BMJ Qual Saf doi:10.1136/bmjqs-2012-001467
  • Original research

Huddling for high reliability and situation awareness

  1. Stephen E Muething1
  1. 1James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  2. 2Division of Hospital Medicine, James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio, USA
  3. 3Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  4. 4Department of Management and Organizations, University of Michigan Ross School of Business, Ann Arbor, Michigan, USA
  1. Correspondence to Linda M Goldenhar, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave ML 7140, Cincinnati, OH 45226, USA; linda.goldenhar{at}
  • Received 19 November 2012
  • Revised 29 April 2013
  • Accepted 17 May 2013
  • Published Online First 6 June 2013


Background Studies show that implementing huddles in healthcare can improve a variety of outcomes. Yet little is known about the mechanisms through which huddles exert their effects. To help remedy this gap, our study objectives were to explore hospital administrator and frontline staff perspectives on the benefits and challenges of implementing a tiered huddle system; and propose a model based on our findings depicting the mediating pathways through which implementing a huddle system may reduce patient harm.

Methods Using qualitative methods, we conducted semi-structured interviews and focus groups to obtain a deeper understanding of the huddle system and its outcomes as implemented in an academic tertiary care children's hospital with 539 inpatient beds. We recruited healthcare providers representing all levels using a snowball sampling technique (10 interviews), and emails, flyers, and paper invitations (six focus groups). We transcribed recordings and analysed the data using established techniques.

Results Five themes emerged and provided the foundational constructs of our model. Specifically we propose that huddle implementation leads to improved efficiencies and quality of information sharing, increased levels of accountability, empowerment, and sense of community, which together create a culture of collaboration and collegiality that increases the staff's quality of collective awareness and enhanced capacity for eliminating patient harm.

Conclusions While each construct in the proposed model is itself a beneficial outcome of implementing huddles, conceptualising the pathways by which they may work allows us to design ways to evaluate other huddle implementation efforts designed to help reduce failures and eliminate patient harm.

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