On the CUSP: STOP BSI Improving Situational Awareness by

Conducting a Morning Briefing

Situation Awareness -- An Overview

• 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

Briefing DefinedA discussion between two or more people, often a team, using succinct information pertinent to an event.

A briefing immediately --1. Maps out the plan of care2. Identifies roles and responsibilities for each team

member3. Heightens awareness of the situation4. Allows the team to plan for the unexpected5. Allows team members’ needs and expectations to be

met

Effective Briefings

Set the tone for the day -- Chaotic versus organized and efficientEncourage participation and ownership by all team members

• Organizes thoughts regarding the procedure• Establishes competence

• Who has what skills• Who performs what• Who knows what

• Predicts what will happen later• Plans for the unexpected, including equipment,

medications, consults

When to Conduct Briefings

• Beginning of the day – Morning briefing• Prior to any procedure in any setting • Situational – Change in patient status results

in deviation from plan of care• Reporting off breaks• Shift change

Who Participates

• Physician doing rounds who is responsible for the ICU patients that day

• Night charge nurse• Day charge nurse

Morning Briefing Process

Three simple questions1. What happened overnight that I need to know

about? 2. Where should I begin rounds? 3. Do you anticipate any potential defects in the day?

What Happened Overnight That I Need to Know About?

You should ask --• Was there adequate coverage?• Were there any equipment issues?• Were new cases posted to the ICU?• Were there unexpected changes in patient acuity?• Were there any adverse events?

Where Should Rounds Begin?

You should ask --• Is there a patient who requires my immediate

attention secondary to acuity? • Which patients do you believe will be transferring

out of the unit today? • Who has discharge orders written?

As You Continue Planning Rounds

You should ask –•How many admissions are planned today?•What time is the first admission?•How many open beds do we have?•Are there any patients having problems on an inpatient unit?

Do You Anticipate Any Potential Defects in the Day?

• Patient scheduling• Equipment availability or problems• Outside patient testing or road trips• Physician or nurse staffing• Provider skill mix

When You Identify Defects or Problems

• Assign a person to the issue and 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

• Continue to report it during morning briefing until it is resolved or use Status of Safety Issues

Status of Safety Issues - CUSP

Unit:

New and OngoingDate Safety Issue Contact Status Goal

CompletedDate Safety Issue Contact Status Goal

On the CUSP:Shadowing Another Provider

Why Do We Need to Shadow?

• To gain perspective of the other providers– Practice – Responsibilities– Work environment

• To identify issues that affect teamwork and communication that may affect patient care, patient care delivery, and patient outcomes

Who Should Have This Experience?

• Patient care areas as part of CUSP• Staff involved in the delivery of patient care in units where

culture score indicate a poor score in teamwork and safety• When there is a difference of >20 percent in culture scores

between provider types • As part of orientation to a new unit• Units with little collaboration between disciplines

How To

• Review the shadowing tool prior to your shadowing experience

• Follow your health care provider through his or her daily activities.

• Review your list of communication and teamwork problems

• Discuss with the provider • Make a plan for resolution

• Set up with questions and prompts for the personnel using it

• Make changes that are specific to your unit

Review the Tool

Section 1

Were any health care providers difficult to approach?•How did that impact the health care provider you followed? (obtained an order, ignored, etc.)•What was the final outcome for the patient? (delay in care, etc.)

Section 2

Did one provider get approached more often for patient issues?•Was it because another health care provider was difficult to work with?

Sections 3-5

Did you observe an error in transcription of orders by the provider you followed?

Did you observe an error in the interpretation or delivery of an order?

Were patient problems identified quickly?

If You Were Following a Nurse

Did you observe that in a crisis or when there was an important issue, a nurse’s page or phone call was not returned quickly?

What was the outcome for this patient?

If You Were Following a Physician

What were the obstacles that a physician faced in returning calls or pages?

What other factors impacted his or her ability to see patients?

How Would You Assess

• Handoffs• Communication during a crisis• Provider skill • Staffing

Recommendations and Actions

Specific Recommendations Actions Taken

• What will you do differently in your clinical practice?

• What would you recommend to improve teamwork and communication

Our Findings

• Handoffs for 4-hour shifts not thorough, increased opportunity to forget key details as this increased the total number of people

• Physician consults usually obtained but not always read by the requesting team

• Nurse often most informed but does not always speak up

Our Findings

• Nurse is the provider most often left with patient information to pass on to another provider; few conversations from MD to MD

• Pharmacists did not realize how critical supplying Pyxis and stock drugs were

• Some providers avoided• EMR was not accessed

Our Findings

• Nurses did not realize how complicated sterile processing was; efforts made to keep trays together

• POE removed an important step; communicating to RN of stat order

• Physicians unaware of unit policies, depend on RNs to complete task

Our Findings

• Some nursing practices, such as labeling, should be used hospital wide

• Isolation policies not adhered to -- Primarily physician personnel, consults; required RNs to speak up

• Assertiveness training indicated

Discussion

• Questions?