Patient Safety Tip of the Week
July 22, 2014
More on Operating Room
Briefings and Debriefings
When we work on improving surgical safety and OR efficiency
one of the first things we look at is whether the organization is doing briefings and debriefings. Preoperative briefings (sometimes called “huddles”)
and postoperative debriefings are tools we have strongly recommended since we
first began talking about the TeamSTEPPS™ training program back in 2007 (see our our May 22, 2007 Patient Safety Tip of the Week “More
on TeamSTEPPS™” and our March 2009 What’s New in
the Patient Safety World column “Surgical
Team Training”). Briefings and debriefings are also core components of many
of the crew resource management programs such as the VA’s Medical Team Training
Program (see our January 11, 2011
Patient Safety Tip of the Week “NPSA
(UK) ‘How to Guide’: Five Steps to Safer Surgery”).
Our April 2012 What’s New in the Patient Safety World column “Operating Room Briefings and Debriefings” focused on structuring OR briefings and debriefings and use of tools such as checklists to facilitate these. Now a new study from Johns Hopkins (Hicks 2014) provides further evidence of successful implementation of OR briefings and debriefings and emphasizes some key points that we always stress:
(1) though standardization of briefings is helpful, the briefings must be customized for the service(s) and disciplines involved in the surgery
(2) you have to have a culture of safety in order to be successful with such programs
(3) you have to demonstrate that action is taken on issues identified at the debriefings
Hicks and colleagues used their OR CUSP (Comprehensive Unit-Based Safety Program) to develop and implement OR briefings and debriefings tailored for colorectal surgery. In our own experience the patient safety and quality improvement projects that are most successful are those done in relatively small settings where the key participants all know each other and work closely together as affinity groups. CUSP’s are prime examples of such affinity groups. We discussed CUSP’s in our March 2011 What’s New in the Patient Safety World column “Michigan ICU Collaborative Wins Big” and referred readers to Pronovost 2006 and Timmel 2010 for good descriptions of the CUSP model. The CUSP model is also nicely described in Peter Pronovost’s book “Safe Patients, Smart Hospitals” (see our July 6, 2010 Patient Safety Tip of the Week “Book Reviews: Pronovost and Gawande”).
Through their briefing and debriefings their colorectal team was able to identify and improve several aspects of patient care. They better identified which patients needed steroids prior to surgery and they developed better ways to identify and separate out tools from the “dirty” parts of procedures to help improve surgical site infection rates. Also, their CUSP identified an issue with availability of interpreter services for patients not speaking English and developed a system to ensure the interpreter appointments the day prior to surgery.
One vital thing they did was to assign a frontline nurse to spend 4 to 6 hours a week addressing defects that were revealed during the briefings and debriefings and provide feedback to all parties that those defects were fixed. Nothing can kill a debriefing program faster than failure to fix those things you found wrong at these debriefings. Fortunately at Hopkins the OR management and hospital leadership provide the resources necessary to fix such issues.
Hicks and colleagues
describe another phenomenon we see all too often at hospitals when briefings
and debriefings are implemented: they are often nurse-driven in the beginning
and do not become fully successful until there is buy-in from surgery and
anesthesiology leadership.
The Hicks article provides examples of their briefing and debriefing tools and checklists. Other examples of such checklists for the preoperative briefings may be found on either the NHS Patient Safety First website or the VA website. Video examples of preoperative briefings may also be found at the NHS website or the VA website. The online version of a study (Bandari 2012) we highlighted in our April 2012 What’s New in the Patient Safety World column “Operating Room Briefings and Debriefings” also provides copies of the tools they used.
The Hicks article also discusses the need to take into account the workflows of all the participants so they can all be freed up at the same time to convene a pre-op briefing.
Some of the issues we’ve previously pointed out that might be discussed in a pre-op briefing/huddle are:
- Do we have all the necessary equipment? Implants? X-rays? Records?
- Consent complete and correct?
- Is a conversion to open procedure likely?
- What kind of complications might we anticipate?
- If the patient was previously on beta blockers, have they been given?
- Is this a high risk case for surgical fire?
- Will it be a long surgery?
- If so, will we need to reposition patient?
- If so, will we need DVT prophylaxis?
- If so, will additional doses of prophylactic antibiotics be needed?
- If so, will breaks or change of team members occur?
- If so, will we need to ease up on traction temporarily?
- If so, how will we be reminded to do all these things?
- Will there be a surgical specimen for pathology?
- Is a second timeout going to be needed (eg. multiple procedures or multiple surgical teams)?
But it’s very important not to make the process too complicated. Your pre-op briefing should probably take no more than about 2-3 minutes. Be sure to customize them. A briefing for an orthopedic surgery case is likely to be significantly different than one for a gynecological procedure.
In debriefings you are basically asking “What went well?”, “What didn’t go well?” and “What could we do better next time?”. You’ll often identify the need to fix broken equipment or ensure the availability of appropriate backup instruments. Sometimes it’s something simple like tray set-ups or equipment set-ups that interfered with the surgeon’s movements during the procedure. But, again, be sure that someone follows up on issues identified and communicates back to the group when they are fixed. Also, make sure you identify at the debriefing any problems you had with team communication during the procedure.
A structured debriefing tool may also be useful. An example of one such tool used at Florida’s Memorial Health System was published recently in the Anesthesia Patient Safety Foundation (APSF) Newsletter (Marks 2014). At Memorial the tool records action items identified at the debriefing. The circulator is the “owner” who is responsible for referring any action items identified to the appropriate person for followup. Corrective action on those identified issues usually takes place within 12-48 hours. They also recommend that a list of the action items and their resolution status be sent to hospital administration on a weekly or monthly basis. (Note that the Marks paper also has some excellent examples of issues identified at debriefings and notes how physician satisfaction improved considerably after implementation of debriefings, even among those surgeons and anesthesiologists who were originally concerned that debriefings would add too much time to procedures).
Importantly, the mere performance of the briefings and debriefings fosters a sense of belonging to teams, empowerment for all members, and better communication. These lead not only to a culture of safety but they also significantly improve job satisfaction for all involved.
Our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” also discussed how huddles and briefings can be useful in a variety of healthcare situations, not just the preoperative one.
Some of our prior
articles on OR briefings and debriefings:
- May 22, 2007 “More
on TeamSTEPPS™”
- December 9, 2008 “Huddles
in Healthcare”
- March 2009 “Surgical
Team Training”
- January 11, 2011 “NPSA
(UK) ‘How to Guide’: Five Steps to Safer Surgery”).
- April 2012 “Operating
Room Briefings and Debriefings”
- July 31, 2012 “Surgical
Case Duration and Miscommunications”
- January 2014 “A
Tool to Assess Pre-op Briefings”
References:
Hicks CW, Rosen M, Hobson DB, et al. Improving Safety and Quality of Care With Enhanced Teamwork Through Operating Room Briefings. JAMA Surg 2014; Published online July 09, 2014. doi:10.1001/jamasurg.2014.172
http://archsurg.jamanetwork.com/article.aspx?articleid=1886241
Pronovost PJ, King J, Holzmueller CG, et al. A Web-based Tool for the Comprehensive Unit-based Safety Program (CUSP). Joint Commission Journal on Quality and Patient Safety 2006; 32(3): 119-129
http://www.ingentaconnect.com/content/jcaho/jcjqs/2006/00000032/00000003/art00001
Timmel J, Kent PS, Holzmueller CG, et al. Impact of the Comprehensive Unit-Based Safety Program (CUSP) on Safety Culture in a Surgical Inpatient Unit.
Joint Commission Journal on Quality and Patient Safety 2010; 36(6): 252-260
http://psnet.ahrq.gov/public/Timmel-JCJQPS-2010-18221.pdf
Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. Hudson Street Press 2010
NHS Patient Safety First. video demonstrating sample pre-op briefings
http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/Perioperativecare/briefings/
NHS Patient Safety First. Quick guide to briefing and debriefing.
Veterans Health Administration. Preoperative Briefing Guide for Use in the Operating Room.
http://www.patientsafety.gov/mtt/VHAPreopBrief.pdf
Veterans Health Administration. Postoperative Briefing Guide for Use in the Operating Room.
http://www.patientsafety.gov/mtt/VHAPostopBrief.pdf
Veterans Health Administration. Preoperative Briefing Video.
http://www.patientsafety.gov/mtt/PreopBriefing.asx
Bandari J, Schumacher K, Simon M, et al. Surfacing Safety Hazards Using Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center. The Joint Commission Journal on Quality and Patient Safety 2012; 38(4): 154-160
http://www.ingentaconnect.com/content/jcaho/jcjqs/2012/00000038/00000004/art00002
Marks SW, Loskove J, Greenfield A, et al. Surgical Team Debriefing and Follow-Up: Creating an Efficient, Positive Operating Room Environment to Improve Patient Safety. Experience from the Memorial Healthcare System, Florida. APSF Newsletter 2014; 29(1): 7-12 June 2014
http://www.apsf.org/newsletters/pdf/spring2014.pdf
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