Transcript Briefing and Debriefing

Briefings and Debriefings
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
Our Approach
Translating Evidence
Into Practice
(TRiP)
1. Summarize the
evidence in a checklist
Reducing Surgical Site
Infections
Comprehensive Unit
based Safety Program
(CUSP)
•
Emerging Evidence
1.
Educate staff on
science of safety
2. Identify local barriers to
implementation
•
Local Opportunities
to Improve
2.
Identify defects
3. Measure performance
•
Collaborative
learning
3.
Assign executive
to adopt unit
4.
Learn from one
defect per quarter
5.
Implement
teamwork tools
4. Ensure all patients get
the evidence
• Engage
• Educate
• Execute
• Evaluate
Technical Work
Adaptive Work
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Comprehensive Unit-based Safety
Program (CUSP)
1.
Educate staff on science of safety
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from one defect per quarter
5.
Implement teamwork tools
– Briefings and Debriefings
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Learning Objectives
• Understand the fundamentals of briefings in
and debriefings teams
• Understand how to implement these tools in
your area
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THE BASICS OF BRIEFINGS AND
DEBRIEFINGS
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Overview of Critical Team Interactions
• Briefings
– Planning and preparation (regularly
scheduled)
• Debriefings
– Learning and improvement
• Huddles
– Re-planning (emergent, ‘as needed’)
• Handoffs
– Ensuring continuity of care
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Briefing Defined
A Briefing is a discussion between two or more people, often a
team, using succinct information pertinent to an event.
What a briefing immediately does:
1. Maps out the plan of care
2. Identifies roles and responsibilities for each team
member
3. Heightens awareness of the situation
4. Allows the team to plan for the unexpected
5. Allows team members’ needs and expectations to be
met
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Effective Briefings
Set the tone for the day… chaotic versus organized and
efficient
Encourage participation by all team members
Are ‘owned’ by all team members
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Organized in thought regarding the procedure
Establishes competence:
Who has what skills
Who performs what
Who knows what
Predicts what will happen later
Plans for the unexpected(e.g., equipment, medications, consults)
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Briefing Checklist
TOPIC
Who is on core team?
All members understand
and agree upon goals?
Roles and responsibilities
understood?
Plan of care?
Staff availability?
Workload?
Available resources?
TeamSTEPPS®
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Team Debrief: What can we do better
next time?
Learning & Improvement
• Brief, informal information exchange and
feedback sessions
• Occur after an event or shift
• Designed to improve teamwork skills
• Designed to improve outcomes
– An accurate reconstruction of key events
– Analysis of why the event occurred
– What should be done differently next time
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Debrief Checklist
TOPIC
Communication clear?
Roles and responsibilities
understood?
Situation awareness
maintained?
Workload distribution?
Did we ask for or offer
assistance?
Were errors made or
avoided?
What went well, what
should change, what
can improve?
TeamSTEPPS®
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Why briefings and debriefings?
• Teams perform better when…
1. They have a high quality plan
2. They share the plan
3. They learn and improve over time
• Briefings and debriefings can help, but they
do not guarantee good planning.
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‘Checking the box’ ≠ mindful
engagement
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How do you get a mindful process?
• Coaching, role modeling, and feedback
– Show that the organization values this process
– Build effective communication behaviors
• ‘Closing the loop’ with outcomes of the
briefing and debriefing process
– E.g., defects identified and corrected
– Establishes the validity (and utility) of the
process
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OR BRIEFINGS AND DEBRIEFINGS
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Root Causes of Hospital
Sentinel Events
Percent of events
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Briefings and Debriefings
• Reductions in communication breakdowns and OR
delays 1
• Reductions in procedure and miscommunicationrelated disruptions and nursing time spent in core 2
• Improved communication and teamwork, feasible
given current workload 3
• Reductions in rate of any complications, SSI and
mortality 4
1 Arch
Surg. 2008;143(11): 1068-1072.
2 J Am Coll Surg. 2009;208:1115-1123.
3 Jt Comm J Qual Saf. 2009;35(8):391-397.
4 N Engl J Med. 2009;360:491-9.
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Time-Out:
The Universal Protocol
• Right patient
• Right procedure
• Right site
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Briefings are an expansion of the
Time-Out.
• Introduction of all team members by first and
last names
• Name/role of all team members written on
white board
• Timeout
• Surgeon shares goal of the operation
• Identification of issues or concerns by team
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What is most likely to go
wrong?
• Safety
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Critical steps of the procedure?
Equipment available?
Do we know how to work the equipment?
Instrumentation available?
Implant needs?
Has attending reviewed latest/final test results
for Lab and Radiology?
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What is most likely to go
wrong?
• OR Best Practices
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Antibiotics – type and re-dosing?
Beta blockers?
Glucose control?
Positioning?
Blood loss and blood availability?
DVT prophylaxis?
Warmers?
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What is most likely to go
wrong?
• Other concerns
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Special precautions?
Bed availability?
ICU bed requirement?
Staffing?
Time allotted for procedure?
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Briefing Best Practices
• All team members should be present, including the
surgical attending, and participate
• May include the patient in the discussion
• Assign a person to own the process
– Initiate the tool/checklist
• Write names of providers on a white board in the
OR
• Use a checklist modified to local context
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Create a
checklist
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Time Out: Prior to Incision
• Confirm patient identity, site and procedure
• Review perfusion plan
– Cannulation, perfusion pressure goals,
temperature, transfusion target
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Confirm sterile environment
Confirm prophylactic antibiotic administration
Confirm beta blocker administration
Discuss glycemic control goals
Confirm blood availability
Other issues
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Time Out Best Practices
• All team members present
• Use a checklist to serve as reminder
• Encourage everybody to participate
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Debriefings – before surgical attending
leaves the OR.
• What could have been done to make the
case safer or more efficient?
• Were there any issues encountered?
• What went wrong?
• Are patient ID, history number, specimen
name and laterality correctly listed on
paperwork via independent verification
• Plan for post-op transition of care
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Debriefings Best Practices
• Develop a system to review identified issues
• Review issues with with CUSP team
– Use the Investigate a Defect Tool to
• Identify contributors
• Develop a plan to prevent from happening
again
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Briefing and Debriefing
“real-time” identification of defects
Before induction of anesthesia
Before skin Incision
Before patient leaves OR
• Team developed new
form based on specific
needs
• Candid discussion with
surgeons about effective
strategies for
briefing/debriefing
• RN given protected time
to address defects and
communicate fixes
• Logbook of defects
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Debriefing Defect Logbook
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Example of Defects Addressed:
Instruments
Problem: Conflict with
colorectal set
• Increased fleet from 2
to 4
• Reorganized contents
of set so it is only pulled
for cases when it is
really needed
Impact: Instruments
available when needed
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Example of Defects Addressed:
Instruments
Revision of Laparoscopic GI Surgery Trays
54 instruments
137 instruments
Impact:
Fewer instruments to count and turnover
Save money and time
Problem: Many open instruments set up for lap
cases which were never used
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Examples of Defects Addressed:
Postings
Problem: Circulating RN and scrub could not tell from posting if an
abdominal and perineal set-up was needed for a case
•Worked with posting office to add “second setup needed” to posting sheet
and surgeon notes section in ORIMIS
Impact: RN and scrub can set up before discussing case with surgeon, fewer
delays
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Examples of Defects Addressed:
Updating DPCs
Problem: Equipment and/or
instruments not available for cases
• Decreased number of DPCs
• Removed argon from colorectal DPCs
• Decreased surgeon to surgeon
variability
• Increased accuracy
Impact: Fewer errors, less counting
required, less instruments to return at
end of case, increased efficiency
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What can we catch?
• Wrong consents
• Wrong patients
• Incorrect equipment, implants or instruments
• Increased attention to comorbidities that have a
surgical impact.
• Addressing specimens
• Addressing issues of best practice/ documentation
• Clarifying perioperative care and procedures before
they are carried out.
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What can we improve?
• Shared mental model
• Reduction in missing equipment and
distractions
– Distractions and teamwork disruptions have
been shown to be associated with errors.
• Reducing hazards
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Adapting to Local Context:
WIFM (what is in it for me)
• Needs to be meaningful to staff
– Does not make sense to have the same
checklist for all procedure types
• Mechanism to address defects identified from
‘2 question’ staff safety assessment and
audits tools
• Fixing defects is a powerful strategy to gain
buy in and encourage participation
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Lessons learned
• Reshaping a culture takes time, commitment,
energy and variety
• Briefings and Debriefings move a culture to
one where improved communication is
encouraged and expected and the hierarchy
is flattened
• Need to address WIFM
– adapt to local context so meaningful to staff
– investigate and fix defects identified
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Next steps
• How will these tools fit into your local context?
• Get input from all stakeholders
• Modify the tool to fit your needs
– Tailor to specific surgical procedure groups
– Mechanism to address defects identified from 2question staff safety assessment and audit tools
• Pilot, revise, and implement
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