© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Briefings and Debriefings

Our Approach 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 Translating Evidence Into Practice (TRiP) 1.Summarize the evidence in a checklist 2.Identify local barriers to implementation 3.Measure performance 4.Ensure all patients get the evidence Engage Educate Execute Evaluate Reducing Surgical Site Infections Emerging Evidence Local Opportunities to Improve Collaborative learning Technical WorkAdaptive Work 2

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 3

Learning Objectives Understand the fundamentals of briefings in and debriefings teams Understand how to implement these tools in your area 4

THE BASICS OF BRIEFINGS AND DEBRIEFINGS 5

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 6

Briefing Defined 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 A Briefing is a discussion between two or more people, often a team, using succinct information pertinent to an event. 7 7

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) 8

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? Briefing Checklist TeamSTEPPS ® 9

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 10

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? Debrief Checklist TeamSTEPPS ® 11

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. –‘Checking the box’ ≠ mindful engagement 12

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 13

OR BRIEFINGS AND DEBRIEFINGS 14

Root Causes of Hospital Sentinel Events Percent of events 15

Briefings and Debriefings Reductions in communication breakdowns and OR delays 1 Reductions in procedure and miscommunication- related 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): J Am Coll Surg. 2009;208: Jt Comm J Qual Saf. 2009;35(8): N Engl J Med. 2009;360:

Time-Out: The Universal Protocol Right patient Right procedure Right site 17

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 18

What is most likely to go wrong? Safety –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? 19

What is most likely to go wrong? OR Best Practices –Antibiotics – type and re-dosing? –Beta blockers? –Glucose control? –Positioning? –Blood loss and blood availability? –DVT prophylaxis? –Warmers? 20

Other concerns – Special precautions? – Bed availability? – ICU bed requirement? – Staffing? – Time allotted for procedure? What is most likely to go wrong? 21

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 22

Create a checklist 23

Time Out: Prior to Incision Confirm patient identity, site and procedure Review perfusion plan –Cannulation, perfusion pressure goals, temperature, transfusion target Confirm sterile environment Confirm prophylactic antibiotic administration Confirm beta blocker administration Discuss glycemic control goals Confirm blood availability Other issues 24

Time Out Best Practices All team members present Use a checklist to serve as reminder Encourage everybody to participate 25

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 26

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 27

Briefing and Debriefing “real-time” identification of defects 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 28

Debriefing Defect Logbook 29

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 30

Example of Defects Addressed: Instruments 137 instruments 54 instruments Impact: Fewer instruments to count and turnover Save money and time Revision of Laparoscopic GI Surgery Trays Problem: Many open instruments set up for lap cases which were never used 31

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 32

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 33

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. 34

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 35

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 36

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 37

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 2- question staff safety assessment and audit tools Pilot, revise, and implement 38