Johns Hopkins University

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Keystone Surgery OR Briefings/Debriefings

• Johns Hopkins University
• Quality and Safety Research Group
• April 2008

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Familiarity with others is a critical component
of effective teamwork

• 74 of all commercial aviation accidents happen
  on the first day of a crew flying together
• Familiarity trumps fatigue
• Highlights the importance of predictable patterns
  of behavior

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Communication Breakdowns are frequently the root
cause of undesirable outcomes
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The Johns Hopkins Comprehensive Unit-based Safety
Program (CUSP)

• Evaluate culture of safety
• Educate staff on science of safety
• Identify defects
• Senior Executive Partnership
• 5. Implement teamwork tools Learn from one
  defect per month
• 6. Evaluate culture of safety

J Patient Safety 2005 Jt Comm J Qual Saf.
200430(2)59-68. http//www.jhsph.edu/ctlt/traini
ng/patient_safety.html
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Step 5b Implement Teamwork Tools

• Briefing and Debriefing
• Morning Briefing
• Shadowing
• Culture Check Up Tool
• Team Check Up Tool

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Briefing Defined

• A briefing is a discussion between two or more
  people, often a team, using succinct information
  pertinent to an upcoming event

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Effective Briefings set the tone for the day
chaotic versus organized and efficient

• Map out the plan of care.
• Identify Roles and Responsibilities for each
  team member.
• Heightens awareness of the situation.
• Allows the team to plan for the unexpected.
• 5. Team members needs, and expectations are met.

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Preoperative Safety Briefing

• Kaiser Permanente Anaheim Medical Center
• Decreased wrong-site surgeries 3 to 0 per yr
• Increased employee satisfaction 19
• Decreased nursing turnover 16
• Improved perceptions of teamwork quality and
  safety climate

The Permanente Journal 20048(2)21- 27
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Johns Hopkins OR Briefing

• Names and Roles
• Time-Out (correct pt, side, procedure)
• What is the plan?
• Issues
• Surgical? (Bleeding, Abx, etc.)
• Anesthesia? (Comorbid dz, IV access, etc.)
• Nursing Issues? (Instruments, Special equip etc.)

Jt Comm J Qual Saf 200632(6) 351-355
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Briefing Checklist

• Have abx been given, if indicated
• Anticipated times of abx redosing
• Glycemic control / beta blockade
• Patient positioning
• Blood availability
• DVT prophylaxis
• Anticoagulation use
• Special precautions
• Are warmers used
• Form signed by nurse, anesthesia provider and
  surgeon

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Agree
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Agree
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Agree
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Agree
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Morning Briefing

• Structured communication
• Focus on safety in real time
• Integrated into routine ICU care
• Easy to use, little training, quick
• Can be adapted to other areas

Jt Comm J Qual Patient Saf. 2005 Aug31(8)476-9.
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Morning Briefing

• Charge nurse, attending/fellow at 730am
• What happened overnight?
• Adverse events, near misses, admissions and
  discharges
• Where should I begin rounds?
• high-acuity patients, patient flow
• What are your concerns regarding potential
  problems for today?
• patient scheduling, equipment availability,
  outside patient testing, staffing, and provider
  skill mix.

Jt Comm J Qual Patient Saf. 2005 Aug31(8)476-9.
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OR Morning Briefing

• What happened overnight that I need to
• know about?
• What cases ran long?
• Was there adequate coverage?
• Were there any equipment issues?
• Were there cases not posted to the ICU that
  should be?
• Was the At Risk attending called?
• Was the PACU nursing team here after 9pm?
• Were inpatients beds available?

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OR Morning Briefing

• Review daily schedule
• - Cases that should be placed on ICU hold?
• - What cases will run late that we need to
  provide coverage for?
• - Are there any cases that were cancelled?
• - Are there any cases that were or need to be
  added on?
• - Is there any case that does not look like it is
  posted well? (time, coverage)
• - How many ICU beds are open?
• - How many acute care PACU beds open?

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Debriefing Defined

• A debriefing is a discussion usually involving
  the whole team, but can be conducted in one on
  one situations, using information learned and
  issues identified in a previous event

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What a Debriefing does?

• Provides an opportunity to fine tune patient care
  delivery.
• Define and update the Roles and Responsibilities
  for each team member .
• Often identifies situations that should have made
  us aware of changing situations.
• Allows the team to express their thoughts on what
  they did well and what they thought could be
  improved upon.
• Identifies obstacles in care delivery

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Debriefings- 3 Main Questions

• Are sponge, needle, and instrument counts correct
• Is the specimen labeled correctly?
• Reflect on the case What went well? Was there
  anything that could be done differently or
  something somebody was concerned about, but
  didnt bring it up or was ignored?
• Is there a system change that could make this
  operation safer for the next patient? If so, who
  will work on making the change and what is the
  follow up date?

Jt Comm J Qual Saf 200632(7) 407-410
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Challenges

• Requires physician, nursing, and administrative
  champions
• Needs to be adapted to local context
• Celebrate cases when harm was mitigated
• Need to dedicate resources to investigate and fix
  defects identified
• This is not checking the box

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Summary

• Teamwork climate is related to clinical and
  operational outcomes
• CUSP is a structured approach to learn from
  mistakes and improve safety culture
• Briefings and debriefings are an effective
  strategy to improve teamwork and communication

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Who are we?

• 75 participating hospitals
• 48 hospitals completed readiness survey
• 27 urban, 21 rural (including 10 critical access)
• 45 community, 16 w/ residents, 3 academic
• Median bed size 172 (14 - 1000)
• Median annual surgical volume
• In-patient 2148 (34 21,500)
• Out-patient 4442 (469 15,269)

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How will be get there?

• Use collaborative model to learn together
• We should not be competing on patients safety and
  quality
• Central support from MHA for technical work
  (evidence and measures)
• Local leadership to execute
• Ohana

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Next Steps

• Complete the readiness survey
• Discuss project with OR and hospital leaders
• Decide what OR teams to start with
• Consider initial focus on 2 specialties
• Create project team (surgeon, anesthesiologists,
  nurses, administrator) meet to develop
  infrastructure select project manager plan to
  meet at least monthly
• Register for April workshop
• Develop plan for educating staff on science of
  safety and implementing CUSP

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Face to FacePreliminary Agenda

• Monday, April 28, 2008
• PreMortem Exercise
• Overview Science of Safety, CUSP, Translating
  Evidence into Practice
• Technical and Adaptive Work of Change
• Briefings and Debriefings
• Tuesday, April 29, 2008
• PreMortem Results
• Tools to Enhance Team Communication, Situational
  Awareness
• Engaging Team Members and OR Staff
• Improving OR Culture
• MSQC and KOR
• LUNCH Physician Engagement and Leadership
  Breakout
• Ensuring Data Quality
• IRB review
• Team Exercise

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Discussion