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

2. 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)

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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
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4. THE BASICS OF BRIEFINGS
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5. 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

6. 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

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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)
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8. 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

9. PRE-OPERATIVE DAILY HUDDLE FOR THE OPERATING ROOM
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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
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11. 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
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12. 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
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13. 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.
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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
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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.)
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16. THE MORNING BRIEFING FOR ICU AND FLOOR SETTINGS
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17. 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

18. 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

19. 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?
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20. 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

21. 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

22. 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

23. 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

24. 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
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SUMMARY COMMENTS
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26. 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
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27. 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
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28. 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
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29. 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)

30. 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
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