draft pending ahrq final review auditing: briefings & debriefings 1 draft pending ahrq final...

DRAFT Pending AHRQ Final Review

Auditing: Briefings & Debriefings 1


Auditing your Briefings and Debriefings Process

Dr. Michael Rosen, Ph.D.

CUSP FOR SAFE SURGERY:SURGICAL UNIT-BASED SAFETY PROGRAM (SUSP)

What is your current role?• Surgeon• Quality improvement practitioner• Infection preventionist• OR nurse• OR technician• Anesthesiologist• OR manager• Educator• Other

2

Polling Question



Learning Objectives

• Re-cap the briefings and debriefings process.• Adapt a briefing and debriefing audit tool for

your OR.• Collect data on participation in OR briefings

and debriefings.• Provide feedback to OR staff and stakeholders.



Recapping Our ApproachComprehensive Unit- based Safety Program

(CUSP)

1. Educate staff on the science of safety

2. Identify defects

3. Partner with a senior executive

4. Learn from defects

5. Improve teamwork and communication

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 Work Adaptive Work



Why Briefings and Debriefings?

Teams perform better when they…1. Have a high quality plan2. Share that plan3. Learn and improve over time

Briefings and debriefings can help, but they do not guarantee good planning.

Checking the box Mindful engagement≠



Briefings and Debriefings

• Reduce communication breakdowns and OR delays1

• Reduce procedure and miscommunication-related disruptions and nursing time spent in core2

• Improve communication and teamwork, feasible given current workload3

• Reduce rate of complications, SSI and mortality4



Auditing Briefing Practices

1. Develop / adapt an auditing tool 2. Train observers3. Collect data4. Provide feedback



Developing 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?– Developing contingency plans

• Are these reflected in your auditing tool?– Modify ours to fit your local needs– Modify other briefing tools in the literature



Example briefing audit tool5

• Briefing logistics• Briefing basics• Specific content• Participation



Train Observers

1. Select observers– Who has time? Who has interest? – How many do you need?

2. Educate on the tool– Walk through the tool with explanations– Explain anything that confuses the observers

3. Conduct a dry run– Score a briefing and discuss any inconsistencies– Use videos if you have them



Our Experience Training Observers

• We used a wide range of observers– Medical students, RNs, residents, fellows, psychologists

• We achieved high reliability with minimal training• Sections with more explicit items were easier to

obtain higher reliability (mean kappa across 19 cases)– Briefing basics kappa = 0.847 – Specific content kappa = 0.820– Briefing participation kappa = 0.569



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



Briefing Basics

Name introduction

Role introduction

Critial goals

Contingency plans

Expectations for assertiveness

Opportunity for questions

0%10%

20%30%

40%50%

60%70%

80%90%

100%

YesNo



Specific Briefing Content

Patient

Site

ABX given

Beta blockers

Access issues

Blood availability

Glycemic control

Warmers

Intra-operative imaging (X-rays, ultrasound)

Prep application

0% 20% 40% 60% 80% 100%

YesNo



Participation:Pausing Other Tasks

Attending surgeon

Surgical Resident

Anesthesia Attending

Anesthesia CRNA

Anesthesia Resident

Circulator

Scrub

0% 20% 40% 60% 80% 100%

Not presentFails to PausePauses other tasks



Participation: Contributing To Briefing Discussion

Attending surgeon

Surgical Resident

Anesthesia Attending

Anesthesia CRNA

Anesthesia Resident

Circulator

Scrub

0% 20% 40% 60% 80% 100%

Not presentDoes not contributeContributes



Provide Feedback

• Present data to stakeholders– Share at CUSP team and other staff meetings– Display charts in common areas

• Use data to improve briefings– Coach and reinforce behaviors– Revise and refine expectations

• Policies• Processes• Checklists



SUSP Website Resources

https://armstrongresearch.hopkinsmedicine.org/susp/cusp/resources.aspxFind a copy of the auditing tool on our website

Look for Module 12

https://armstrongresearch.hopkinsmedicine.org/susp/cusp/resources.aspx



References

1. 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.

2. Henrickson SE, Wadhera RK, Elbardissi AW, et al. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg 2009; 208(6):1115-1123.

3. Berenholtz SM, Schumacher K, Hayanga AJ, Simon M et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf 2009; 35(8):391-397.

4. Haynes AB, Weiser TG, Lipsitz SR, Breizat AH et al. A surgical Safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360(5)491-499.

5. Johnston FM, Tergas AI, Bennett JL, et al. Measuring briefing and debriefing checklist compliance in surgery: A tool for quality improvement. Am J Med Qual 2013.



KAISER PERMANENTE HAWAII

Elaine Moreno, MSN, CNORManager, Operating Room



Debriefing Form Two sided form that is placed on the pt’s chart and turned in after the case

PREOPThe front of the form is initiated and used by the Preop RN

It is a communication tool among the Periop team

INTRAOPThe back of the form is used by the OR RN to document debriefing comments such as what went well, good catches, and any room for improvements

Verify Procedure, specimen, post op management, etc.

POSTOPRN performs hand-off communication.Procedure, Meds, etc. and turns in the debriefing form to the OR front desk.

FOLLOW-UPDaily• OR Clerical staff inputs all debriefing

comments into an excel database.• The following day the OR Charge

RN reviews the debriefing comments and documents any follow-up in the same excel database. Notifies OR Management for any urgent or safety matters

Weekly• Reviewed by the OR Charge Nurse &

OR Management• Follow-ups are shared with OR staff

during OR Dept. huddlesMonthly• Reviewed in HRST – Highly

Reliable Surgical Teams. Filter debriefing comments for each specialty.

• Debriefing results posted on Dept communication board

Quarterly• Shared with Regional HRST

Committee



Examples of Debriefing Comments

What went well, or Good Catches • Labeling of specimen• Procedure name• Patient was Jehovah’s Witness• Staff came in to help• Consent did not match case schedule• Equipment/Instrumentation needed




• Debriefing comments: Scheduling Errors• Issues identified – Incorrect procedures in the electronic scheduling system– Laterality errors– Delays, incorrect instruments, supplies were picked – Safety issue

• Follow-up– Met with clinic staff , surgeons– Provided education




• Debriefing comments : X-ray Delay• Issues identified: – X-ray changed process to call for a technician.– Answering machine message sent to their pager– Not responsive, with delays upsetting surgeon

• Follow-up:– Filtered all debriefing comments related to x-ray delay– Presented Radiology management with all comments




• Debriefing comments: Poor Quality Disposable Light Handles

• Issues identified – Disposable light handles were changed– Surgeons / staff expressed concern for quality and an

increased likelihood for contamination

• Follow-up– Contacted vendor– Changed product




• Debriefing comments: Instrument tray problem• Issues identified: – Count sheet did not match number of instruments in tray– Increase possibility of instrument count error

• Follow-up:– Working with Sterile Processing Management regarding

instrument discrepancies– Providing education to SPD staff from Specialty Team

Leads




• Debriefing comments: Preference Card not updated• Issues identified: – Delay in case– Incorrect supply / instrument

• Follow-up: – OR Charge Nurse assigned follow-up to Specialty Team

Lead



Kaiser Permanente Hawaii

• Questions

draft pending ahrq final review auditing: briefings & debriefings 1 draft pending ahrq final...

Documents

briefings debriefings

auditing tool

time briefings

debriefings process

auditing briefing practices

feedback slide

literature slide

briefing tools