Huddles and their effectiveness at the frontlines of clinical care: a scoping review

Abstract

Background

Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research.

Methods

A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts.

Results

Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%).

Discussion

Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes.

Study Registration

This scoping review was registered with the Open Science Framework on 18 January 2019 (https://osf.io/bdj2x/).

INTRODUCTION

Brief, focused, stand-up meetings known as huddles have the potential to improve medical care by enabling collaborative and efficient information exchange and fostering a shared view of current clinical conditions.¹ Huddles have been shown to minimize hierarchical barriers to care delivery, enhance frontline staff satisfaction, and improve clinical outcomes.² In contrast to historically dominant provider-centric medical practice models, huddles operationalize medicine as a cooperative science: all team members (e.g., physicians, nurses, medical assistants, administrative staff, laboratory workers) work together for the patient’s good,³ promoting stronger teamwork and communication⁴ and situation awareness on the unit floor.¹ This increased communication with and among members of the team may also lead to better understanding of the daily work of frontline staff, potentially a key to sustaining quality improvement.⁵

Ideally, huddles optimize participant engagement, last 10–15 min, focus only on essential patient and procedural information,^1,6 and are held on a regular basis;⁷ in practice, however, huddles take many forms. Some may involve only the patient’s immediate clinical team, meeting as needed at the patient’s bedside.⁸ Others may involve all clinical and non-clinical staff and be scheduled for the start of each workday or other regular interval.⁹ Huddle structure may also vary, depending, in part, on the use of any facilitation strategies, scripts, or communication tools such as CUS (“I am concerned! I am uncomfortable! This is a safety issue!”)¹⁰ or SBAR (Situation-Background-Assessment-Recommendation).¹¹ Yet despite understanding some of the myriad variations in huddle structures and processes, knowledge of huddle implementation and effectiveness at the frontlines of health care remains fragmented and is limited to particular settings. In a preliminary search for relevant reviews available through MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis, we found three systematic reviews focusing on the use of huddles: one to promote patient safety in the perioperative setting² and two focused on their use in inpatient settings.^12,13 A more comprehensive understanding of huddle practices and characteristics has the potential to help clinicians and health care administrators across diverse settings understand how this process can help improve patient care.

In contrast to the prior, narrow systematic reviews on huddles in specific settings, this scoping review thus provides a comprehensive overview of the scope and volume of research on the broad category of clinical-setting huddles that involve frontline staff. In keeping with standard indications for conducting a scoping review,¹⁴ this review has the following purposes: to describe characteristics of such huddles (e.g., structures, processes), identify empirical support for the effectiveness of huddles for improving health care quality, and highlight knowledge gaps and opportunities for more detailed evidence syntheses and empirical research.

METHODS

We performed this scoping review using the Joanna Briggs Institute’s established method for a scoping review¹⁵ and guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).¹⁶ The final protocol was prospectively registered with the Open Science Framework¹⁷ on 18 January 2019 (https://osf.io/bdj2x/) and published in the peer-reviewed literature.¹⁸

Scope of the Review

We used the PCC (Population, Concept, and Context) framework to define eligibility criteria.¹⁶ To be eligible for inclusion, articles had to (1) take place in any clinical or medical setting that provides health care patient services, including inpatient, outpatient, or residential settings; (2) include frontline staff members (i.e., employees with patient contact, including health care providers and non-clinical/administrative staff);¹⁹ (3) describe, investigate, or explore the huddling practice as a targeted intervention to improve processes and outcomes broadly related to quality of care (e.g., staff engagement and satisfaction, perceptions of safety culture, adverse drug events, patient length of stay); and (4) provide empirical data. Eligible study designs included qualitative studies; experimental and quasi-experimental studies (e.g., randomized or non-randomized controlled trials, before and after studies, interrupted time-series studies); analytic observational studies (e.g., prospective or retrospective cohort studies, case-control studies); and descriptive cross-sectional studies. Dissertations, gray literature, and conference proceedings that met inclusion criteria were also considered. We excluded study protocols; articles that described huddles as a platform through which other interventions were disseminated; articles that solely focused on adherence to a checklist (e.g., surgical safety checklist); simulation studies, and research summaries lacking original data.

Data Sources and Searches

To be as comprehensive as possible, we performed an initial limited search of PubMed and CINAHL Plus with Full Text, followed by an analysis of each identified article’s title, abstract, Medical Subject Headings (MeSH) terms, and keywords. For our full search, we used all resulting relevant MeSH terms and keywords to search the following databases: PubMed, EBSCOhost (including CINAHL Plus with Full Text, Dentistry & Oral Sciences Source, ERIC, Health Business Elite, Health Policy Reference Center, PsycArticles, PsycBooks, Psychology and Behavioral Sciences Collection, PsycINFO, Rehabilitation & Sports Medicine Source, Social Work Reference Center, and SocINDEX with Full Text), ProQuest (including the Family Health Database, Health & Medical Collection, Health Management Database, Nursing & Allied Health Database, Psychology Database, and PTSDpubs), and OvidSP. Appendix 1 lists the full search strategy used for PubMed, CINAHL Plus with Full Text, EBSCOhost, ProQuest, and OvidSP. We augmented the full database search by scanning the reference list of the Institute for Healthcare Improvement’s (IHI’s) white paper that guides health care practitioners in using daily huddles as part of a quality management system⁵ for additional articles that we then assessed. Studies published in English from inception to May 31, 2019, were considered for inclusion.

Study Selection

All articles identified during the full database and additional searches were uploaded into EndNote X8.2 (Clarivate Analytics, Philadelphia, PA, USA), and duplicates were removed. We conducted an initial screening for inclusion based on titles and abstracts. Two reviewers (C.B.P., C.W.H.) independently conducted the first screening of the abstracts based on the inclusion criteria to identify articles to include for further review. Disagreements on article inclusion were resolved by discussion or with input from two additional reviewers.

Following this, we reviewed the full text of those articles that met initial screening. Two independent reviewers assessed each article against the inclusion criteria, with disagreements resolved through discussion or with input from a third reviewer. Full-text articles that did not meet the inclusion criteria were excluded from the scoping review. Results of the search are presented in a PRISMA flow diagram (Fig. 1).¹⁶

Figure 1.

PRISMA flow diagram.

Data Abstraction and Quality Assessment

Seven reviewers independently abstracted relevant data from each full-text article meeting all inclusion criteria. An Excel spreadsheet was used to collect data about, for example, clinical setting, study design, huddle purpose, participating staff, and indicators of huddle effectiveness. The data abstraction tool is available in Appendix 2. To summarize huddle purpose, we began with an adapted list of the four benefits of huddles as outlined by the IHI (engage, update, recognize, and identify)²⁰ and added two additional ones based on our findings (plan, provide) (Table 1).

Table 1 Huddle Purpose and Outcome Measures (N=158 Articles)

Two secondary reviewers (C.B.P., C.W.H.) independently abstracted relevant data from all full-text articles to assess consistency with primary reviewers. As in the study selection process, disagreements between primary and secondary reviewers were resolved through team discussion or in consultation with a third reviewer. We did not perform formal assessments of methodological quality because a scoping review aims to provide an overview of the existing evidence, irrespective of quality.^15,16 We did categorize studies by evidence quality (e.g., peer-reviewed, gray literature, presence of a control comparison group), however, to inform future research.

Role of the Funding Source

This work was supported by the US Department of Veterans Affairs, Veterans Health Administration, Office of Geriatrics and Extended Care, through the VA Community Living Centers’ Ongoing National Center for Enhancing Resources and Training. The funder had no role in study design or conduct, data collection, analysis or interpretation, or reporting.

RESULTS

We identified a total of 2,185 publications through electronic database searches and reference lists (Fig. 1). After removal of duplicate publications across databases (N=1,330) and exclusion after initial title and abstract review (N=535), we performed full-text review of 325 studies. Two researchers (a primary and secondary reviewer) independently reviewed each article, with 90% agreement between both reviewers prior to resolution through team discussion or in consultation with a third reviewer. One-hundred fifty-eight studies met inclusion criteria;^{1,6,8,9,11,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173} 139 (88.0%) were peer-reviewed and 19 (12.0%) were gray literature. Details related to our broad objectives are summarized below. Select details on the included studies are available in Appendix 3.

Year and Location of Studies

The first study meeting eligibility criteria was published in 2004;¹¹ the majority (71.5%; N=113) were published between 2014 and 2019.^{8,9,21,22,25,27,30,31,32,34,35,36,37,39,41,42,43,44,47,48,49,51,53,56,57,58,62,63,65,67,68,69,70,72,74,76,77,79,81,83,85,87,89,90,92,93,94,96,97,99,100,101,102,104,105,106,107,108,110,111,112,113,115,116,117,118,119,120,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,141,142,144,146,147,148,149,150,152,153,154,155,156,157,158,159,161,162,163,164,165,166,167,168,169,170,173} Seventy-four percent (N=117) were performed in the USA,^{1,6,8,9,11,21,23,25,27,28,30,33,34,35,37,38,39,40,42,43,44,46,47,48,49,50,51,52,53,55,56,57,58,59,60,61,62,64,65,69,71,72,74,76,77,78,84,85,86,87,88,89,91,93,96,97,98,99,100,101,102,104,106,107,109,112,114,115,116,117,118,119,120,121,122,123,124,125,126,128,129,130,131,132,135,136,137,138,139,140,141,142,143,144,145,146,147,149,150,151,152,153,155,156,158,159,160,161,164,165,166,167,168,169,170,172,173} 13.9% (N=22) in the UK,^{22,26,29,31,36,41,54,63,67,70,75,79,83,92,94,105,110,111,113,133,154,162} 8.9% (N=14) in Canada,^{24,32,45,68,73,80,82,90,103,108,127,134,157,171} and 3.2% elsewhere (the Netherlands [N=2],^81,163 Thailand [N=1],⁹⁵ Israel [N=1],⁶⁶ and Australia [N=1]¹⁴⁸).

Clinical Setting

A majority (30.4%; N=48) of all studies described implementation of huddle-based interventions throughout entire hospitals or health care systems.^{1,6,21,23,25,28,30,37,39,41,42,47,56,57,62,63,71,73,74,83,87,89,91,94,98,104,105,109,114,115,117,123,125,128,129,130,131,133,135,136,137,143,150,160,162,165,169,170} Specific unit-level clinical settings included the following: perioperative settings/operating room (15.2%; N=24),^{11,24,26,29,38,45,46,52,59,65,66,70,75,76,78,79,80,81,82,84,86,95,103,113} intensive care units (12.7%; N=20),^{33,44,50,61,77,88,96,108,110,112,121,124,138,140,151,152,159,163,171,172} inpatient medical or surgical departments (13.3%; N=21),^{35,49,51,54,60,67,85,92,99,100,101,111,116,118,141,147,154,155,157,168,173} long-term care facilities (6.3%; N=10),^{31,40,97,120,122,127,132,139,148,166} primary care (6.3%; N=10),^{43,55,58,64,68,69,93,142,149,164} emergency departments (5.1%; N=8),^{8,90,145,146,151,153,158,161} and labor and delivery (3.8%; N=6).^{53,72,119,126,156,167} Two percent or fewer studies were specific to each of the following settings: neurology and stroke (N=3),^34,107,144 oncology (N=2),^48,98 dental (N=2),^22,36 behavioral health (N=2),^27,139 pathology (N=1),³² radiology (N=1),⁹ cystic fibrosis (N=1),¹⁰² outpatient echocardiography laboratory (N=1),¹⁰⁶ and brain and spinal cord rehabilitation (N=1).¹³⁴

Study Design

Among peer-reviewed studies, 107 used quantitative methods only and 32 used qualitative or mixed methods. Among studies in the gray literature, 18 used quantitative and 1 used qualitative methods.

Only 9 studies (5.7%), all from the quantitative peer-reviewed literature, used a comparison group design.^{38,49,87,90,115,121,138,141,162} Nearly half of all studies (N=75) were analytic observational,^{1,23,26,28,31,34,37,41,46,47,48,50,51,55,58,59,60,61,67,71,72,74,75,76,77,78,79,80,83,84,86,89,91,94,96,97,99,101,106,107,109,110,111,112,115,117,119,123,125,128,129,130,132,133,134,137,140,142,143,146,147,148,150,153,157,158,159,160,161,163,166,167,168,170,172} 34.2% (N=54) were experimental or quasi-experimental,^{8,11,27,29,32,33,35,38,42,43,45,49,51,52,53,56,65,70,73,81,85,87,90,92,95,102,103,104,105,108,113,114,116,118,120,121,122,124,125,126,131,135,136,138,139,141,144,149,152,155,156,162,165,173} and 9.5% (N=15) were descriptive cross-sectional.^{9,22,30,36,39,40,57,64,66,93,100,127,151,169,171} Twenty-one percent of studies (N=33) used qualitative methods,^{6,21,24,25,29,30,31,37,43,44,54,55,57,58,62,63,64,66,68,69,77,80,82,87,88,98,127,142,145,148,154,157,164} among which half (N=17) used mixed methods.^{29,30,31,37,43,57,58,64,66,68,77,80,87,127,142,148,157}

Huddles were the sole intervention in 42.4% of studies (N=67)^{6,8,9,11,24,25,26,28,29,30,36,38,40,42,43,44,45,46,47,51,52,54,55,57,58,59,60,62,63,65,66,67,68,74,75,76,77,78,80,81,82,83,84,85,86,88,89,95,104,105,109,110,113,116,117,123,125,127,130,134,136,138,140,144,153,164,169} and part of a larger intervention bundle in 57.6% (N=91).^{1,21,22,23,27,31,32,33,34,35,37,39,41,48,49,50,53,56,61,64,69,70,71,72,73,79,87,90,91,92,93,94,96,97,98,99,100,101,102,103,106,107,108,111,112,114,115,118,119,120,121,122,124,126,128,129,131,132,133,135,137,139,141,142,143,145,146,147,148,149,150,151,152,154,155,156,157,158,159,160,161,162,163,165,166,167,168,170,171,172,173}

Huddle Purpose

Studies used huddles for multiple purposes (Table 1). The majority (67.7%) of studies (N=107) described huddles as being used to engage team members in thinking and talking about their work and to improve communication, collaboration, and/or coordination.^{6,8,11,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124} Roughly equal numbers of studies described huddles used to identify issues requiring immediate attention or escalation to high-level management for resolution (27.2%; N=43);^{1,8,9,21,25,27,29,30,32,37,39,44,53,55,57,59,63,69,75,84,87,93,98,116,122,126,134,144,146,149,153,154,155,156,157,158,159,160,161,162,165,167,171} update team members about safety and quality issues that affect their work, including reviewing prior issues (24.1%; N=38);^{6,29,32,40,57,72,73,77,83,87,89,110,111,113,118,122,123,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,167,168,169,170,171,173} and plan for or improve processes for future work (22.8%; N=36).^{9,31,34,50,55,57,59,60,66,69,71,93,100,108,121,122,130,132,134,135,140,141,142,143,144,145,146,147,148,149,150,151,166,168,170,172} Fewer studies described huddles used to recognize work-related issues that may be addressed by training, coaching, or revising tools and methods (4.4%; N=7)^{40,57,62,89,112,152,169} or to provide a framework for running Plan-Do-Study-Act cycles (1.3%; N=2).^163,164

Theories and Tools

More than one-third of the studies (37.3%; N=59) were based on a conceptual rationale,^{1,6,11,21,23,27,30,31,32,35,37,42,47,49,53,54,57,58,61,62,63,66,67,69,70,73,75,78,83,89,90,94,98,107,115,119,120,121,123,125,126,127,128,132,133,135,145,146,147,148,156,159,162,163,164,166,170,172,173} such as a theory (why the subject of interest will have an impact) and/or a framework or model (how a theory is operationalized).¹⁷⁴ Among these studies, the most common were high reliability organizational principles (17.6%; N=9),^{1,6,63,69,70,123,125,128,135} crew resource management (17.6%; N=9),^{11,54,61,75,78,89,94,98,121} and Lean Six Sigma (15.7%; N=8).^{27,30,32,49,115,126,163,170}

Only 7.6% of studies (N=12) mentioned organizing their huddles using existing tools or communication scripts (e.g., SBAR; Table 2);^{8,21,23,65,73,94,101,138,145,146,159,166} 15.8% (N=25) developed and published their own huddling tools.^{27,29,36,42,45,46,49,50,51,56,60,68,78,80,87,89,96,98,104,112,130,134,136,141,153}

Table 2 Common Tools Used to Communicate in or Monitor Frontline Staff Huddles

Participating Staff

In studies that identified huddle participants’ job categories (N=120), nurses were involved in 88.3% of the studies (N=106);^{1,6,8,9,11,21,24,25,26,28,29,30,34,35,36,37,38,39,40,41,42,43,44,45,46,49,50,51,53,54,55,56,57,58,59,60,62,63,65,66,68,69,70,71,72,73,75,77,78,79,80,81,83,84,85,86,87,88,89,91,95,96,98,99,100,103,104,110,111,112,113,114,117,119,120,121,122,123,125,127,129,130,133,136,138,140,142,143,144,145,146,147,148,149,150,152,153,155,157,158,159,160,162,164,165,173} physicians in 75.8% (N=91);^{6,9,11,24,26,28,29,30,32,35,36,38,39,40,41,42,43,44,45,46,49,50,51,53,54,55,56,57,58,59,62,63,65,66,68,69,70,71,72,73,75,78,79,80,81,83,84,85,86,87,91,94,95,96,98,99,100,101,103,104,108,109,110,111,112,113,114,117,118,119,121,122,123,134,136,140,141,142,145,146,149,152,153,155,157,158,160,162,164,165,172} members of ancillary services (e.g., social workers; pharmacists; technicians; case managers; respiratory, physical, or occupational therapists) in 50.8% (N=61);^{11,26,28,29,30,36,37,38,39,40,45,49,50,54,63,65,66,69,70,71,75,78,80,81,83,84,85,89,91,94,96,98,99,100,101,103,105,109,110,111,112,114,117,118,121,122,125,136,142,143,144,146,149,152,155,157,158,159,160,162,164} managers in 23.3% (N=28);^{1,6,9,21,25,27,30,32,34,40,44,57,63,69,74,88,89,98,117,123,126,136,143,150,162,164,169,172} and other frontline staff (e.g., clerical staff, environmental services) in 13.3% (N=16).^{9,30,32,37,55,58,63,68,89,94,98,125,136,162,164,169} Many huddles were interdisciplinary in nature, including participants from more than one job category. More than 24% of all studies (N=38) did not specify participants’ job categories. Three percent (N=5) of all studies explicitly included patients and/or their family members and peer supports.^{27,30,53,57,125}

Nurses, usually charge nurses or nurse managers, facilitated the huddles in 40.0% of studies (N=20)^{1,28,29,30,43,44,57,60,85,88,89,112,125,129,130,136,138,147,149,150} where information on facilitator job category was included (N=52).^{1,9,21,22,28,29,30,33,35,40,43,44,47,51,54,55,57,59,60,68,69,71,83,84,85,87,88,89,98,99,100,108,111,112,117,123,125,127,129,130,135,136,138,145,147,149,150,162,164,169,170,171} Other huddle facilitators were attending physicians or medical directors (32.0%; N=16), ^{9,22,28,29,30,40,54,55,57,71,84,87,98,99,100,136} unspecified administrative leaders (26.9%; N=14),^{9,21,30,33,44,47,57,83,88,123,136,150,169,170} physician trainees (13.5%; N=7),^{1,35,51,55,100,108,117} unspecified members of the health care team (13.5%; N=7)^{57,59,68,69,127,145,162} or safety team (7.7%; N=4),^{47,135,136,171} and pharmacists (6.0%; N=3).^111,136,164 In 67.1% (N=106) of all studies, information about huddle leaders was lacking.

Among studies that specified the number of huddle participants (N=31),^{1,8,31,42,45,53,55,58,62,65,68,71,72,82,87,91,100,104,118,127,138,140,142,144,145,148,153,158,163,165,169} a range of 2 to 20 frontline staff members attended huddles. Nearly 77% of the studies (N=121), however, did not specify the number of participants.

Huddles, when duration was specified, lasted anywhere between 2 and 30 min. Most of these huddles were held either once (41.1%; N=53)^{6,9,26,27,29,34,35,39,40,42,45,47,51,55,60,62,67,68,69,73,74,77,80,81,85,87,92,93,102,104,108,111,113,114,116,117,118,123,126,129,131,138,140,142,143,144,149,155,160,162,169,170,172} or twice (12.7%; N=20) daily,^{1,23,28,33,37,43,44,58,59,88,89,90,120,128,133,145,154,156,157,160} 24.7% (N=39) before or after an event of interest (e.g., surgery, fall, activation of sepsis alarm),^{8,22,24,36,49,53,54,64,65,66,71,72,78,82,83,84,91,96,100,105,109,112,119,121,122,130,135,136,137,141,146,150,152,158,161,165,168,173} and 8.9% (N=14) on a weekly basis or more infrequently.^{30,31,32,66,110,127,132,134,147,148,163,164,166,171} Nearly 18% of studies (N=28) did not provide this level of detail when describing the huddles.

Effectiveness of Huddles

All 9 quantitative studies with a control comparison group reported statistically significant improvements associated with huddles.^{38,49,87,90,115,121,138,141,162} Of the 123 quantitative studies without a control comparison group, all but 2 reported improvements. Half (N=60) of these studies reported positive findings reaching statistical significance.^{1,27,29,32,33,35,39,41,45,46,51,52,56,58,61,65,71,72,75,78,79,80,81,84,85,91,94,99,101,102,103,104,106,109,112,113,116,117,118,119,122,125,129,130,134,135,139,142,143,144,146,148,149,152,155,156,157,163,165,173} All studies reported at least one outcome, with many reporting multiple process and clinical care outcomes. Of the 63.9% (N=101) studies measuring work and team process outcomes (Table 1), all but 1 reported that the huddle had a statistically significant positive impact on frontline staff.^{6,8,9,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,125,126,127,128,129,130,131,140,141,142,143,144,145,146,147,148,150,153,154,155,156,157} Of these, studies found evidence for improved efficiency, process-based functioning, and communication across clinical roles (64.4%; N=65);^{6,8,9,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,125,126,127,140,141,142,143,144,145,153,154,155} improved situational awareness and staff perceptions of safety and safety climate (44.6%; N=45); ^{6,8,11,26,30,31,35,36,37,40,45,46,47,53,55,56,57,60,62,63,67,68,69,71,73,74,75,76,77,78,79,80,81,82,83,84,85,86,128,129,145,146,147,153,156} increased staff satisfaction and engagement (29.7%; N=30);^{6,8,11,30,33,37,38,41,47,49,58,59,60,62,63,68,69,77,79,85,87,88,89,127,128,130,142,148,156,157} perceptions of a more supportive practice climate (26.7%; N=27); ^{6,8,9,11,28,30,40,43,47,49,50,57,58,62,66,67,68,69,71,79,84,85,90,91,127,154,156} and enhanced self-efficacy among frontline staff to implement evidence-based practices and/or improve care (20.8%; N=21).^{29,30,34,38,48,51,54,58,66,71,77,81,87,92,93,94,95,127,131,148,154} Only 2 qualitative studies (less than 2% of all studies) specifically assessed and reported on unintended negative consequences of the huddling practice, including added pressure on staff time and workload,²² exclusion of clinical trainees, and inadvertent reinforcement of medical hierarchies.²⁴ We summarize the major findings on huddle team process outcomes in Fig. 2.

Figure 2

Positive work and team process outcomes associated with frontline huddles (with percent of studies reporting each outcome; N=101). Studies could report more than one outcome; percent totals are over 100.

Seventy studies (44.3%) measured clinical care outcomes^{1,11,25,27,30,31,34,36,41,49,50,51,56,63,72,74,86,89,94,97,99,100,101,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,128,}