We’ve long been strong advocates of using pre-op “huddles” (also known as preoperative briefings) and post-op debriefings as patient safety tools. And don’t forget: huddles are not just for the OR! 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. Such huddles have benefits far beyond just remembering things that need to be done. 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.
Preoperative briefings 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”).
Checklists have been utilized more often for the preoperative briefings or huddles than for postop debriefings. We previously noted a study by Lingard et al (Lingard 2008) that used a checklist to structure short team briefings and documented reduction in the number of communication failures. Another group (Paull 2010) demonstrated that implementation of preoperative checklist-driven briefings was associated with increased compliance with antibiotic prophylaxis and DVT prophylaxis. Our April 2012 What’s New in the Patient Safety World column “Operating Room Briefings and Debriefings” highlighted a study (Bandari 2012) that demonstrated how structured tools for OR briefings and debriefings can identify a whole host of patient safety issues. The online version of the article provides copies of the tools used. Our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” discussed an article by Nundy and colleagues at Johns Hopkins (Nundy 2008) that found a very simple format for pre-operative briefings led to a 31% reduction in unexpected delays in the OR and a 19% reduction in communication breakdowns that lead to delays. Other examples of 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.
Now the patient safety group at Johns Hopkins (Fabian 2013) has developed a tool to audit preoperative briefings and finds something we have also encountered: any checklist for the pre-op huddle should be customized for the particular service in which it is being utilized.
Their tool was developed with 4 domains: briefing logistics, briefing basics, specific briefing content, and briefing participation. The audits with the tool showed wide variation across surgical services in both content of the briefings and participation in the briefings. They conclude that the variation across service lines suggests the need for service-specific customization of the briefing tool in surgery.
We often implement interventions that make sense and have been demonstrated to improve outcomes but then we neglect to ensure that the intervention is being used and actually working. The pre-op briefing is one such intervention. In our July 31, 2012 Patient Safety Tip of the Week “Surgical Case Duration and Miscommunications” we noted an article (Gillespie 2012) on factors involved in prolonging surgery. They noted that preoperative briefings occurred in only 12.5% of cases, despite that practice having been “mandated” at the study hospital.
The tool in the current study from Hopkins is a practical way to audit your briefing implementation.
In our April 2012 What’s New in the Patient Safety World column “Operating Room Briefings and Debriefings” we listed many of the issues that might be discussed in a pre-op briefing/huddle. The pre-op briefing should be kept as simple as possible. Anticipate things and try to discuss the most serious things that might happen, but don’t make the process so complex and long that team members lose their attention. A typical pre-op huddle or briefing ordinarily takes no more than 3-4 minutes. We’ve found that simple checklists help the team complete those briefings. But we also noted that checklists that are too complicated are not good. We do have a tendency to add too many things to the checklists. Generally you should keep checklists to fewer than 10 items. Checklists should also be reviewed and revised as needed. Items that are not providing useful information can be deleted.
So don’t just “mandate” pre-op briefings. Make sure they are useful to the services you design them for, that they are used, and that they improve care.
See our prior columns on huddles, briefings, and debriefings:
· April 9, 2007 “Make Your Surgical Timeouts More Useful”
· May 22, 2007 “More on TeamSTEPPS™”
· December 9, 2008 “Huddles in Healthcare”
· March 10, 2009 “Prolonged Surgical Duration and Time Awareness”
· January 11, 2011 “NPSA (UK) ‘How to Guide’: Five Steps to Safer Surgery”
· March 2009 “Surgical Team Training”
· April 2012 “Operating Room Briefings and Debriefings”
· July 31, 2012 “Surgical Case Duration and Miscommunications”
Lingard L, Regehr G, Orser B, et al. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17
Paull DE, Mazzia LM, Wood SD, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. Am J Surg 2010; 200(5): 620-623
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
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
NHS Patient Safety First. video demonstrating sample pre-op briefings
NHS Patient Safety First. Quick guide to briefing and debriefing.
Veterans Health Administration. Preoperative Briefing Guide for Use in the Operating Room.
Veterans Health Administration. Postoperative Briefing Guide for Use in the Operating Room.
Veterans Health Administration. Preoperative Briefing Video.
Fabian M. Johnston FM, Tergas AI, Bennett JL, et al. Measuring Briefing and Checklist Compliance in Surgery: A Tool for Quality Improvement. American Journal of Medical Quality 2013; first published on November 22, 2013 as doi:10.1177/1062860613509402
Gillespie BM, Chaboyer W, Fairweather N. Factors that influence the expected length of operation: results of a prospective study. BMJ Qual Saf 2012; 21(1): 3-12 Published Online First: 14 October 2011 doi:10.1136/bmjqs-2011-000169
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