GA 395 | Implementing Tiered Huddles with Sarah Cook

If they experience a challenge, then something can be done about it. Right? This is such a great opportunity to foster trust and engagement between caregivers and leadership. Aside from healthcare. I mean, these tiered huddles can be anywhere.

Today. I'm very excited to welcome Sarah Cook to the show. Now, Sarah and I had brainstormed over email what to talk about on this episod and we settled in on the topic of tiered huddles. And so what I can say about this episode was I really loved it. It's one of those episodes to where Sarah's a good storyteller, so she's kind of sharing some stories from what's going on and how they're using tiered huddles. But it's also extremely informative and I was able to really dig in and ask a lot of clarifying questions that I was genuinely curious about. And then I was also trying to listen as if I was a list. Even if I thought I knew what she was going to say, I asked the question anyhow because I wanted her to go ahead and say it. And yeah, I really enjoyed this one. I think you're going to like it. So show notes for this episode will be found over@gembapodcast.com just look for episode 395. Again, gembapodcast.com look for episode 395. Finally, if you do want to learn more about this whole idea of tiered huddles and maybe Lean Daily Management, we've got a really good suite of video in our what we call our Lean Daily Management series of videos over in our School of Lean. So head over to gembacademy.com go to the school of Lean and poke around in the Lean Daily Management section. And the first video of all of our courses is always free and you don't need a subscription. So there's an incredible amount of content that you can watch. But if you do want to learn more about all this stuff, we got you covered over@gembacademy.com okay, enough from me. Let's get to the show. Sarah, welcome to the show. How are you?

I'm awesome. How are you?

I'm doing well. Doing well. All right. I'm really excited for this episode. This is going to be a fun topic and we brainstormed a few different ideas as we led up to this one, but I think we settled on an awesome one. So I know you've listened to the show, Sarah, and we do like to get things going with our guests sharing a quote. So do you have one.

I do. It's from the very lovely Brene Brown. So she says we don't have to do all of it alone. We were never meant to. And for me, this just. I know that probably a saying that a lot of people are using is during COVID or when we were going through the worst of the pandemic. I know that a lot of people have felt that we're kind of struggling kind of on our own, but continuous improvement is a team sport. And so I really like to use this quote and just remember that we're all in this together.

Yeah, for sure. And we can't do it alone. Right. Especially continuous improvement.

Absolutely.

Awesome. Okay, well, hey, tell us a little bit about your background, Sarah. Tell us how you first got involved in all this continuous improvement stuff, and then, for sure, tell us what you're up to these days.

Yeah, so I am a performance engineer at Monument Health in South Dakota, but I started out as a clinical laboratory scientist in microbiology and molecular science. When I started out in that career at the va, I started to become very interested in quality improvement and how we could make things work better, and we'd have new employees come through, and you're just looking for those points of standardization and how you're watching the process of, you know, learning how to do a certain task, and then the next day you're with someone else, and it's. You're getting taught, you know, in a totally different way and just kind of coming up with ideas and thinking about how to do it better. And so eventually, eight years later, my family and I moved to Monument in Rapid City, South Dakota, for a role in microbiology education and quality. And after about a year, my focus became really quality safety and really focusing on lean. And I'd heard other people talk about lean, and I didn't really know what it was. But then when I started to learn about it, it just felt like everything just kind of clicked together. And it was the philosophy, it was the tools. It all made sense, and especially with my role. And then eventually, I left the laboratory setting to become a performance engineer, which is really, you know, doing process improvements. And then I started this work in all different areas and departments, and I was deployed all over the place to all the other hospitals within the system. And just now that we're speaking, I just accepted a position as a management consultant for a firm named Pepper Foster in Portland, Oregon. So I'll be starting my new chapter pretty soon.

Nice. Well, good stuff. All right, listen, I think. So the main topic today is what we call tier huddled huddles. So how about we begin with you just maybe laying out, like, what are tiered huddles? Talk about maybe some framework, the purpose, that sort of thing.

Yeah. So tiered huddles. And this is for us, and we've modeled a lot of our framework after Cleveland Clinic. So this isn't necessarily the way that it has to be. This is just how we're doing it.

Sure.

So our tiered huddles are a series of 15 minute focus conversations that are escalated from Tier 1, which is considered frontline caregiver, and then it moves up all the way through the senior executive level. And, you know, these huddles, they start out in their own specific departments and then they escalate and they kind of make their way throughout the entire organization, really helping us connect, you know, in these really short time increments and in terms of framework. So I would say that. So our first huddle of the day is considered, you know, this is tier one, and this is really frontline caregivers only. And what they're doing is they're working to resolve common issues or things that have come up, and then they determine with their supervisor, whatever leader present, which things that they're going to escalate to the next tier. The second tier would be supervisors, managers who are doing essentially the same thing. They're trying to resolve what they can, and then they're escalating up to the next level. Our tier 3 huddle is probably our largest, and it's typically a little bit longer than 15, 20 minutes. That's we're really connecting, not so much leadership focus, but really department focused from all over Rapid City market. But also we're bringing in those hospital leaders like presidents and VPs also. One of the things that makes that tier three huddle a little bit different is that we add a topic of names for paws for unexpected deaths. So we'll have a, you know, we'll hear the first name of whoever that patient was, and we'll have a moment of silence for them, which I think is really impactful. And then the tier 4 moves up to additional hospital leaders and executives. And then the final Tier 5 huddle is with C Suite CEO and other senior executives.

Okay, so a few questions in on these various tiers then. So tier one huddles, which is frontline associates there. So in a large facility, are there multiple huddles going on, let's say in the morning, or is it. Or how does that work?

Yeah, so we have five separate hospitals, but I mean, really, we look at it as five markets. And so at each of those different hospitals, the expectation is really that those tier one huddles are happening. First thing, you have some flexibility. So we have nursing staff that starts their shift at 6.30am we have other teams, maybe not clinical, start their days at 8am and so the expectation is that tier one and that tier two huddle, you have some flexibility in the time that that's at. You just have to be prepared to bring all of that information that's needed and all those updates at the 9 o' clock tier 3 huddle. So, yes, they should all be happening. Those Tier 1 and Tier 2 should be happening before that 9:00am, Mark.

Okay, but on the Tier 1 in particular, will nurses have a tiered huddle and then the other associates have a different huddle or is it just one tier one huddle and that one hospital?

No, so the. Exactly what you said the first time. So those different units, so we have, you know, ICU will have their own separate huddle. Ninth floor will have their own huddle on, you know, but it's not quite, it's separated really into units. But we also need to remember that there are other departments too that aren't, you know, they're not nursing, you know, we're looking at laboratory, pharmacy and those ancillary departments, but also non clinical corporate service teams as well.

Okay, got it. So then, am I right to assume then, tier two huddles, there's will, there'll be representatives from each tier one huddle that go to the tier two huddles. Is that how that works or.

Yeah, absolutely. So for that tier one, there'll be a leader present at that tier one huddle that's going to help connect what was discussed there to the next tier. So a supervisor will be at that tier one huddle, or whatever it is, manager. And then that next tier, there'll be someone that was present at that tier one huddle.

Got it, Got it. All right. All right. So, yeah, let's talk a little bit about how you pull these off. Like what kind of tools and things do you need to make it happen?

Yeah, so I think there's a few tools. So the tools that our team decided that we really needed are essentially a huddle template or a script. And that was really the first thing that we needed. And then the second thing were really, where are we going to put all this information? And so we were using visual management, SharePoint, so that people could come back and they could see what was discussed in those tiered huddles. But I'll go back to the huddle script. So that template essentially indicates what information needs to be communicated or relayed in each of these huddles. So when we rolled out tiered huddles, we helped create an example for both clinical and non clinical huddles. And those teams had the freedom to kind of keep these non negotiable pieces, which I'll talk about, but also add things that are really specific for them. So for example, a specific nursing unit may add to their huddles fall risk patients. If a bundle is placed Clabsi's Cautis and patient financial Services, they might add to their script metrics that they're monitoring, like hospital billing claims or efforts for client billing standardization. When we started working with the CEO of Monument Health, we were able to develop a list of really non negotiables pieces of the huddle template that would be standard across the system. And so those ones that we had were major patient experiences, critical staffing issues, critical supply and equipment events with harm events with major process failure issues that affect other departments and falls, and then good catches and high risk suicide. So those things would be on everyone's huddle script, but different pieces of the script. You know, people might add things that are more specific to their unit, but those are really the heart of all the templates.

I got it, I got it. Now you mentioned earlier SharePoint, so is, but you also mentioned boards. So are we talking physical boards or a combination of physical boards with some stuff shared electronically? SharePoint, like how does that working?

Yeah, it's both. So as that 9am safety call is happening, the Tier 1 and Tier 2 and Tier 3 information is being combined on a pretty significantly large whiteboard dry erase board. And information is being documented on that board as that those tier three is kind of rolling through and then the compilation of all of those tiers, they end up going on SharePoint so that if you miss the huddle or you were gone for a couple days, then you could go back and you could see information that was being escalated.

Got it, got it. Very good, very good. All right. So I know this isn't an easy thing to pull off and I'm sure there's been a lot of learning along the way. So what kind of challenges and barriers have you guys faced?

Yeah, so I think one of the most challenging things, what was the definition of these non negotiables? What counted as a good catch or what counted as a major process failure? We had interpretations for those things. I think we had started out with this understanding that people are going to understand what a major process failure is. We were operating on some assumptions in the beginning. There was a perception that, especially regarding events with harm. So. And I think this is something that, you know, a lot of healthcare systems have struggled with, but there was a perception that, you know, this meant harm to the patient. And so often our caregivers experience violence from patients. So whether that's physical or verbal, and we really had to continue to coach caregivers to share that information in huddles that really meant harm to them as a caregiver. And that's one of the things that our CEO wanted to know. She wanted to know if caregivers had experienced any harms. Were they okay? Because what we didn't want is to have these types of events really stack up over time and something happening and just not being proactive or knowing where did this come from? Has this been going on for a long time? And so having these tiered huddles really helped us really secure those security FTEs or any other processes that we could improve. We really developed a really strong workplace violence committee and different subcommittees off of that because we were realizing over time that this is a huge opportunity. But at the same time, you don't know what you don't know. You have to coach caregivers to know that. Yeah, we want to know if something's happened to you. This is not something that you should expect as part of your job. Something really. We continue to work through that now.

Got it. So when I think about one thing I'm curious about is you mentioned some of the things that you guys are monitoring on a. On a regular basis. So we have. When we think about indicators, we have leading indicators and lagging indicators. Right. Lagging indicators, it's like the sale is done or closed. Right. And the leading indicator is how many sales calls you make that day. Right. Like from that example. So what's the percentage, would you think of leading indicators versus lagging indicators that are focused on in these. In these various huddles?

I would say I think the intent is always to focus on the leading indicators and trying to be proactive, But I would say it's about 2/3 or maybe even 50. 50. I think we're still working on leading and lagging, so I'd say it's about half and half.

Yeah, I mean, leading indicators are hard, you know, I mean, lagging, it's pretty straightforward, right?

Yeah. And that's absolutely. The intent in these huddles is really to get ahead of things. But we know that there are some circumstances where you just need to know if something has occurred.

Right, right. Or you can start seeing a trend like, hey, why is this keep happening? That's in a way, it's lagging, but it's also leading. So.

Yeah, yeah, absolutely.

Yeah. Good stuff, good stuff. Talk about some of the benefits that you've realized as a result of these tiered huddles.

So one of the benefits that we've had is for, you know, caregivers to know that if they experience a challenge, then something can be done about it. Right. This is such a great opportunity to foster trust in an engagement between caregivers and leadership. Really. I mean, aside from health care. I mean, huddle. These tiered huddles can be anywhere. We know that they exist in the military. So when I talk about caregivers, I just want the audience to know that this is not specific to health care. So. But my experience is. But either way. So in my example of benefits, I think I want to talk through one that we went through in the very beginning. So our team was working with a pediatric unit around the same time that we were deploying tiered huddles. Right around that time, we also had an addition to our hospital, the heart and vascular unit. What ended up happening is that the pediatric unit and the new addition had the same room numbers. I think at first we thought, well, that's probably not going to be that big a deal. And what we started to see is that family members, physicians were going to the wrong places. They would end up at HBU, but they meant to be at PEDs. We thought, okay, so this is kind of coming up frequently or at least regularly in our tiered huddles. How about we add some signage? Okay, so let's add signs. Signs were added, some arrows, and then it kept happening. And caregivers were kind of feeling really frustrated, like, hey, I'm spending a lot of my time redirecting people back to the right places. Is any going to do anything about this? And eventually we just said, hey, just keep reporting it, keep reporting it. And then not even two weeks later, we were able to make those room number changes and epic. And I feel like those caregivers walked away with, okay, so when I do this, then something can happen. You know, people are going to act on these things. And I think that really started to change the mindset about tiered huddles. And is this really value added for me? Is this another chunk of time I need to commit? What am I really going to get out of this. And I think that really started to change. And so we started to get more communication, bouncing around to different nursing units. Like, well, I talked about the room number thing, and then something happened. And so that was really good for us. And so it was really. It was really nice to kind of see that unfold.

Yeah. Well, it's like in any human relationship, whether it's with your significant other or your colleagues, when we're struggling, we're probably not communicating well. Right. And so I feel like what these huddles are doing for folks is just, it's. It's amplifying the. The communication, the frequency, you know, of this communication. And when things are happening, we can immediately, you know, get it out there. Right. You don't have to live with it, so to speak.

Yes. And I think one of the other benefits is that you learn when to react and maybe most importantly, when not to react. You know, you're identifying these situations, but you're, like you mentioned before, you're trending them. You know, is this really a problem? We're going to keep an eye on it. And so you're actually starting to find those trends, and so you know where to focus your efforts rather than hopping on every single thing that comes through. You're really using your resources and your time wisely.

Yeah. Hey, so how long have you guys been at it using tiered huddles? Like, years or.

It's exciting. We're a little bit over a year now. It's so exciting.

Okay, so if you could go back to yourself a year ago and you have just like 10 minutes to give yourself some tips as it relates to tiered huddles, what tips would you give your year old self or year before self?

Yeah, I love this question. Yeah. Because I love that if we can all make mistakes and share them on podcasts, maybe we can save someone else. So I think one of the challenges that we've had is that some leaders felt that they were already aware of the issues happening in their department. And at one point, we suggested to executives to attend their tier one huddles, depending on what level of executive leadership you were. So let's say if you're a vice president, you might attend a tier one huddle maybe once a month to see your caregivers in that department and really not necessarily do a Gemba walk, but just be present, maybe hear some concerns and kind of watch that dynamic. Right. And some leaders took us up on this and some didn't. We had a C suite executive who Attended a huddle, a tier one huddle that was occurring by phone and they ended up being the only person on the phone. No one else was on the huddle. And so everyone is operating from a place of assuming that these huddles are happening just like they're designed. And if I could go back, I, I think that we would set that expectation to attend a tier one huddle rather than really a recommendation or a suggestion. And it's not as if we would want anything punitive to come from that for not huddling or following the process. But what we want is to make it easy to do the right thing and get value from it. And we need to understand the challenges and the barriers that exist so we can help address them. We've learned that no news is not always good news. We, you know, if you don't hear anything, that's a red flag for us. We need, yeah, you know, you want to hear those concerns.

Yeah. As they say, no problem is a problem. Right, right, exactly. Yeah. What about. So someone's listening right now and they, they're interested in getting started. Maybe they're healthcare, maybe they're in some manufacturing facility. Doesn't really matter. Do you have any similar like meta level tips that you folks who want to kind of get started with tiered huddles?

Oh, what do you mean by meta level?

Just like high level. Just like. Oh, just no matter the industry I guess is what I meant. Like. No, no matter if they're in a hospital or they're in a car manufacturing plant. Doesn't matter the industry. Like just some general tips for, for, for tiered huddles.

Yeah, absolutely. I think that my tip would be to put poor as much effort as you can into that tier one huddle. Focus the most time. And I mean this is just my experience. If you can get tier one down, you will be free.

Why do you say that's very interesting. Why do you say that?

Yeah, because that, I mean for us that was the, I mean it continues to be the biggest challenge. You know, the tears get smaller and smaller as you move up through the ranks. The largest one, the most complex one, the most diverse one is going to be the tier one huddles. And don't, I mean if you are in healthcare, make sure that you are inclusive to the non clinical areas. Right. The patient, financial services, revenue, integrity. It make sure that they get some attention in this process just as much as a clinical area. But really the focus, I think the most challenging part is tier one. But it, once you got that Then I think you're, you'll be way better off.

You're free. I love it.

Yeah, you're free. You're not free.

I know, I know, I know. You're. You're freer. Yeah, yeah, yeah. Oh, such a, such a, such a good advice and such a, such an awesome conversation here, Sarah. I've really, really enjoyed it. So, I mean, do you have any kind of final words of wisdom or tips that you want to leave with folks?

Yeah, I would say that whatever industry that you're in, we all want to make sure that we're practicing active listening and open communication. And I really mean truly, truly listening. I think that what some industries need is to really get closer to their frontline caregivers or employees and, you know, make sure that you're not creating a whole lot of distance and be safe and help keep others safe and keep learning out there.

I love it. I love it. Hey, if people want to connect with you, Sarah, what's the best way?

Yeah, LinkedIn is a great way to get ahold of me. I'm kind of starting to slowly break up with Facebook. So LinkedIn is a great place.

Yeah, yeah. I think when it, you know, we're recording this here in early October, I think it Facebook went down for. What was that a few days ago? And I wonder, I wonder if the world's productivity like shot up for a few hours. You know, we need some data, right? We need some data on that. Yeah. Good stuff. All right, well, hey, Sarah, this has been really, really fun. We're gonna link to your LinkedIn there in the show notes so folks can go to GembaPodcast.com Episode 395 and it's Sarah Cook. It's C O O K. Right. Just so easy enough to find. And yeah, thanks again for coming on. Keep up the great work and thanks for all the work that you're doing for humanity.

Thank you, Ron. You too.

All right, take care. Thanks for listening. Whether you've been on the continuous improvement journey for many years or perhaps you're just getting started, Gemba Academy is here to support you. And while we're best known for our more than 1500 Lean and Six Sigma teaching and virtual tour videos, we also have a team of experienced Lean and Six Sigma practitioners available for one on one coaching as well as a variety of of Lean and Six Sigma certification options. To learn more and to schedule a demo, head on over to gembaacademy.com.