1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2012 Optional SUSP Tools: Briefing Audits, Morning Huddle, and Shadowing

2. 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

3. Learning objectives Understand Briefing Audits as a method for building more effective pre-case communication. Understand the Morning Huddle process and how it can improve organization throughout the day. Understand Shadowing as a strategy for building teamwork and safety culture.

4. BRIEFINGS AND DEBRIEFINGS

5. 5 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 ®

6. 6 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 ®

7. 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 Armstrong Institute for Patient Safety and Quality 7

8. 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 Armstrong Institute for Patient Safety and Quality 8

9. Auditing briefing practices 1.Develop / adapt an auditing tool 2.Train observers 3.Collect data 4.Provide feedback

10. Develop / Adapt 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? –E.g., developing contingency plans Are these reflected in your auditing tool? –Take and modify ours, or others in the literature

11. Example briefing audit tool Briefing logistics Briefing basics Specific content Participation

12. Train observers 1.Select observers –Who has time? Who has interest? –How many do you need (depends on the boundaries you set)? 2.Educate on the tool –Walk through the items and explain anything that confuses the observers 3.Conduct a dry run –Score a briefing together, compare, and discuss any inconsistencies (you can use videos for this if you have them).

13. Our experience training observers We used a wide range of observers –Medical students, RNs, residents, fellows, psychologists We achieved high reliability with little time spent training –Sections with more explicit items were easier to obtain higher reliability (mean kappa across 19 cases) Briefing basics, kappa =.847 Specific content, kappa =.820 Briefing participation, kappa =.569

14. 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

15. Briefing Basics

16. Specific Briefing Content

17. Participation – Pausing other tasks

18. Participation—Contributing to briefing discussion

19. Provide feedback Present data to stakeholders –CUSP team and other staff meetings –Charts displayed in common areas Use data to… –Revise / refine briefing expectations (policies, processes, checklists) –Coach and reinforce behaviors

20. PRE-OPERATIVE DAILY HUDDLE Armstrong Institute for Patient Safety and Quality 20

21. 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 21

22. 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 22

23. 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 23

24. 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 Armstrong Institute for Patient Safety and Quality 24

25. 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 25

26. Huddle Process Armstrong Institute for Patient Safety and Quality 26 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.)

27. SHADOWING

28. Why Do We Need to Shadow? To gain perspective of the other providers –Practice –Responsibilities –Work environment To identify issues that affect teamwork and communication that may impact patient care, patient care delivery and outcomes 28

29. Who should have this experience? Patient care areas as part of the Comprehensive Unit Based Safety Program (CUSP) Staff involved in the delivery of patient care in units where culture score indicate a poor score in teamwork and safety When there is a difference of > 20% in culture scores between provider types As part of orientation to a new unit Units with little collaboration between disciplines 29

30. How To? Review the tool prior to your shadowing experience Follow your fellow worker through their daily activities. Review your list of communication and teamwork problems Discuss with your fellow worker Make a plan for resolution 30

31. Review the Tool Set up with questions and prompts for the personnel using it. You should make changes that are specific to your unit! 31

32. Section 1: Section 1: Were any health care workers difficult to approach? Things to think about: –How did that impact the health care worker you followed? obtained an order, ignored etc. –What was the final outcome for the patient? delay in care, etc. 32

33. Section 2: Section 2: Did one provider get approached more often for patient issues? Things to think about: –Was it because another health care provider was difficult to work with? 33

34. Section 3-5 Did you observe an error in transcription of orders by the provider you followed? Did you observe an error in the interpretation or delivery of an order? Were patient problems identified quickly? 34

35. Planning for improvement Specific RecommendationsActions taken 35 What will you do differently in your clinical practice?What will you do differently in your clinical practice? What would you recommend to improve teamwork and communicationWhat would you recommend to improve teamwork and communication

36. 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

37. Questions?