Auditing Your Briefings and Debriefings Process: Slide Presentation

Slide 1: AHRQ Safety Program for Surgery—Implementation

Auditing Your Briefings and Debriefings Process

Slide 2: Learning Objectives

• Recap the briefings and debriefings process.
• Adapt a briefing and debriefing audit tool for your operating room.
• Collect data on participation in operating room briefings and debriefings.
• Provide feedback to operating room staff and stakeholders.

Slide 3: Recapping Our Approach

Image: Three columns presenting CUSP, Reducing SSIs, and TRIP:

ADAPTIVE WORK:

Comprehensive Unit-based Safety Program (CUSP):

Prework: Measure frontline perceptions of safety culture with HSOPS survey.

1. Educate staff on science of safety.
2. Identify defects.
3. Partner with a senior executive.
4. Learn from defects.
5. Improve teamwork and communication.

TECHNICAL WORK:

Reducing Surgical Site Infections:

1. Emerging evidence [Skin preparation, Normothermia, Glucose control, Antibiotic redosing].
2. Local opportunities to improve.
3. Collaborative learning.

Translating Research 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).

Slide 4: Why Briefings and Debriefings?

Teams perform better when they…

1. Have a high quality plan.
2. Share that plan.
3. Learn and improve over time.

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

Checking the box ≠ Mindful engagement

Slide 5: Why Briefings and Debriefings?

• Reduce communication breakdowns and operating room delays.¹
• Reduce procedure and miscommunication-related disruptions and nursing time spent in the core^.2
• Improve communication and teamwork, feasible given current workload.³
• Reduce rate of complications, surgical site infections (SSIs), and mortality.⁴

Slide 6: Auditing Briefing Practices

1. Develop or adapt an auditing tool.
2. Train observers.
3. Collect data.
4. Provide feedback.

Slide 7: Developing a Briefing Audit Tool

• What are the local expectations for briefings?
  • What is the policy?
  • What forms and structures should be in place?
• What are best practices outside of current expectations?
  • Develop contingency plans.
• Are these reflected in your auditing tool?
  • Modify tool to fit local needs.
  • Modify other briefing tools in the literature.

Slide 8: Example Briefing Audit Tool⁵

• Briefing logistics.
• Briefing basics.
• Specific content.
• Participation.

Image: Sample briefing audit tool used at The Johns Hopkins Hospital.

Slide 9: Example Briefing Audit Tool⁵

Briefing logistics:

• Who initiated briefing?
• Was anyone using a script?
• When did briefing occur?

Image: Logistics section of briefing form:

Who initiated briefing?

• Surgery attending.
• Anesthesia attending.
• Surgery resident.
• Anesthesia resident.
• Nurse.
• Anesthesia CRNA.

Was anyone using a script?

• Yes.
• No.

When did briefing occur?

• Before patient entered.
• Before induction.
• Before incision.

Slide 10: Example Briefing Audit Tool⁵

Briefing basics:

• Introduce by name? By role?
• Discuss critical goals?
• Discuss contingency plan?
• Set expectation for assertiveness?
• State explicit opportunity for questions?
• Confirm agreement?

Image: Sample form questions, with space to record Yes or No responses:

• Did all introduce themselves by name?
• Did all introduce themselves by role?
• Critical goals and steps for case discussed?
• Pertinent contingency plans discussed?
• Expectation for assertiveness set? (e.g., ‘if anyone sees any problems, please speak up’)
• Explicit opportunity for questions or concerns?
• Explicit request for confirmation before moving on (e.g., ‘is everyone OK?’)

Slide 11: Example Briefing Audit Tool⁵

Specific content:

• Did briefing cover the patient, procedure, and site information?
• Antibiotics, airway risk, allergies?
• Bleeding concerns, blood availability, and glycemic control?

Image: Sample form questions with space to record Yes or No responses:

• Patient.
• Procedure.
• Site.
• Patient consent.
• Antibiotics (ABX) given.
• ABX redosing time.
• Beta blockers.
• Airway risk.
• Access issues.
• Bleeding concerns (e.g., anticoagulant use).
• Blood availability.
• Allergies.
• Glycemic control.
• Deep vein thrombosis prophylaxis.
• Warmers.
• Lab/radiology review.
• Intra-operative imaging (X-rays, ultrasound).
• Patient positioning.
• Skin preparation application.

Slide 12: Example Briefing Audit Tool⁵

Participation by role:

• Present or physically present in room?
• Paused other tasks or not engaged in other tasks during briefing?
• Spoke up or participated in the conversation?
• What issues were raised?

Image: Participation section of briefing audit tool

Slide 13: Training Observers

1. Select observers:
   • Who has the time and interest?
   • How many observers do you need?
2. Educate on the briefing audit tool:
   • Explain the tool to observers.
   • Allow observers to ask clarifying questions.
3. Conduct a dry run:
   • Score a briefing and discuss any inconsistencies.
   • Use videos if possible.

Slide 14: Training Observers

• Select observers with a diverse range of skills:
  • Medical students.
  • Nurses.
  • Residents.
  • Fellows.
  • Psychologists.
• Can achieve high reliability with minimal training.

Image: Chart showing briefing category and Mean Kappa (n=19 cases):

• Briefing basics 0.847.
• Specific content 0.820.
• Participation 0.569.

Explicit sections obtain higher reliability scores.

Slide 15: Collect Data

• Set 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?
  • How will you track observations? By intact team? By surgeon?
• Define process roles and responsibilities:
  • Schedule observations.
  • Plan data entry.

Slide 16: Briefing Basics

Image: Bar chart with YES (blue) and NO (red). Each row, or category, sums to 100%:

• Opportunity for questions - 20% Yes.
• Expectations for assertiveness - 0% Yes.
• Contingency plans - 10% Yes.
• Critical goals - 10% Yes.
• Role introduction - 50% Yes.
• Name introduction - 40% Yes.

Slide 17: Specific Briefing Content

Image: Bar chart with YES (blue) and NO (red). Each row, or category, sums to 100%:

• Skin preparation application - 0% Yes.
• Patient positioning - 20% Yes.
• Intraoperative imaging - 10% Yes.
• Lab/radiology review - 30% Yes.
• Warmers - 30% Yes.
• Deep vein thrombosis (DVT) prophylaxis  - 100% Yes.
• Glycemic control - 40% Yes.
• Allergies - 100% Yes.
• Blood availability - 10% Yes.
• Anticoagulant use - 10% Yes.
• Access issues - 20% Yes.
• Airway risk - 20% Yes.
• Beta blockers - 40% Yes.
• Antibiotics redosing time - 0% Yes.
• Antibiotics given - 90% Yes.
• Patient consent - 60% Yes.
• Site - 70% Yes.
• Procedure - 80% Yes.
• Patient - 80% Yes.

Slide 18: Participation: Pausing Other Tasks

Image: Bar chart with NOT PRESENT (blue), and FAILS TO PAUSE  (red), and PAUSES OTHER TASKS (green). Each row, or category, sums to 100%:

• Scrub - 0% NP, 80% FP, 20% POT.
• Circulator - 0% NP, 10% FP, 90% POT.
• Anesthesia resident  - 78% NP, 0% FP, 22% POT.
• Anesthesia CRNA - 22% NP, 0% FP, 78% POT.
• Anesthesia attending - 66% NP, 12% FP, 22% POT.
• Surgical resident - 10% NP, 40% FP, 50% POT.
• Attending surgeon - 20% NP, 0% FP, 80% POT.

• Not Present = NP.
• Fails to Pause = FP.
• Pauses Other Tasks = POT.

Slide 19: Participation: Contributing to Briefing

Image: Bar chart with NOT PRESENT (blue), and DOES NOT CONTRIBUTE  (red), and CONTRIBUTES (green). Each row, or category, sums to 100%:

• Scrub - 0% NP, 90% DNC, 10% C.
• Circulator - 0% NP, 0% DNC, 100% C.
• Anesthesia resident - 78% NP, 0% DNC, 22% C.
• Anesthesia CRNA - 22% NP, 0% DNC, 78% C.
• Anesthesia attending - 68% NP, 10% DNC, 22% C.
• Surgical resident  - 10% NP, 60% DNC, 30% C.
• Attending surgeon - 0% NP, 40% DNC, 60% C.

Not Present = NP Does Not Contribute = DNC Contributes = C.

Slide 20: 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.

Slide 21: 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. PMID: 19015465.
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. PMID: 19476900.
3. Berenholtz SM, Schumacher K, Hayanga AJ, 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. PMID: 19719074.
4. Haynes AB, Weiser TG, Lipsitz SR, et al.; Safe Surgery Saves Lives Study Group. A surgical Safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360(5)491-499. PMID: 19144931.
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 2014 Nov-Dec; 29(6):491-8. Epub 2013 Nov 22. PMID: 24270170.

Slide 22: Hospital Case Study

Subtitle slide: [Hospital not identified by name or location.]

Slide 23: Debriefing: One Team’s Approach

• Two-sided form with four sections:
  • Preoperative.
  • Intraoperative.
  • Postoperative.
  • Followup.
• Placed on patient’s chart.
• Submitted at the case conclusion.

Slide 24: Debriefing Process

Image: The four categories are located in four boxes, with an arrow from one box pointing right to the next box (left to right):

PREOP

Front of the form.

• Preoperative nurse initiates.
• Primary perioperative team communication tool.

INTRAOP

Back of the form.

• Operating room nurse coordinates.
• Verify procedure, specimen, and postoperative management.
• Document debriefing comments including what went well, good catches, and improvement opportunities.

POSTOP

• Nurse-led handoff communication.
• Include procedure, medications, etc.
• Submit debriefing form to the operating room front desk.

FOLLOWUP

• Daily.
• Weekly.
• Monthly.
• Quarterly.

Slide 25: Debriefing Process

FOLLOWUP

Daily:

• Operating room clerical staff enters debriefing comments into a spreadsheet.
• Operating room charge nurse reviews the debriefing comments each day and adds followup instructions.
• Operating room charge nurse also notifies operating room management of any urgent safety matters.

Weekly:

• Operating room charge nurse and operating room management review compilation of briefing comments.
• Share followups with operating room staff during department huddles.

Monthly:

• Segment comments for each specialty and review in respective Highly Reliable Surgical Team (HRST) meetings.
• Post results on department communication board.

Quarterly:

• Share with regional HRST committee.

Slide 26: Examples of Debriefing Comments

Good catches and positive comments:

• Label of specimen.
• Correct procedure name.
• Impact of patient’s religion on care decisions.
• Staff came in to help.
• Consent did not match case schedule.
• Necessary equipment/instrumentation included.

Slide 27: Examples of Debriefing Comments

Concerns or opportunities for improvement:

• Scheduling errors.
• Radiology delay.
• Inferior disposable light handles.
• Instrument tray problem.
• Outdated preference card.

Slide 28: Examples of Debriefing Comments

Debriefing comments: Scheduling errors.

• Types of issues identified:
  • Incorrect procedures in the electronic scheduling system.
  • Laterality errors.
  • Delays, incorrect instruments, or supplies.
  • Safety issues.
• Followup:
  • Met with clinic staff and surgeons.
  • Provided additional education.

Slide 29: Examples of Debriefing Comments

Debriefing comments: Radiology delay.

• Issues identified:
  • Radiology department initiated new process to request an x-ray technician.
  • Voicemail messages not responsive enough for open surgical cases.
  • Excessive delays upset surgeon and surgical team.
• Followup:
  • Filtered all debriefing comments related to x-ray delay.
  • Presented Radiology management with all comments.
  • Modified call process to accommodate surgical needs.

Slide 30: Examples of Debriefing Comments

Debriefing comments:  Inferior disposable light handles.

• Issues identified:
  • Disposable light handles were changed.
  • Providers expressed concern for quality including an increased likelihood of contamination.
• Followup:
  • Contacted vendor.
  • Changed product.

Slide 31: Examples of Debriefing Comments

Debriefing comments:  Instrument tray problem.

• Issues identified:
  • Count sheet mismatch to number of instruments in tray.
  • Increase possibility of instrument count error.
• Followup:
  • Worked with sterile equipment management regarding instrument discrepancies.
  • Provided additional education to improve process and reduce errors in operating room.

Slide 32: Examples of Debriefing Comments

Debriefing comments: Outdated preference card.

• Issues identified:
  • Outdated preference card caused delay in case.
  • Incorrect supplies and instruments pulled.
• Followup:
  • Operating room charge nurse assigned to update preference cards.
  • Revised card system to standardize core needs by procedure with individual surgeon special requests.

Slide 33: Debriefing Process

Image: The four categories are located in four boxes, with an arrow from one box pointing right to the next box (left to right):

PREOP

Front of the form.

• Preoperative nurse initiates.
• Primary perioperative team communication tool.

INTRAOP

Back of the form.

• Operating room nurse coordinates.
• Verify procedure, specimen, and postoperative management.
• Document debriefing comments including what went well, good catches, and improvement opportunities.

POSTOP

• Nurse-led handoff communication.
• Include procedure, medications, etc.
• Submit debriefing form to the operating room front desk.

FOLLOWUP

• Daily.
• Weekly.
• Monthly.
• Quarterly.