximately two months following the implementation of the huddles. The pre-intervention and post-intervention data aimed to evaluate the effect of daily huddles on staff members’ attitudes to teamwork and communication.
One of the inclusion criteria for the evaluation was that a respondent must be an employee of the instrument-processing department. There were no exclusion criteria or control groups. This project used a convenience sample of instrument-processing department technicians.
The tool used to evaluate the project outcomes was the T-TAQ (Baker et al 2008). The T-TAQ may be administered as a stand-alone measure to assess attitudes towards the core components of teamwork, and it may be administered organisation-wide or on individual units.
The T-TAQ is a validated tool that includes 30 measurement items divided into five teamwork constructs: communication, leadership, mutual support, situation monitoring and team structure. Each of the five teamwork constructs includes six items, which are statements that respondents are asked to score on a Likert scale from 1 (strong disagreement) to 5 (strong agreement). An example of a statement in the team structure construct is: ‘Effective team members can anticipate the needs of other team members.’ An example of a statement in the mutual support construct is: ‘To be effective, team members should understand the work of their fellow team members.’ Thus, a score of 5 would indicate a favourable attitude towards a teamwork construct, while a score of 1 would indicate an unfavourable attitude towards a teamwork construct.
Data collection and analysis of the T-TAQ results followed the guidance included in the T-TAQ manual (Baker et al 2008), which instructs that data analysis should provide either a total score for each teamwork construct or an average score. The average score for the constructs was included in the statistical analysis of this data.
Data were collected from the T-TAQ survey, which was sent to the instrument-processing department staff respondents via an online data capture tool. The survey was anonymous and was accessible only while staff were on the organisation’s intranet. Data was exported from the online data capture tool and statistical analysis was completed using Microsoft Excel.
The project evaluation used a convenience sample from an instrument-processing department of 41 individuals within a hospital in the Southeast region of the US. Pre-intervention data were obtained from ten respondents, and post-intervention data from 19 respondents. The survey was anonymous, and respondents were not assigned unique identifiers.
The author’s facility has robust research and quality departments, and staff pursuing research have access to an algorithm that determines whether a project requires institutional review board (IRB) approval. Such approval was not required because this project aligns with guidelines for quality improvement projects. The author also submitted the project to a university IRB, which determined that the project did not require IRB approval.
There were no statistically significant changes in the pre-intervention and post-intervention T-TAQ scores. Table 2 shows the pre-intervention T-TAQ mean scores, as well as the ranges and standard deviations. Table 3 shows the post-intervention T-TAQ mean scores.
In addition to the survey findings, other information can be considered when assessing the success of a service improvement project, not least its sustainability. The sustainability of a project is influenced by many factors, such as continuous effort, leadership, implementation, culture, cost and communication (Ament et al 2017). The support of department leaders was crucial to the effectiveness of this project and is essential when initiating and maintaining change, particularly the attitudinal changes that must occur within teams (Lee et al 2012). The implementation of huddles in the instrument-processing department detailed in this article had been ineffective in previous years despite multiple attempts, but the methodical planning and implementation, as well as the use of the huddle board, contributed to this project’s sustainability. This sustainability is demonstrated by the fact that, at the time of writing, the huddles were still being held, more than 18 months after their implementation.
The department leaders also reported several anecdotal findings to the author. The instrument-processing staff reported ‘looking forward’ to the huddles, and the department leaders noticed a marked improvement in staff morale during the first week of the project. Staff were observed laughing and talking with one another while working and staff members’ contributions during huddles improved during the third PDSA cycle.
Resistance to change can vary based on group cohesion and can affect what may already be an unstable environment (Rodat 2018). Because of the potential for resistance to change, one of the first items added to the huddles – and later permanently adapted in the second iteration of the huddle board (Figure 2) – was the ‘three good things’. This concept was added to decrease resistance to change. During the huddles, staff members were given the opportunity to verbalise three things that they were grateful for, with the aim of mitigating resistance and negative reactions common during change implementation. Examples included: ‘My sister is getting married on Saturday,’ and ‘We are delighted to welcome a new member of staff.’ Gratitude is correlated with joy and can connect individuals to purpose and optimism, so this technique was used to offset the pessimism that can accompany change and impede implementation and sustainability (Watkins et al 2018).
Future considerations for service improvement projects might include requesting additional qualitative input from staff members regarding their perspectives on the value of the huddle.
While the results did not indicate statistically significant changes in the T-TAQ scores, there were subjective positive changes in staff morale that correlated with the implementation of the huddles. This service improvement project demonstrated the potential for enhancing efficiencies within instrument-processing departments through enhanced collaboration and communication. Other units may benefit from daily huddles that use a huddle board to standardise content and develop an organised process for handovers. Standardising huddle content was supported by Franklin et al (2020), who undertook a systematic review examining multidisciplinary team huddles. Huddles are an easily adaptable tool and should include relevant metrics such as key performance indicators.
During this service improvement project, the use of huddle boards served as a visual management tool, providing consistent availability of data and enabling instrument-processing staff members to monitor progress, and evaluate daily goals and tasks. This inexpensive quality improvement tool is easily sustainable.
One limitation of this project evaluation was that it used a convenience sample. This meant that the sample lacked obvious generalisability to the population as a whole and had the potential for biased results due in part to the reasons why some individuals may have chosen to participate or not. However, this was unavoidable since the project was completed in a specific department. In addition, survey response rates were low; this was in part because the survey was sent to staff via their work email address and was only accessible on the organisation’s intranet. To improve response rates, it would be advisable for future evaluations to use survey software accessible from personal devices, quick response (QR) codes for easy accessibility, or a shorter survey tool (Harrison et al 2019). Another limitation was that the same staff did not complete the survey before and after the intervention.
The main aim of quality improvement projects is to enable positive change in a specifically identified service. In this project, the implementation of daily huddles using a huddle board was not found to have a statistically significant effect on T-TAQ scores. However, the huddles were found to have a positive effect on staff perceptions of teamwork, attitudes and morale.
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