Progress and learning Implementation of Debriefing Lesley Jordan, RUH Hospitals Bath NHSFT

RUH Progress Implemented Prelist briefing and WHO SSCL 2009 Reliably 99.9 % compliance with CL 99% compliant with prelist brief Last never event in operating theatre March 2012 Struggled with debrief ! Checklist – well embedded - good engagement Prelist briefing excellent – wouldnt think about doing list without Continue to drive quality checklist and feedback QA etc BUT Debreif – struggle

Why? How did we implement checklist – what did we do? Think about doing the same to embed the debreif

Didn't’t happen overnight! Developed checklist in ONE theatre over several months Prelist Brief developed as part of testing Learnt each time we did it and adapted ( PDSAs) Only spread when it was working had team of champions that helped spread Essential measures showed the benefit list progressed smoothly finished on time Prelist brief took 5 minutes Surgeons very positive / staff very positive Think about doing that with Debrief – Test first in one theatre - think abut measures / capture benefits / time spent Act Plan Study Do What are we trying to accomplish? How will we know that our change is an improvement? What changes can we make that will result in the improvement we seek?

Next few years… Spread to all theatres BUT not full engagement Culture change needed 2011/12 - 3 INCIDENTS Presented events to all staff If checklist used well - incident prevented Presented Near misses HOW CL is used that is important – CULTURE Human factor training in teams Observational quality audits using themes to improve the quality ??Identify any ‘stories ‘ from Debrief to demonstrate importance Definitely improved culture and enagagement and continued monitorng qulaity audits has driven quality Can we identifiy any ‘stories ‘ – debrief made significant difference

Challenges with Debrief? Last few years challenging environment Frequent changes to list organisation pressures , particularly bed issues Difficult to maintain morale Focused in ensuring maintain high quality WHO SSCL Further improvements to our processes – Regular Debrief BUT more difficult than CL More difficult to demonstrate benefit At end of list when staff next priority to think about But not as easy to show benefit / practically more difficult as at end of list when staff next priority to think about Need to test and remember will take time but if persist will happen Keen for today to get practical input inot making it happen

CULTURE Debrief is next step in developing our culture Aim: Empower staff to improve everyday processes Use to promote and celebrate positive practice

First steps Planning: Identified champions Thought about difficulties : Time : “ all lists finish late” Benefit : How do we demonstrate the benefits? How do we empower staff to address issues? How do we spread good practice and celebrate? Measures? ACTIONS: Over-running lists previous 2 months – 77% lists finished on time Agreed simple draft format for debrief Test the format and gather measures to support issues above Address issues as we tested before spreading further

PDSA TESTING First PDSA: Champion surgeon tested following her list Learning: Tweaking of questions to gather positive issues Discuss timing of the debrief at Prelist Brief

PDSA TESTING Second PSDA: First PDSA: Champion surgeon tested following her list Learning: tweaking of questions to gather positive issues Discuss timing of the debrief at Prelist Brief Second PSDA: Added further information to Debrief so could gather data Testing spread to theatre where already occasionally occurring Learning : 100% occurred before 5pm 100% took < 10 minutes Form busy – Collect measures. Not the process we ultimately want Appreciated by staff and good for morale and teamwork Reasons for not occurring : Morning list over run/ staff already sorting out afternoon list / staff changed PAUSE and reflect

Progress in ‘test’ theatres Theatre 8 – Urology lists Theatre 9a – Champion surgeons lists First 3 months – are happening and are increasing More importantly – at first stages and we’ve learnt a lot ! Not going to sort all issues at once Measurement strategy and capture – now know more about what we need LEARNT A LOT!

Issues identified Related to equipment – solved at time Overbooking of lists – overruns Poor communication of list changes Patient arrived with no arm band – feedback Outcome Majority addressed at time/ feedback/ escalated Little evidence of subsequent action

Learning? Clinical Stakeholders: ‘What’s in it for me?’ ACTIONS: ‘ How is value demonstrated? ‘Where are the issues addressed and fedback “ Nice to do” – not priority ACTIONS: 1. Work on process – efficient and effective 2. Change culture so that Debrief priority Measures - Gather further information and details Positive stories ! Empower staff to action improvement Senior managerial engagement

Third PDSA Simplified Debrief format. Laminate to provide structure for debrief Measures decided Collected separate weekly measurement sheet Use white board in test theatre Names of team / Capture any issues for debrief Book for issues and outcomes

Next steps Staff survey – attitudes & ideas Quest meeting – June 5th Videos for Prelist Brief, Sign In, Time Out and Sign Out – add Debrief Include basic human factors Newsletter to share learning ? ? Summary – started tested and learnt from testing – need to work on moving process practically – white board and laminate Measures important to support spread – in particualr – benefit so actions and embedding as priority Today really value to get ideas and support