46 ISE Magazine | www.iise.org/ISEmagazine
Implementing a tiered huddle system during the COVID-19
pandemic in a large academic healthcare system
The COVID-19 pandemic has placed healthcare systems under unprecedent-
ed pressure. It has created new operational challenges and magnified existing
patient safety concerns. The pandemic has also highlighted how healthcare
workers’ well-being is crucial to keep patients safe and provide stability for
healthcare systems.
We applaud healthcare workers for their resilience, dedication and creativity
to manage day-to-day operations. However, the rapid changes in processes,
procedures and care settings have placed significant pressure on front-line
staff, creating conditions prone to human errors. In these challenging times
and circumstances, reporting errors, understanding their causes and learning
from them has become even more vital to prevent patient harm.
Hospital-based huddle programs have been recognized as innovative ways
to improve communication, care coordination, situational awareness, safety
culture and long-term patient safety outcomes. Huddles are short regular
debriefings that are designed to engage healthcare workers about existing
or emerging safety-related issues. They promote cohesive and independent
communication and encourage healthcare workers to think as a team, em-
powering front-line staff by providing a forum for open and honest com-
At the University of North Carolina-Chapel Hill (UNC), a large academic
healthcare system, we implemented a tiered huddle system, an evidence-based
intervention across our four hospitals, over 300 areas and more than 10,000
healthcare workers from August 2020. A tiered huddle system is a series of
brief, focused virtual meetings about 15 minutes in length held daily, includ-
ing weekends and holidays. They rapidly identify and escalate safety, quality
and operational issues from a broad array of front-line staff to a focused group
of senior leaders. The most critical issues are escalated to senior levels within
hours through different tiers. This helps to identify safety issues that require
the immediate attention of senior hospital leadership.
The three-tiered huddle structure (seen in Figure 1) helps in resolving is-
sues locally and escalating other concerns to the next level. This helps address
events in real time to prevent occurrences of safety issues and it improves col-
Solutions in practice
by Lukasz Mazur, Bret Shultz, Cristie Dangerfield,
Karthik Adapa, Erin Burgess and Thomas S. Ivester
case study
The implementation of the tiered huddle system
at UNC has given the healthcare system a head
start on addressing patient safety issues.
July 2021 | ISE Magazine 47
laboration across units and work areas.
UNCs tiered huddle system is characterized by the follow-
ing key generalizable components to make them run effec-
Standard agenda: All huddles follow a standard agenda
(SAFESS+: safety, announcement, flow, equipment, sup-
plies, stafng and + representing workplace violence, patient
experience and well-being) throughout the organization, at
every area, to keep meetings running quickly and smoothly.
A “golden zone” has been proposed from 9 to 11 a.m. each
weekday to ensure protected time for teams to participate in
huddles and to address any identified issue.
Standard tools: All huddles are encouraged to use gen-
eralizable standard work and templates to conduct and docu-
ment work huddles at each tier.
Standard behaviors: All huddles are encouraged to start
and end on time. All information is written down, each per-
son shares his or her metrics and issues, represented by mul-
tidisciplinary teams, and issues and concerns are probed and
resolved. During huddles, leaders thank
team members for raising issues; build
psychological safety and trust among
team members by encouraging them to
focus on solving issues, rather than plac-
ing blame; and foster an environment to
value others’ perspectives by providing an
opportunity to improve their problem-
solving skills over their immediate desire
to solve an issue.
Facilitation: Tier I and II huddles are
facilitated by areas’ managers and direc-
tors respectfully. Tier III huddles are fa-
cilitated by executive senior leaders on a
rotating basis.
The implementation of the tiere huddle
system at UNC has given the healthcare
system a head start on addressing patient
safety issues. Our healthcare workers par-
ticipate actively, share current, actionable
information and insights across teams
that readily provide feedback and act in
real time. Tier I and II participants are
connecting with the right resources to proactively solve issues.
The structure also promotes interdisciplinary collaboration
between providers, nurses, police, pharmacy, therapy services,
coaches and administration, and facilitates problem-solving,
team building and sharing critical information. In a six-month
period, the range and breadth of issues addressed were exten-
sive (seen in Figure 2 on Page 48). At the Tier III alone, more
than 500 unique issues were tackled, resulting in a nearly 85%
resolution rate within the three weeks of reporting. We have
been able to address a wide variety of challenges to improve
patient and provider experience.
The huddles enable our providers to interact with oth-
er members of the care team and speak about patients and
their concerns. Our participants report increasing comfort
in sharing good catches, identifying safety issues, learning
from their errors and improved transparency in discussing
safety events. Tiered huddles allow open dialogue regard-
ing difficult conversations resulting in staff members looking
through the lens of their team members. This results in a
cohesive work environment and bridging differences effec-
tively. A consistent and dedicated time and place to conduct
the huddles has helped participants and clinics investigate
problems quickly, align the teams efforts for the day, com-
municate potential solutions and reinforce accountability and
consistency in practice.
Within the first six months of implementing the system, the
number of incidents reported increased by approximately 75%.
Thus, our experience suggests that a tiered huddle system has
enormous potential to promote patient safety and minimize
Tiered huddle structure
Dividing the system into three levels helps to resolve issues locally and pass other
concerns to the next level.
Our experience suggests that a tiered
huddle system has enormous potential
to promote patient safety and minimize
preventable harm across multiple
healthcare settings.
48 ISE Magazine | www.iise.org/ISEmagazine
case study
If you’ve been involved in a project that put solutions to the test in a
real-world environment, it could be a potential Case Study article. Please
send your idea to Managing Editor Keith Albertson at kalbertson@iise.org
for consideration.
Do you have a Case Study to share?
preventable harm across multiple healthcare settings. It is also
a powerful tool for trust and team building, accountability,
information sharing and improving team cohesion during the
COVID-19 pandemic.
Safety huddles have not always been successfully imple-
mented in healthcare. We recognize that implementing evi-
dence-based innovations like this system and sustaining them
in diverse healthcare settings is complex owing to the dynamic
interplay between multiple dimensions. Implementation ef-
fectiveness theories help us understand how to effectively
implement complex interventions such as tiered huddles that
involve a coordinated effort from multiple people.
Future research efforts must explore the association be-
tween factors that influence the implementation effectiveness
of tiered huddles. They include implementation climate, in-
novation-values fit, clinic characteristics, adoption and fidelity
of the systems implementation and the impact on changes in
safety events, patient harm and safety culture.
Lukasz Mazur, Ph.D., is an associate professor and a director of the
Division of Healthcare Engineering-Ofce of Quality Excellence for
UNC Hospitals. He is an IISE member.
Bret Shultz is a research project manager in the Division of Healthcare
Engineering-Ofce of Quality Excellence for UNC Hospitals.
Cristie Dangereld, MSN, RN, CCRN-K, CNL, is a patient
safety ofcer in the Ofce of Quality Excellence for UNC Hospitals.
Karthik Adapa, M.D., MPH, is a human factors lab manager in the
Division of Healthcare Engineering-Ofce of Quality Excellence for
UNC Hospitals.
Erin Burgess, PMP, is an associate vice president in the Ofce of
Quality Excellence for UNC Hospitals.
Thomas S. Ivester, M.D., MPH, is a vice president of Medical Affairs
and chief medical ofcer for UNC Hospitals.
Measuring results
The Tier III huddle data shows more than 500 unique issues were addressed with an almost 85% resolution rate within three weeks of
reporting for the period of August 2020 through January 2021.