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Tiered daily huddles: the power of teamwork in managing large healthcare organisations
  1. Tomislav Mihaljevic
  1. Cleveland Clinic Foundation, Cleveland, Ohio, USA
  1. Correspondence to Dr Tomislav Mihaljevic, Cleveland Clinic Foundation, Cleveland, Ohio 44195-5243, USA; mihaljt{at}

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Successful management of large healthcare organisations has always been challenging but never more than today. We must all think, work and act differently to deliver the highest quality and safest patient care amidst the challenges of payment reform, regulatory requirements, expense growth and resource constraints.1 2 These problems are particularly challenging for non-profit academic medical centres given the need to balance financial demands with commitments to teaching, research and the communities we serve. We observed that in our large healthcare organisation (66 000 caregivers serving approximately 2 million unique patients annually), our leadership team holds immense responsibility but lacked daily insight into our performance, and as a result, took action in retrospect. In order to address this challenge we built a tiered huddle system across our hospitals and outpatient facilities that has produced significant learnings and rapid results. We now reflect and share what we have done and hope others can benefit from this simple, powerful practice.

Building a system

Our tiered huddle system was built on a cultural foundation of every caregiver capable, empowered and expected to make improvements every day. Core to our ‘culture of improvement’ is a strong team-based culture in which all caregivers feel safe and supported to solve problems. In addition, I valued the daily, hospital-wide huddles we used in some of our hospital locations, and sought the same level of daily operational awareness for leaders across a large system. Huddles are not new in healthcare. However, tiered huddles are uncommon in large organisations due to their novelty, complexity and an overall lack of current, actionable information.3 In early 2018 we developed our system of tiered daily huddles in order to improve our daily insight into our operations and empower caregivers and teams at all levels to identify and solve problems on a daily basis.

After a few small pilots we rapidly implemented tiered daily huddles throughout 17 hospitals and 40 outpatient facilities. Each hospital was equipped with a standard structure and process, and coaching was provided by our continuous improvement team. Initially, the huddle mechanics, including information sharing and follow-up, were our primary focus. Over time we were able to develop more effective problem-solving behaviours, including asking better questions to determine root cause and assess the application of standard work. We use six ‘tiers’ of huddles to aggregate information and solve problems at all levels of the organisation in a multidirectional fashion (figure 1). During these brief (typically 15 min or less), structured and sequenced conversations, we identify and solve problems, sharing information and (when needed) problems with the next huddle ‘tier’. By the time the tier 6 huddle occurs (led by the executive team) at 11:00, some 25 000 caregivers have engaged in sharing information and identifying and solving problems. Board members have the opportunity to attend; their engagement fosters their understanding of the process and how it helps us deliver on our mission.

Figure 1

Health system tiered daily huddles structure. Six sequential huddle tiers are used to share information and address problems identified by caregivers and teams at all levels of the organisation. Huddle tiers 1 through 4 occur within a single hospital location in our outpatient facility. In tiers 5 and 6 information is aggregated across all of our clinical facilities and support functions. CEO, chief executive officer.

Each huddle has a standard agenda centred on our ‘care priorities’: care for our patients, our caregivers, the organisation and our community. This agenda is consistent across the six tiers, although the level of detail discussed for each problem will vary at each tier (table 1). Teams may add topics specific to their area, but these care priorities remain constant. Examples of problems identified and addressed include challenges in delivering patient care (staffing challenges, equipment failures, supply or inpatient bed shortages), caregiver safety concerns (bloodborne pathogen exposures) and unanticipated patient surges. Time is also allotted to bring up any additional items not already covered in the standard agenda. Team members capture action items for follow-up and review any items requiring action from the previous day. A standard review and update process ensures the content remains aligned to our care priorities and evolves to meet the changing needs of the organisation.

Table 1

Example huddle participants and problem discussion at each tier

Rapid creation of an effective tiered daily huddle system across our large system required tremendous executive-level ownership and commitment. Prior to creation of the system, it was difficult for some to see the potential benefit of this massive effort. Some felt they already possessed sufficient information to manage their areas effectively; tiered huddles felt like an additional demand on their time. In order to address this challenge, we engaged selected senior leaders in visits to other organisations who had created similar systems, providing an opportunity to see how the system functions and the value it could provide. We then asked these leaders to serve as pilot areas and, once they had well-functioning tiered huddles within their areas, host visits to enable other leaders to experience the huddles. We also feel our decision to rapidly implement across many hospitals was to our benefit, as huddles were quickly established as an expectation, and conversations with local leaders centred on when each site would start, rather than ‘if’. Other challenges included determining the best structure (should tiers occur based on function (all pharmacy leaders tier up through pharmacy) or geographic (all leaders across a given location huddle together)). We chose a geography-based construct, feeling the discussion is most relevant when shared by leaders at a given site. Specialties (like pharmacy) typically have concurrent and complementary communication streams in place. In some cases senior leaders were uncomfortable to see challenges—often problems of which they were not yet aware—discussed openly. The shift to embracing problems more openly at all levels of the organisation required consistent and ongoing coaching; we now see this shift as one of the greatest benefits of our tiered daily huddle system.

Assessing impact

The tiered huddle system builds on pre-existing local huddles in several important ways. First, by adding ‘tiers’ we are able to rapidly share current, actionable information and insights across teams, provide feedback and take action in real time. We are able to quickly address a wide variety of challenges to improve patient and caregiver experience. Our caregivers recognise and appreciate the organisation’s rapid response to challenges facing them, such as workplace violence. Within the first year one of our hospitals identified and resolved 454 problems at their hospital-wide tier 4 huddle.

Second, the tiered structure fosters uniformity and ‘systemness’ by standardising the way we share and act on quality, safety, patient experience, and operational issues and information. The huddles provide a consistent time and place to quickly investigate problems, communicate interventions and reinforce accountability and consistency in practice, and we have realised immediate system-wide impacts across patient safety and quality indicators. Within the first year serious safety events decreased dramatically; patient falls decreased 15%. Safety event reporting increased dramatically while the proportion of events with patient harm dropped.

Uniformity in the way we evaluate and manage our capacity and demand information across our hospitals enables us to better leverage our resources to serve patients. Now we can see trends and opportunities across locations on a daily basis. Increases in outpatient visits (4.1%) and surgical cases (5%) allowed more patients to be reached with our care.

Finally, the tiered huddles promote a culture of teamwork, safety and accountability. The daily cadence of tiered huddles provides a consistent time and place to share information and challenges, helps ensure problems are shared and supports an environment of transparency and empowerment. At the end of each day’s huddle we pause and read the first names of patients who have expired in our care. This small gesture reminds us of our purpose and keeps us grounded in our mission.


Healthcare organisations face new challenges every day. Tiered huddles enable us to face daily challenges with rapid learning, improvement and growth. Today teams of caregivers, managers and leaders across our system have an inclusive view and insight to our performance and feel empowered to identify and solve problems on a daily basis. Tiered daily huddles also have assisted with rapid integration of four new hospitals into our system. Our patients and our caregivers are seeing the results, as we strive to create the best place for healthcare delivery and the best place to work in healthcare. We have seen dramatic improvements in the way we work together and in our outcomes from this simple yet powerful practice. I am confident others can do the same.

Adds to the body of knowledge

  • Provides a framework (structure and timing) for creating a system of tiered daily huddles.

  • Outlines steps to create a mature system of tiered daily huddles.

  • Demonstrated benefits of tiered huddles for managing daily operations in a large, complex organisation.



  • Contributors This is a single-authored manuscript. I certify that I (TM) have fully contributed to the creation, writing and critique of this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are included and additional data are available upon request.