Debriefing process can strengthen process for critical incidents

High-risk areas such as the ED, ICU, OR may benefit the most

A new article in The Joint Commission Journal on Quality and Patient Safety1 has provided evidence-based recommendations for a process that may be especially relevant in light of the recent spate of natural disasters: debriefing. While debriefings are commonly conducted to review staff performance following a disaster, the authors note that such a process also can have great value following any critical incident — especially in high-risk areas of the hospital such as the emergency department, the ICU, and the operating room.

In their article the authors lay out 12 evidence-based best practices and tips for a debriefing:

  • Debriefs must be diagnostic.
  • Ensure that the organization creates a supportive learning environment for debriefs.
  • Encourage team leaders and members to be attentive of teamwork processes during performance episodes.
  • Educate team leaders on the art and science of leading team debriefs.
  • Ensure that team members feel comfortable during debriefs.
  • Focus on a few critical performance issues during the debriefing process.
  • Describe specific teamwork interactions and processes that were involved in the team's performance.
  • Support feedback with objective indicators of performance.
  • Provide outcome feedback later and less frequently than process feedback.
  • Provide both individual and team-oriented feedback, but know when each is most appropriate.
  • Shorten the delay between task performance and feedback as much as possible.
  • Record conclusions made and goals set during the debriefing to facilitate feedback during future debriefings.

"These debriefing principles come from research in aviation, the military, and crisis management organizations," explains Eduardo Salas, PhD, Pegasus Professor of Psychology at the University of Central Florida in Orlando and lead author of the article. "We know from our findings that teams that engage in a debriefing perform better [in the future] because they learn. It is a key component, especially for teams, to evaluate what happened and what can improve, what the weaknesses were, and set goals for better performance."

A debriefing, he says, differs significantly from a root-cause analysis. "To be useful, it has to happen right after the incident or critical event, although depending on the nature of the situation, it can be a couple of days," says Salas. A debriefing, he adds, has to be not only timely, but also developmental.

"When a team discusses a weakness, they have to come up with a remediation task," he says, adding that the debriefing also must be diagnostic. "Saying we have a communication problem is not sufficient; that's' a big bucket," he emphasizes. "A debriefing really helps you understand what led to what."

"What we expect is for the presenter of the case to present all the factual information," adds co-author Jeffrey S. Augenstein, MD, PhD, professor of surgery at the University of Miami and director of the Ryder Trauma Center, who notes that his facility has computerized records, so if there are questions they can refer to it. "We really try to figure out if the outcome that was less than perfect was related to a process problem, an error, and so forth, and then try to put things in place to correct those problems," Augenstein says.

Make it happen

Salas concedes that holding a debriefing as quickly as possible after a critical incident (which he defines as "any event that may cause harm by the actions done by the team or failure of the team to prevented harm") is a challenge for medical professionals with hectic performance requirements. "In health care, especially in ORs and ERs, where you have very busy nurses and physicians, the work load can serve to prevent them from really engaging in this discipline," he observes."But my sense is it still needs to happen right after the event, even if it's only a couple of minutes, or half an hour."

Salas continues: "I've seen some good debriefs take a minute and a half; the team goes directly to the key issue and then right to the developmental stage. Of course, I've also known some to take two hours."

Salas recalls one successful debriefing. "There was a miscommunication in the OR, and after they went out of the room the surgeon called a brief huddle, brought the issue up, and was supported by a nurse who said it shouldn't have happened. Next, he asked the team how they could self-correct the problem."

One or two suggestions were put forth, says Salas, and the surgeon recommended that those changes be incorporated into the protocols. "The surgeon opened up the channels of communication so everyone could speak up, they came up with recommendations, they were accepted by the team, and they went on," he says.

Augenstein recalls an event that occurred a number of years ago. "A patient came to one of our ICUs and had an injection of a material that was less than optimal because the vials were somehow not marked," he relates. "The patient had an adverse outcome, and immediately a new process was put in place where you couldn't bring things into the OR without clearance; everything around the operating table had to be marked where it was." This process change, he says, occurred "literally overnight."

Augenstein says he has seen many effective debriefings in aviation and military settings, and they all contained the same element. "The team leader acknowledges something went wrong and the team needs to do better. The team leader opens up and sends a signal that it's OK to talk about 'our' mistake."

Promoting debriefings

If debriefings are not common practice in a particular facility, says Salas, the quality manager is the one who ought to promote them. "They can create incentives, train people, and send signals that debriefings are a good way for a team to learn about their mistakes," he advises.

Beyond that, he says, the whole hospital leadership team should be involved. "I know hospitals in Florida that put up posters right inside or just outside the OR," he shares. "They highlighted the five things a team needs to talk about after an event; the team huddles next to the sign and debriefs."

It is best if the message comes from the top that mistakes do get made, but that medical teams need to improve, and that there will be no punishment involved, says Salas.

It should not be difficult, he continues, for the quality manager to "sell" upper management on the concept. "Just show them the science that demonstrates debriefing works and generates performance improvement," he advises. In addition, he says, you can do small qualitative and quantitative studies in your own hospital. "You'll be able to say, 'This team spent just three minutes discussing a problem, and look what happened!'" Salas offers, "So if they do not believe the outside data, call a 'mini study' where you can show these things make a difference."

Reference

  1. Salas E, Klein C, King H, Salisbury M, et al. Debriefing Medical Teams: 12 Evidence-Based Best Practices and Tips. Jt Comm J Qual Patient Saf. September 2008, Vol. 34, No. 9: 518-527.

[For more information, contact:

Eduardo Salas, Pegasus Professor of Psychology, University of Central Florida. Phone: (407) 882-1325.]