1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Briefings and Debriefings Elizabeth Martinez, MD, MHS Michael Rosen, PhD

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 Armstrong Institute for Patient Safety and Quality 3

4. THE BASICS OF BRIEFINGS AND DEBRIEFINGS Armstrong Institute for Patient Safety and Quality 4

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 5

6. 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. Situation Awareness: An Overview 6

7. 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

8. 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) Armstrong Institute for Patient Safety and Quality 8

9. 9 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 ®

10. 10 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

11. 11 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 ®

12. It isn’t just about the checklist: Safety Culture and Improvement Quality & Safety Intervention Patient Outcomes Safety Culture Safety culture moderates the effectiveness of safety and quality improvement efforts –Safety climate scores correlated with the degree of reduction in mortality and morbidity achieved in the implementation of a surgical checklist (r =.71, p <.05) Haynes et al., 2011

13. 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 13

14. 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 14

15. OR BRIEFINGS AND DEBRIEFINGS Armstrong Institute for Patient Safety and Quality 15

16. The Problem Poor communication and teamwork among members of the OR team can result in patient harm –Complexity –Cognitive workload –Shared mental model –Hierarchy Use of OR Briefings have been shown to reduce breakdowns in teamwork and communication and improve outcomes Armstrong Institute for Patient Safety and Quality 16 Haynes AB, et al. N Engl J Med 2009; 360(5):491 Henrickson SE, et al. J Am Coll Surg 2009; 208(6):1115

17. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Why focus on surgery?

18. Root Causes of Hospital Sentinel Events Percent of events

19. What are Briefings and Debriefings? Points in time for team discussions Briefing occurs before the case starts Debriefing occurs at the end of the case What we would want if we were the patient? Focus on continuously improving safety

20. Purpose of Briefing, Time Out and Debriefing Tool To provide a structured approach to OR team briefs, time outs and debriefs: –Enhances communication –Allows for final verifications of the patient, procedure and plan –Identify areas for improvement To allow all team members to pause before and after the procedure. Armstrong Institute for Patient Safety and Quality 20

21. Who Should Use this Tool? ALL OR Team members –Surgical attending and surgical staff –OR nursing –Anesthesiologists –Perfusionists –Technologists –Anybody who will be participating in the intraop care Armstrong Institute for Patient Safety and Quality 21

22. How to Use this Tool Complete this tool daily for each surgical case –Briefing: Prior to bringing the patient into the room –Time Out: Just prior to incision –Debriefing: at the completion of the case, prior to the attending surgeon leaving the room Armstrong Institute for Patient Safety and Quality 22

23. Time-Out: The Universal Protocol Right patient Right procedure Right site Armstrong Institute for Patient Safety and Quality 23

24. 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 Armstrong Institute for Patient Safety and Quality 24

25. 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?

26. 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?

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

28. Briefing Best Practices Should be performed before the patient enters the OR 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 Armstrong Institute for Patient Safety and Quality 28

29. Create a checklist

30. Modify a checklist Armstrong Institute for Patient Safety and Quality 30

31. Briefing Tool/Checklist Serves as a reminder to address the key issues –Cognitive workload –Complexity of patients Meant to start a conversation Armstrong Institute for Patient Safety and Quality 31

32. 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 Armstrong Institute for Patient Safety and Quality 32

33. Time Out Best Practices All team members present Use a checklist to serve as reminder Encourage everybody to participate Armstrong Institute for Patient Safety and Quality 33

34. 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

35. 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 Armstrong Institute for Patient Safety and Quality 35

36. 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. 36

37. To improve safety…. The individuals on the team must recognize they are not in separate, unrelated roles. The focus must be on big picture – not on isolated tasks. The team must pause before the procedure to have a conversation.

38. 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.

39. 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 Armstrong Institute for Patient Safety and Quality 39

40. Lessons learned Reshaping a culture takes time, commitment, energy and variety Surgeons are critical to the success A checklist is key to changing behavior Briefings and Debriefings move a culture to one where improved communication is encouraged and expected and the hierarchy is flattened Communication, through Briefing and Debriefing, minimizes harm

41. SUMMARY COMMENTS Armstrong Institute for Patient Safety and Quality 41

42. 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 42

43. 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 43

44. 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 –OR briefings and Time out –OR Debriefings

45. 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 Armstrong Institute for Patient Safety and Quality 45