Outstanding Innovation in Delivery Solutions:
Lisa Yerian, MD & Nate Hurle


Lisa Yerian, MD, Chief Improvement Officer, and Nate Hurle, Sr. Director, Enterprise Continuous Improvement both have a passion for improvement. Dr. Yerian is a surgical pathologist and member of the gastrointestinal and hepatopancreaticobiliary services. Her interest in improvement propelled her to a role in Continuous Improvement, where she met Nate Hurle. Hurle is an industrial engineer by trade and spent the early part of his career working in the manufacturing industry. Prior to joining Cleveland Clinic’s improvement team, he worked in process improvement at Eastman Kodak Company. Together in 2020, Dr. Yerian and Hurle are being honored with the Outstanding Innovation in Delivery Solutions Award for their work on implementing Tiered Daily Huddles throughout Cleveland Clinic.

Tiered Daily Huddles arose from a need for a holistic process to identify and solve problems across the enterprise on a daily basis. Though many departments and workgroups have had some reporting structure in place for some time, they often lacked the ability to escalate a problem for assistance and/or let leadership know of daily challenges and performance. The purpose of tiered daily huddles is three-fold: 1.) foster a culture of teamwork and safety, 2.) build operational awareness at all levels, and 3.) further support caregivers. There are six ascending Tiers, with Caregivers & Managers/Supervisors in Tier 1 and the CEO and Operating Council in Tier 6. Putting a defined structure in place for discussing and solving problems, Tiered Daily Huddles have created transparency at all levels of the organization.

When the Continuous Improvement team began the process of researching Tiered Daily Huddles, they looked to other organizations for inspiration – including Intermountain Healthcare and St. Louis Children’s Hospital. Huddles began in earnest within the Nursing Institute at Main Campus. The implementation process for Tiered Huddles moved quickly. As soon as Dr. Mihaljevic assumed the role of Cleveland Clinic’s CEO & President, Tiered Daily Huddles were introduced, and by April 2018, the first Tier 6 Huddle was held. By the end of May 2018, all Ohio hospitals were huddling through Tier 5 (regional hospital level), and by July, Cleveland Clinic Florida was integrated. In January 2019, the newest Florida hospitals, Martin and Indian River, were introduced to the concept, and individual institutes were participating in Tiered Huddles by Fall 2019.

 “Huddles are very easy to start…,” explained Dr. Yerian, “…once you start you can mature the process over time.” But the shining feature of the structure remains the ability to create a specific time and place for team members to come together to talk openly about problems they face in their work, collaborate on understanding and solving those problems, and quickly and effectively escalate problems to leaders for assistance where needed. In the first year after implementation of tiered daily huddles, the organization saw a 15% reduction in falls, an 11% reduction in falls with injury, and a 23% reduction in ICU central line-associated bloodstream infection (CLABSI) enterprise-wide.

As the Huddles mature, Continuous Improvement is, no surprise, working to improve them. The team has created a standard process to make changes to the huddle agenda, is implementing a technical tool for reporting data from all locations, and is working to improve the quality of the conversation in each Huddle to make sure problems are discussed openly and solved effectively. Through their evolution, the hope is that the culture of safety at Cleveland Clinic continues to improve, fully developing leaders and empowering caregivers to solve problems at every level of the enterprise. Tiered Daily Huddles support our culture of improvement – helping to ensure that every caregiver is capable, empowered and expected to make improvements every day!

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