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

2. 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

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

4. 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?

5. Next few years…
Spread to all theatres BUT not full engagement Culture change needed 2011/ 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

6. 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

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

8. 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

9. 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

10. 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

11. 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!

12. 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

13. 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

14. 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

15. 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