Table 2:

Examples of well- and poorly-executed steps of the Kotter model in hospitals implementing team huddles

Well Executed Steps	Poorly Executed Steps
Step 1: Establishing a sense of urgency
Hospital A used their AHRQ HSOPS survey data to identify problem areas (teamwork and communication) as perceived by staff, and supplemented the survey results with anecdotal evidence to pinpoint the issues. Hospital F also based their rationale for huddles on their HSOPS survey results and identified specific issues to address in the ED department, their pilot site.	Hospital B implemented huddles because their hospital system promoted them. However, the change team did not identify any particular issues that huddles were supposed to address. Hospital H did not have a clear rationale for implementing huddles. They were generally trying to “improve communication,” but did not specify any concrete issues to address.
Step 2: Creating a guiding coalition
Hospital A’s change team was fully engaged, and each of them served as a coach for the units implementing huddles. Hospital E assembled a nursing-focused team that could facilitate the implementation in nursing. A Med-Surg nurse was particularly active and led the implementation team.	Hospitals B did not have anyone committed to implementing huddles, but the CEO formally led the effort. When he later left the hospital, no one else stepped in. Hospital H did not have a team. The OR Assistant Manager led the implementation by herself.
Step 3: Developing a vision and strategy
Hospital A developed a clear vision to use huddles hospital-wide. They strategized to start at the Lab, then spread to other clinical and non-clinical units, and finally institute hospital-wide manager huddles. Hospital F also envisioned all units would use the huddles and planned to implement them at a different unit each month.	Hospital B only had a general idea to “implement TeamSTEPPS,” and never developed a vision or a plan for huddles. Hospital D initially launched straight into implementation, without a vision or plan. They later had to backtrack and develop a more coherent plan with a timeline.
Step 4: Communicating the change vision
Hospital A emphasized huddles during staff training and, just prior to implementation at each site, they did a short “refresher training” specifically on huddles. Hospital G used several strategies to communicate including training, newsletters, and skills fair. They emphasized their goals and explained why they were implementing huddles.	Hospital C trained the unit managers and tasked them with implementing huddles. They informed the unit staff about the huddles during huddles at their respective units. Hospital E only communicated about TeamSTEPPS in general and did not explain why they chose to implement huddles or how they would help.
Step 5: Empowering broad-based action
Hospital A first empowered unit managers to support and lead huddles, and then later engaged unit staff. Towards the end, the staff sometimes even lead the huddles themselves. Hospital G trained and empowered clinical leaders to lead huddles. In turn, they engaged their staff, who reportedly felt empowered by the huddles.	Hospital B change team wanted to empower the charge nurses to lead huddles, but one staff nurse from the change team ended up leading most huddles herself. Hospital E instructed the charge nurses to lead the huddles. However, the team had to hold them accountable and regularly attend the huddles to make sure they did not stop.
Step 6: Generating short-term wins
Hospital A, in order to generate enthusiasm, picked lab as a pilot unit because they were small (“small department, small win”). They thought nursing was too big of a unit to provide an early win. Hospital F started the implementation in the ED department, whose manager was on the change team and championed the huddles, which generated a big win early on.	Hospitals B started the implementation in nursing, reasoning that if it can work in nursing, it can work anywhere. They did not generate any short-term wins. Hospital C picked Med-Surg as the first implementation site. They tried to start slow and develop the huddles, but failed to generate short terms wins and enough enthusiasm to sustain their efforts.
Step 7: Consolidating gains and producing more change
Hospital A spread the huddles from the lab to the other units, as planned. They used several strategies to monitor progress, including log sheets, surveys, and staff feedback. Hospital D used a combination of audits and staff feedback to monitor progress and make necessary changes to the process.	Hospital C had some initial success, but could not sustain their efforts. They also failed to monitor their progress adequately. Hospital F failed to build on the momentum from their early win in the ED. Despite their plans for hospital-wide huddles, they only spread them to one other unit.
Step 8: Anchoring new approaches in the culture
Hospital A reported at the end of our study that all departments were huddling regularly, though some issues in nursing remained. They said huddles were their first true success, where they became part of the daily routine. Hospital D managed to “hardwire” huddles in their Med-Surg unit along with bedside shift reports (they implemented both tools simultaneously)	Hospital B did not institutionalize huddles in any of their units and suspended implementation activities after the CEO left. Hospital C had limited success in two units, but the huddles did not become part of the routine by the end of our study. They identified one problem was that huddles were not a priority.

Notes: AHRQ = Agency for Healthcare Research and Quality; HSOPS = Hospital Survey on Patient Safety Culture; ED = Emergency Department; Med-Surg = Medical-Surgical Unit