1. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 1 DRAFT Pending AHRQ Final Review Auditing your Briefings and Debriefings Process Dr. Michael Rosen, Ph.D. CUSP FOR SAFE SURGERY: SURGICAL UNIT-BASED SAFETY PROGRAM (SUSP)

2. What is your current role? Surgeon Quality improvement practitioner Infection preventionist OR nurse OR technician Anesthesiologist OR manager Educator Other 2 Polling Question

3. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 3 Learning Objectives Re-cap the briefings and debriefings process. Adapt a briefing and debriefing audit tool for your OR. Collect data on participation in OR briefings and debriefings. Provide feedback to OR staff and stakeholders.

4. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 4 Recapping Our Approach Comprehensive Unit- based Safety Program (CUSP) 1.Educate staff on the science of safety 2.Identify defects 3.Partner with a senior executive 4.Learn from defects 5.Improve teamwork and communication 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

5. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 5 Why Briefings and Debriefings? Teams perform better when they… 1.Have a high quality plan 2.Share that plan 3.Learn and improve over time Briefings and debriefings can help, but they do not guarantee good planning. Checking the boxMindful engagement ≠

6. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 6 Briefings and Debriefings Reduce communication breakdowns and OR delays 1 Reduce procedure and miscommunication-related disruptions and nursing time spent in core 2 Improve communication and teamwork, feasible given current workload 3 Reduce rate of complications, SSI and mortality 4

7. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 7 Auditing Briefing Practices 1.Develop / adapt an auditing tool 2.Train observers 3.Collect data 4.Provide feedback

8. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 8 Developing a Briefing Audit Tool What are the local expectations for briefings? – What is the policy? – What forms/structures are supposed to be in place? What are best practices outside of current expectations? – Developing contingency plans Are these reflected in your auditing tool? – Modify ours to fit your local needs – Modify other briefing tools in the literature

9. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 9 Example briefing audit tool 5 Briefing logistics Briefing basics Specific content Participation

10. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 10 Train Observers 1.Select observers – Who has time? Who has interest? – How many do you need? 2.Educate on the tool – Walk through the tool with explanations – Explain anything that confuses the observers 3.Conduct a dry run – Score a briefing and discuss any inconsistencies – Use videos if you have them

11. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 11 Our Experience Training Observers We used a wide range of observers – Medical students, RNs, residents, fellows, psychologists We achieved high reliability with minimal training Sections with more explicit items were easier to obtain higher reliability (mean kappa across 19 cases) – Briefing basicskappa = 0.847 – Specific contentkappa = 0.820 – Briefing participationkappa = 0.569

12. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 12 Collect Data Set your boundaries – Specific department or service line? Create a sampling strategy – Given the boundaries you set, and the resources you have, what number of observations should you target? – What’s the best way to track observations? By intact team? By surgeon? Define your process roles and responsibilities – Schedule for observations – Data entry

13. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 13 Briefing Basics

14. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 14 Specific Briefing Content

15. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 15 Participation: Pausing Other Tasks

16. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 16 Participation: Contributing To Briefing Discussion

17. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 17 Provide Feedback Present data to stakeholders – Share at CUSP team and other staff meetings – Display charts in common areas Use data to improve briefings – Coach and reinforce behaviors – Revise and refine expectations Policies Processes Checklists

18. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 18 SUSP Website Resources https://armstrongresearch.hopkinsmedicine.org/susp/cusp/resources.aspx Find a copy of the auditing tool on our website Look for Module 12

19. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 19 References 1.Nundy S, Mukherjee A, Sexton JB et al. Impact of preoperative briefings on operating room delays: A preliminary report. Arch Surg 2008; 143(11):1068-1072. 2.Henrickson SE, Wadhera RK, Elbardissi AW, et al. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg 2009; 208(6):1115-1123. 3.Berenholtz SM, Schumacher K, Hayanga AJ, Simon M et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf 2009; 35(8):391-397. 4.Haynes AB, Weiser TG, Lipsitz SR, Breizat AH et al. A surgical Safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360(5)491- 499. 5.Johnston FM, Tergas AI, Bennett JL, et al. Measuring briefing and debriefing checklist compliance in surgery: A tool for quality improvement. Am J Med Qual 2013.

20. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 20 KAISER PERMANENTE HAWAII Elaine Moreno, MSN, CNOR Manager, Operating Room

21. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 21 Debriefing Form Two sided form that is placed on the pt’s chart and turned in after the case PREOP The front of the form is initiated and used by the Preop RN It is a communication tool among the Periop team INTRAOP The back of the form is used by the OR RN to document debriefing comments such as what went well, good catches, and any room for improvements Verify Procedure, specimen, post op management, etc. POSTOP RN performs hand- off communication. Procedure, Meds, etc. and turns in the debriefing form to the OR front desk. FOLLOW-UP Daily OR Clerical staff inputs all debriefing comments into an excel database. The following day the OR Charge RN reviews the debriefing comments and documents any follow-up in the same excel database. Notifies OR Management for any urgent or safety matters Weekly Reviewed by the OR Charge Nurse & OR Management Follow-ups are shared with OR staff during OR Dept. huddles Monthly Reviewed in HRST – Highly Reliable Surgical Teams. Filter debriefing comments for each specialty. Debriefing results posted on Dept communication board Quarterly Shared with Regional HRST Committee

22. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 22 Examples of Debriefing Comments What went well, or Good Catches Labeling of specimen Procedure name Patient was Jehovah’s Witness Staff came in to help Consent did not match case schedule Equipment/Instrumentation needed

23. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 23 Examples of Debriefing Comments Debriefing comments: Scheduling Errors Issues identified – Incorrect procedures in the electronic scheduling system – Laterality errors – Delays, incorrect instruments, supplies were picked – Safety issue Follow-up – Met with clinic staff, surgeons – Provided education

24. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 24 Examples of Debriefing Comments Debriefing comments : X-ray Delay Issues identified: – X-ray changed process to call for a technician. – Answering machine message sent to their pager – Not responsive, with delays upsetting surgeon Follow-up: – Filtered all debriefing comments related to x-ray delay – Presented Radiology management with all comments

25. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 25 Examples of Debriefing Comments Debriefing comments: Poor Quality Disposable Light Handles Issues identified – Disposable light handles were changed – Surgeons / staff expressed concern for quality and an increased likelihood for contamination Follow-up – Contacted vendor – Changed product

26. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 26 Examples of Debriefing Comments Debriefing comments: Instrument tray problem Issues identified: – Count sheet did not match number of instruments in tray – Increase possibility of instrument count error Follow-up: – Working with Sterile Processing Management regarding instrument discrepancies – Providing education to SPD staff from Specialty Team Leads

27. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 27 Examples of Debriefing Comments Debriefing comments: Preference Card not updated Issues identified: – Delay in case – Incorrect supply / instrument Follow-up: – OR Charge Nurse assigned follow-up to Specialty Team Lead

28. DRAFT Pending AHRQ Final Review Auditing: Briefings & Debriefings 28 Kaiser Permanente Hawaii Questions