When Tom Mihaljevic, MD, took over as president and CEO of Cleveland Clinic five years ago, something began to weigh heavily on his mind.
"I was bothered by the fact that I didn't know what was happening every single day at the Clinic," Dr. Mihaljevic said at Becker's Annual Meeting. "People would typically come to me and say, 'Oh, we had a bad week.' Or, 'We had a bad month.' There's very little that anyone can do with that information."
A homey nickname like "The Clinic" can almost make it seem like Cleveland Clinic is a singular location. But Dr. Mihaljevic's concern is especially understandable when accounting for his organization's size and scope. It employs more than 77,000 people with locations in Ohio, Nevada, Florida, Abu Dhabi, London and Canada. In 2022, the system was home to 12.8 million outpatient encounters, 303,000 hospital admissions and observations, and 270,000 surgeries and procedures. Patients came from every state and 185 countries.
As a new CEO looking to gain a stronger pulse on patient care throughout a wide system footprint, Dr. Mihaljevic tried out what has since become an essential daily practice: tiered 15-minute huddles.
"They're easily, in my opinion, one of the most important instruments that we have at our disposal to run a large integrated healthcare delivery system," Dr. Mihaljevic said.
Tiered huddles were piloted at Cleveland Clinic's main campus in January 2018. Now, throughout every part of Cleveland Clinic, every group of caregivers that provides direct patient care in every department, ward or hospital gathers every single morning in a structured format.
"The format is the same," Dr. Mihaljevic said. "It's only 15 minutes long, with the teams of caregivers speaking about what is important for their work that day. It always starts with quality, safety, patient experience, environmental care, infrastructure, and anything that needs to be addressed for caregivers' patients and their fellow caregivers."
The huddle has a dual purpose of sharing what is important for that team that day, and identifying any problems or questions and addressing them as a team. If they are unable to address the problem or question at hand, they pass that information up to the next tier.
There are six tiers total, with the first four focused on hospitals. Tier one is caregivers at the unit level and their managers or supervisors. Tier two is managers and directors. Tier three is the hospital's nursing directors, chief nursing officer, operations president and COO. Tier four is the hospital president, COO, associate CNO and CNO. The fifth and sixth tiers are focused on the Cleveland Clinic enterprise, with the fifth involving hospital system presidents, COOs, CNOs and executive CNOs, and the sixth involving the enterprise CEO and operations council.
"By 11 o'clock, and it's exactly at 11 o'clock every single morning, there is the sixth layer of the daily huddle that happens with the executive and broader leadership team," Dr. Mihaljevic said. "We share with everyone and understand what's going on under the roof of Cleveland Clinic in entirety of the organization. Every single day, we know exactly how many central line infections we've had. We know how many serious safety events, where they occurred and what the reason was. We know how many patients we are serving in the outpatient setting and inpatient setting, and whether there are any problems with throughput and the environment of care."
The tiered model of the huddles means issues or problems escalated from the bedside to higher chains of command are often resolved within 24 hours. As a result, managers spend less time and energy trying to follow up on issues.
The huddles are also a time for reflection. Staff read the first names of patients who died while receiving treatment or care within Cleveland Clinic facilities.
"That was a suggestion that came from our former chief digital officer who thought this would be a way to really ground us," Dr. Mihaljevic said. "We are in a very humane profession and we do care for the lives of people that we serve. And we end with the moment of silence."
Five years into the daily huddles, Dr. Mihaljevic cannot imagine the Clinic without them. They have forced every department in the system to analyze events the same way to strengthen transparency around quality and safety. They create daily leadership and problem-solving opportunities at every tier. They also extend opportunities for trust-building as employees know pressing problems they raised will be elevated to leadership within hours.
"The effort to provide uniformity of care and with the same experience and the same quality across this global footprint starts, actually, with the way that we communicate among ourselves and our patients every single day," Dr. Mihaljevic said.