Briefings and Debriefings in The Operating Room: The VA Experience

Briefings and Debriefings in
the Operating Room:

The VA experience
B Carney MD
Field Office, NCPS
White River Junction, VT
Military Health System – Learning Action Network (LAN) 09 JAN 2008

Introduction
• Background
• VA NCPS MTT Program
• OR Briefing/Debriefing Project
• Evaluation
• Results
• Summary
2
Lessons learned
• Implementation
• Tools
• Physician engagement
• Barriers
• Critical success factors
• Measurement
• Spread and sustainment
3
History of VA NCPS MTT program
• 2003-05: Pilots of voluntary program

• August 06: Current protocol starts
• October 06: Memorandum from USH
requires participation of all VAMCs
• January 07: National Rollout
• January 08: 54 of 130 VAMCs trained
• July 09: Last of 130 VAMCs trained
4
Design of VA NCPS MTT program
• Goal- Improve patient safety thru enhanced
communication
• Target- Surgical services (OR and ICU)
• Method- CRM communication techniques
• Components
– Preparation starting 2m before LS (Learning Session)
– Formation of implementation team (IT)
– All day Learning Session
– Project(s) that must include briefing/debriefing (B/DB)
in the operating room
5
Facility commitment
• Plan and prepare for the LS
• Organize a multidisciplinary IT
• Close OR to elective procedures on day of LS
• Implement MTT project involving B/DB for a
minimum of 1y following the LS
• Participate in quarterly follow-up interviews with
NCPS support for a minimum of 1y
• Administer the Safety Attitudes Questionnaire in
staff meetings to LS attendees 1y follow the LS
6
Preparation and planning
• Begins 2 months prior to LS

• 3 teleconferences with NCPS faculty
• Formation of multidisciplinary
Implementation Team (IT) to prepare for
the LS and MTT project
• IT must include Facility Director’s Office
Chief of Surgery, OR Nurse Manager,
Chief of Anesthesiology, NSQIP Nurse
7
Learning Session (LS)
• Full day
• Administer Safety Attitudes Questionnaire
• Methods- interactive dialogue, faculty role
play, clinical teaching films
• Content- variety of communication “tools”
• preoperative briefings
• postoperative briefings
• patient centered interdisciplinary rounds
• rules of conduct
• SBAR (situation, background, assessment,
recommendation) handoffs
8
Project(s)
• B/DB in the OR must be accomplished
• Implementation begins immediately
following LS
• For 1y after the LS
– Facility is committed to sustain
– NCPS supports and obtains follow-up data via
semi-structured quarterly interviews
– Safety Attitudes Questionnaire readministered
9
Description of B/DB
• Preoperative Briefing
– Conducted in the OR
– Immediately prior to the procedure
– With all surgical team members present
• Postoperative Debriefing
– conducted in the OR
– near the conclusion of the procedure
– all team members present
10
Implementation of Preoperative Briefing
• Who (introductions)?
– All surgical team members present
• Where?
– In the OR suite
• When?
– Prior to the induction of anesthesia
• How?
– Checklist- specialty specific briefing guide
• What (shared mental model)?
– Roles/responsibilities, situation awareness, workload, task assistance
– Resources (instrumentation, implants, blood products, imaging,
pathology specimens, personnel)
– “Stop the line”
11
Implementation of Postoperative Debriefing
• Who?
– All surgical team members
• Where?
– In the OR suite
• When?
– During surgical wound closure
– After all counts have been recorded as correct
• How?
– Checklist
– Respecting the anesthesia provider who is monitoring the patient, the
surgical team closing the wound, and the circulator performing multiple
tasks
• What?
– Roles/responsibilities, situation awareness, workload, task assistance
– Resources (instrumentation, implants, blood products, imaging,
pathology specimens, personnel)
– Went well? Didn’t go well? Lessons learned from this procedure?
12
Potential gains of B/DB
• QUALITY
– Improve performance measures (infection prevention)
• SAFETY
– Avoid undesirable events in the OR
– Fatigue management
• EFFICIENCY
– Reduce frequency of staff members leaving the room for instruments,
equipment, and other items
– Streamline surgical instrument and equipment processing
• TEAMWORK
– Promote situational learning and teaching
– Improve communication
• SATISFACTION
– Improve morale and job satisfaction in OR
13
Evaluation
• B/DB Project by facility
– Process
– Outcome
• MTT Program by NCPS (Kirkpatrick)
– REACTION
– LEARNING
– BEHAVIORAL CHANGE
– ORGANIZATIONAL IMPACT
14
B/DB project evaluation by facility
• Measure, Target, Date
• Process
– % of Surgical Service procedures with a briefing and
debriefing (50%, 4m)
• Outcome
– SIP-1 (10% increase, 6m)
– On time start - 1st case of day (20% increase, 4m)
– Beta blocker admin (25% increase, 4m)
– Glycemic control (50% increase, 4m)
– Temperature control (50% increase, 4m)
– # "WAITING TIME EVENTS" per procedure (< 2, 4m)
15
Waiting Time Events
• Instruments
• Equipment
• Radiology
• Laboratory
• Personnel
• Blood
• Medication
• Fluids
16
MTT program evaluation by NCPS
• LS assessment by participants
• Safety Attitudes Questionnaire (SAQ)
before LS and 12+m after LS
• Quarterly semi-structured interview
• NSQIP (National Surgical Quality
Improvement Program)
• All Employee Survey (AES) Job
Satisfaction Index
17
Results
• 500 providers at 10
VAMCs underwent
MTT from 0806-
1206
• They have now
completed 1y
follow-up
18
Reaction
• How did participants react to the training?
• Measured with participant LS questionnaire
Objective Questions given at the end of the learning session % reporting objective met completely or mostly
Demonstrate communication techniques proven effective in hi-risk work 81
Identify barriers to effective communication and implement strategies to remove barrier 80
Develop an action plan for a project to improve communication in their VA facility 74
Model learned communication techniques to VA facility staff and colleagues 76
19
Learning
• Has the training resulted in an increase in knowledge,
skills, or attitudes?
• Measured with SAQ
– Administered before LS and 12+m after LS
– Snapshot of safety culture thru surveys of frontline
worker perceptions
– Aviation-derived tool that has been validated
– Allows organizations to determine provider attitudes,
compare themselves to other organizations, prompt
interventions, and measure effectiveness of interventions
– Assesses provider attitude of 6 factors- teamwork
climate, safety climate, job satisfaction, stress
recognition, perceptions of management, working
conditions
20
Teamwork Climate
• Perceived quality of collaboration

• Negatively correlated with VTE, annual nurse
turnover rates, absenteeism, delays
• Example- “The Physicians And Nurses Here
Work Together As A Well-Coordinated Team.”
21
Safety Climate
• Perceptions of a strong and proactive

organizational commitment to patient safety
• Negatively correlated with rates of decubitus
ulcers, VAP, sepsis, SSI
• Higher safety climate clinical areas also have
a higher incident reporting volumes (more
trust and participation)
• Example- “I Would Feel Safe Being Treated
Here As A Patient.”
22
Job Satisfaction
• Positivity about the work experience

• If this is low, don’t tax the staff with new
quality or safety initiatives
• Example- “I Like My Job.”
23
Stress Recognition
• Acknowledgement of how performance is

influenced by stressors
• There is often an inverse relationship between
stress recognition and teamwork climate. As
the teamwork improves, individuals begin to
feel invulnerable and develop a “bring it on”
attitude that is less realistic about the
influence of fatigue, workload, and multi-
tasking.
• Example- “I Am Less Effective At Work When
Fatigued.”
24
Perceptions of Management
• Approval of managerial actions

• Unit management is usually more positive
than the hospital level
• Example- “The Levels Of Staffing In This
Clinical Area Are Sufficient To Handle The
Number Of Patients.”
25
Working Conditions
• Perceived quality of the work environment and

logistical support
• Example- “All The Necessary Information For
Diagnostic And Therapeutic Decisions Is
Routinely Available To Me.”
26
Safety Assessment Questionnaire
Working Conditions Scale

Score
Perceptions of Management
Scale Score
Stress Recognition Scale

Score
Pre-MTT
One-Year FU
Job Satisfaction Scale Score
Safety Climate Scale Score
Teamwork Climate Scale

Score
0% 20% 40% 60% 80%

Percent of Respondent Scoring 75%
or above in the Domain
Significant improvement in teamwork climate (p= 0.006),

safety climate (p= 0.03), perceptions of management (p= 0.001),
and working conditions (p< 0.001)
27
Behavioral change
• Have participants changed their behavior in
the workplace as a result of the training?
• Measured with quarterly interview
• Impact (1=no impact, 5=significant impact)
• Facilities reported high impact on patients
average, 4.4
• Facilities reported some impact on staff
average, 3.7
• Quality, Safety, Efficiency, Teamwork
28
Quality
• Improved measures (5)
– Antibiotic prophylaxis
– Also reported for other infection measures
(normothermia, hair removal), use of beta blockers in
cardiac patients, and VTE prophylaxis
• Assisted with compliance in Insuring Correct
Surgery, Resident Supervision, and Medication
Reconciliation
• Specific process improvement accomplished for
blood availability, equipment availability, and
patient positioning
29
Safety
• Wrong site surgery avoided because of the
preoperative briefing (2)
• Problem detected at preoperative briefing (4)
– 2 cases cancelled due medical contraindications
– 2 cases where lack of equipment detected
• Change in care
– patient brought to OR for cholecystectomy
– nurse noted discolored limb during briefing
– further assessment confirmed pulseless extremity
– required emergent treatment
30
Efficiency
• All 9 sites reported improvements
– Improved first case on time start (7)
– Decreased # waiting time events (4)
– Decreased length of surgical procedures (2)
• No site reported an increase in the length
of surgical procedures with the
implementation of briefings/debriefings
• Efficiency improvements attributed to
revision of instrument packs (3)
31
Teamwork
• Facilitation of a shared mental model of

the proposed procedure (4)
• “stop the line” (3)
• Additional case planning/preparation by
scrub technician (2)
32
Organizational impact
• Has the training affected process or outcome
such as increased production, improved
quality, reduced adverse events, decreased
costs, or return on investment?
• Measured with NSQIP and AEP
• NSQIP
– Risk-adjusted morbidity and mortality rates for
major noncardiac surgery
• AEP Job satisfaction index
– 9 questions answered on 5 point Likert scale
– Able to drilldown to work group and profession
33
Lessons learned
• Implementation
• Tools
• Physician engagement
• Barriers
• Critical success factors
• Measurement
• Spread and sustainment
34
Summary
• Introduction
• Background
• VA NCPS MTT Program
• OR Briefing/Debriefing Project
• Evaluation
• Results
35

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Briefings and Debriefings in

the Operating Room:

Military Health System – Learning Action Network (LAN) 09 JAN 2008

• 2003-05: Pilots of voluntary program

• Begins 2 months prior to LS

Demonstrate communication techniques proven effective in hi-risk work 81

Identify barriers to effective communication and implement strategies to remove barrier 80

Develop an action plan for a project to improve communication in their VA facility 74

Model learned communication techniques to VA facility staff and colleagues 76

• Perceived quality of collaboration

• Perceptions of a strong and proactive

• Positivity about the work experience

• Acknowledgement of how performance is

• Approval of managerial actions

• Perceived quality of the work environment and

Working Conditions Scale

Stress Recognition Scale

Safety Climate Scale Score

Teamwork Climate Scale

0% 20% 40% 60% 80%

Significant improvement in teamwork climate (p= 0.006),

• Facilitation of a shared mental model of

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