© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2012

Optional SUSP Tools: Briefing Audits, Morning Huddle, and Shadowing

Our Approach

Comprehensive Unit based Safety

Program (CUSP)

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

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

Learning objectives

• Understand Briefing Audits as a method for building more effective pre-case communication.

• Understand the Morning Huddle process and how it can improve organization throughout the day.

• Understand Shadowing as a strategy for building teamwork and safety culture.

BRIEFINGS AND DEBRIEFINGS

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TOPIC

Who is on core team?

All members understandand agree upon goals?

Roles and responsibilitiesunderstood?

Plan of care?

Staff availability?

Workload?

Available resources?

Briefing Checklist

TeamSTEPPS®

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TOPIC

Communication clear?

Roles and responsibilities understood?

Situation awarenessmaintained?

Workload distribution?

Did we ask for or offerassistance?

Were errors made or avoided?

What went well, what should change, what can improve?

Debrief Checklist

TeamSTEPPS®

Why briefings and debriefings?

• Teams perform better when…1. They have a high quality plan2. They share the plan3. They learn and improve over time

• Briefings and debriefings can help, but they do not guarantee good planning.– ‘Checking the box’ ≠ mindful engagement

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How do you get a mindful process?

• Coaching, role modeling, and feedback– Show that the organization values this process– Build effective communication behaviors

• ‘Closing the loop’ with outcomes of the briefing and debriefing process– E.g., defects identified and corrected– Establishes the validity (and utility) of the process

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Auditing briefing practices

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

Develop / Adapt 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?– E.g., developing contingency plans

• Are these reflected in your auditing tool?– Take and modify ours, or others in the literature

Example briefing audit tool

• Briefing logistics• Briefing basics• Specific content• Participation

Train observers

1. Select observers– Who has time? Who has interest? – How many do you need (depends on the boundaries you

set)?2. Educate on the tool

– Walk through the items and explain anything that confuses the observers

3. Conduct a dry run– Score a briefing together, compare, and discuss any

inconsistencies (you can use videos for this 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 little time

spent training– Sections with more explicit items were easier to

obtain higher reliability (mean kappa across 19 cases)

• Briefing basics, kappa = .847 • Specific content, kappa = .820• Briefing participation, kappa = .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 Procedure

SitePatient consent

ABX givenABX redosing time

Beta blockersAirway risk

Access issuesBleeding concerns (e.g., anticoagulant use)

Blood availabilityAllergies

Glycemic control DVT prophylaxis

WarmersLab / radiology review

Intra-operative imaging (X-rays, ultrasound)Patient positioning

Prep application

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

YesNo

Participation – Pausing other tasks

Attending surgeon

Surgical Resident

Anesthesia Attending

Anesthesia CRNA

Anesthesia Resident

Circulator

Scrub

0%10%

20%30%

40%50%

60%70%

80%90%

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%10%

20%30%

40%50%

60%70%

80%90%

100%

Not presentDoes not contributeContributes

Provide feedback

• Present data to stakeholders– CUSP team and other staff meetings– Charts displayed in common areas

• Use data to… – Revise / refine briefing expectations

(policies, processes, checklists)– Coach and reinforce behaviors

PRE-OPERATIVE DAILY HUDDLE

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The Problem

• Scheduling surgical procedures is often complicated by:– unanticipated problems and obstacles– poor communication among anesthesiologists,

surgeons, resident/CRNA colleagues and nurses

• This inefficiency in patient care delivery wastes patient and provider’s time and increases stress for both parties

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What is a Pre-Op Daily Huddle?

• A dialogue between 2 or more people using concise and relevant information to promote effective communication prior to beginning patient procedures in the operating room suites

• An opportunity for all participants to voice concerns and address issues that will affect the quality of patient care delivery and patient flow

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Purpose of Tool

• To provide a structured process to assist the anesthesia coordinator and charge nurses in:– anticipating potential problems during the day– increasing efficiency of patient flow

• To allow the anesthesiology and OR nursing coordinators to readjust the OR schedule to ensure efficient and timely flow of patient care

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Who Should Use this Tool?

• Anesthesiologist/OR coordinators – who make staff assignments and plan for patient flow within

the Operating Room Suites

• OR Nurse Coordinators/Charge nurses – who make staff assignments and are responsible for patient

needs being met

• ICU staff – who use the OR schedule to triage ICU bed availability, as

well as identify other operations not posted for an ICU bed that may require one

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How to Use this Tool

• Complete this tool daily during a meeting between the Anesthesiologist OR coordinator and the OR Nursing Coordinator

• Can be completed in part the night before and finished the next morning and/or could be used prior to the start of the first morning case

• Major issues that involve significant delays/cancellations are communicated directly to the appropriate attending surgeon or other appropriate staff members no later than 07:00 by the Anesthesiologist OR coordinator

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Huddle Process

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I• What happened today, (last evening, overnight if applicable) that I need to

know about?

II

• Anesthesiology and OR Coordinators should meet with the Nursing Coordinator to plan the day and review the schedule together.

• Review the day schedule for any changes, cancellations, or add-on cases.• Are there any concerns after reviewing the OR schedule?

III• Do you anticipate any potential defects or risks during the day? If so, how can

you reduce these risks? (May be completed at the beginning or end of the day.)

SHADOWING

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 impact patient care, patient care delivery and outcomes

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Who should have this experience?• Patient care areas as part of the Comprehensive Unit Based

Safety Program (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% in culture scores

between provider types

• As part of orientation to a new unit

• Units with little collaboration between disciplines

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How To?

• Review the tool prior to your shadowing experience

• Follow your fellow worker through their daily activities.

• Review your list of communication and teamwork problems

• Discuss with your fellow worker

• Make a plan for resolution

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Review the Tool

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

• You should make changes that are specific to your unit!

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Section 1: Were any health care workers difficult to approach?• Things to think about:

– How did that impact the health care worker you followed?• obtained an order, ignored etc.

– What was the final outcome for the patient? • delay in care, etc.

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Section 2: Did one provider get approached more often for patient issues?

• Things to think about:– Was it because another health care

provider was difficult to work with?

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Section 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?

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Planning for improvement

Specific Recommendations Actions taken

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• What will you do differently in your clinical practice?

• What would you recommend to improve teamwork and communication

Our Approach

Comprehensive Unit based Safety

Program (CUSP)

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

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

Questions?