Morning Briefings and Huddles Elizabeth Martinez, MD, MHS Michael Rosen, PhD

Comprehensive Unit-based Safety Program (CUSP) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Pre-Operative Daily Huddle (OR) Morning Briefing (ICU and Floor)

Armstrong Institute for Patient Safety and Quality Learning Objectives Understand the fundamentals of briefings in teams Understand the purpose of the CUSP daily briefing tools Understand how to implement these tools in your area Pre-operative daily huddle in the Operating Room Morning briefing in the ICU and Floor Armstrong Institute for Patient Safety and Quality

THE BASICS OF BRIEFINGS Armstrong Institute for Patient Safety and Quality

Situation Awareness: An Overview Members of the team have an understanding of “what’s going on” and “what is likely to happen next.” Teams are alert to developing situations, sensitive to cues and aware of their implications. We have been lagging behind other risk averse industries. We have borrowed. Interpreting cues- change in patient, problem that exists that may require an intervention or decision.- YOU must appreciate the cues significance Based on knowledge and experience from similar situations We will call these yellow flags because they indicate caution 5

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: Maps out the plan of care Identifies roles and responsibilities for each team member Heightens awareness of the situation Allows the team to plan for the unexpected 5. Allows team members’ needs and expectations to be met Briefings help us to better: 1. In cases where there is time to prepare, it lets us Map out a plan of care 2. Allows the team to learn names, assigned and responsibilities. 2. Monitor a situation and raise flags, as appropriate 3. Ensure each other’s needs and expectations are met In the end, we anticipate briefings will help us have a shared mental model, develop contingency plan and use our clinical knowledge to plan for the best care delivery. 6

Armstrong Institute for Patient Safety and Quality 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 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) Armstrong Institute for Patient Safety and Quality

When to Conduct Briefings Beginning of the day - Morning Briefing Prior to any procedure in any setting Situational – change in patient status results in deviation from plan of care Reporting-off-breaks, change of shift When To Brief Start of the day Appendix I in CUSP toolkit Prior to a procedure On the spot / As the situation changes Hand-offs (e.g., breaks, shift change, continuum) For those of you who have teamStepps training you might have noted that they have taken the briefing process, which is what this is and given them names for specific. I for instance a situational change you might call for a team huddle, still a briefing process in which you gather information about your patient, tests etc and report out to the team to decide on a plan of care. SBAR is a type of briefing designed to use on nuclear naval subs and they realized they needed structured briefing, Situation, Background, Assessment , Recommendation. 8

PRE-OPERATIVE DAILY HUDDLE FOR THE OPERATING ROOM Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality The Problem Scheduling surgical procedures is often complicated by: unanticipated problems and obstacles poor communication among anesthesiologists, surgeons, resident/CRNA colleagues and nurses This inefficiency in patient care delivery wastes patient and provider’s time and increases stress for both parties Armstrong Institute for Patient Safety and Quality

What is a Pre-Op Daily Huddle? A dialogue between 2 or more people using concise and relevant information to promote effective communication prior to beginning patient procedures in the operating room suites An opportunity for all participants to voice concerns and address issues that will affect the quality of patient care delivery and patient flow Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Purpose of Tool To provide a structured process to assist the anesthesia coordinator and charge nurses in: anticipating potential problems during the day increasing efficiency of patient flow To allow the anesthesiology and OR nursing coordinators to readjust the OR schedule to ensure efficient and timely flow of patient care Armstrong Institute for Patient Safety and Quality

Who Should Use this Tool? Anesthesiologist/OR coordinators who make staff assignments and plan for patient flow within the Operating Room Suites OR Nurse Coordinators/Charge nurses who make staff assignments and are responsible for patient needs being met ICU staff who use the OR schedule to triage ICU bed availability, as well as identify other operations not posted for an ICU bed that may require one Ideally the coordinators from nursing, surgery and anesthesia will plan for the pre-op daily huddle the night before, using copies of the same OR schedule. Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality How to Use this Tool Complete this tool daily during a meeting between the Anesthesiologist OR coordinator and the OR Nursing Coordinator Can be completed in part the night before and finished the next morning and/or could be used prior to the start of the first morning case Major issues that involve significant delays/cancellations are communicated directly to the appropriate attending surgeon or other appropriate staff members no later than 07:00 by the Anesthesiologist OR coordinator Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Huddle Process I What happened today, (last evening, overnight if applicable) that I need to know about? II Anesthesiology and OR Coordinators should meet with the Nursing Coordinator to plan the day and review the schedule together. Review the day schedule for any changes, cancellations, or add-on cases. Are there any concerns after reviewing the OR schedule? III Do you anticipate any potential defects or risks during the day? If so, how can you reduce these risks? (May be completed at the beginning or end of the day.) Armstrong Institute for Patient Safety and Quality

THE MORNING BRIEFING FOR ICU AND FLOOR SETTINGS Armstrong Institute for Patient Safety and Quality

Who Participates The Physician doing rounds who is responsible for the ICU patients that day The Night Charge Nurse The Day Charge Nurse This will vary depending on the type of unit. 17

Morning Briefing Process Three simple questions: What happened overnight that I need to know about? Where should I begin rounds? Do you anticipate any potential defects in the day? The answers are important and potentially could impact Each member of your team and the patients under your care. 18

1. What Happened Overnight That I Need to Know About? You should be thinking about… Was there adequate coverage? Were there any equipment issues? Were new cases posted to the ICU? Were there unexpected changes in patient acuity? Were there any adverse events? Armstrong Institute for Patient Safety and Quality

2. Where Should Rounds Begin? Is there a patient who requires my immediate attention secondary to acuity? Which patients do you believe will be transferring out of the unit today? Who has discharge orders written? You might decide to start with the patient who is most ill and proceed based on patient acuity Which patients will be transferring out? Checking to see if they meet criteria and finish implementing any therapies, changing lines etc. Who has transfer orders? The patient with orders may rise up the hierarchy in who is rounded on because if they are stable they may be your first patient’ out and your first open bed- Nursing staff can be updated on any new admission or that they will potentially take the next admission 20

As you continue planning rounds How many admissions are planned today? What time is the first admission? How many open beds do we have? Are there any patients having problems on an inpatient unit? In this way everyone is on the same page- you are gaining and understanding of the how the day is evolving, what you need to plan for, whom you need to inform of changes in patient assignments. Potential patients that may need ICU care that are not planned. 21

3. Do You Anticipate Any Potential Defects in the Day? Patient scheduling Equipment availability/ problems Outside Patient testing/Road trips Physician or nurse staffing Provider skill mix Defects, problems, glitches to smoothly sailing through your day. 22

When You Identify Defects / Problems Want to assign a person to the issue - have them follow up Identify actions taken to meet any patient or unit needs Report back to the staff what those actions were or will be If ongoing - continue to report it during morning briefing until it is resolved or alternatively use Appendix E Status of Safety Issues. 23

Status of Safety Issues (Cusp Manual, Appendix E) Unit:___________________________________ New and Ongoing Date Safety Issue Contact Status Goal Completed Date Safety Issue Contact Status Goal Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality SUMMARY COMMENTS Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Why briefings? Teams perform better when… They have a high quality plan They share the plan Briefings can help, but they do not guarantee good planning. ‘Checking the box’ ≠ mindful engagement Armstrong Institute for Patient Safety and Quality

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 process E.g., defects identified and corrected Establishes the validity (and utility) of the process Armstrong Institute for Patient Safety and Quality

Effective communication in briefings Communication at transition points in care is often one-sided. Hesitancy to speak up and ask questions Use solution-focused assertiveness Make an opening statement to set a non-threatening tone State the concern or problem Offer a potential solution Come to agreement about the problem and solution Armstrong Institute for Patient Safety and Quality

Comprehensive Unit-based Safety Program (CUSP) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Pre-Operative Daily Huddle (OR) Morning Briefing (ICU and Floor)

Armstrong Institute for Patient Safety and Quality Next steps Think about how these tools fit into your local context Get input from all stakeholders Modify the tool to fit your needs Pilot, revise, and implement Armstrong Institute for Patient Safety and Quality