Steven and Yolanda discuss the ins and outs of routine team debriefs: What are they? Who should use them? How should they be implemented? How can they potentially improve patient safety?
Related CMPA Perspective article:
Team debriefs: Participate and minimize your medical-legal risks
https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2019/team-debriefs-participate-and-minimize-your-medical-legal-risks
Institute for Healthcare Improvement (IHI) Framework for Improvement
http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
Announcer: You’re listening to CMPA: Practically Speaking.
Dr. Yolanda Madarnas: Hi everyone. I’m Yolanda Madarnas.
Dr. Steven Bellemare: And I’m Steven Bellemare. Welcome to our podcast.
Yolanda: Steven, you look like you’re itching to jump into something.
Steven: I am. I have three situations I will put to you here, Yolanda.
Yolanda: Fire away.
Steven: Think about it. A crash C-section, delegating an intra-articular steroid injection to a resident, or a patient in an outpatient clinic that’s double-booked, causes a bit of a scene, security gets called. What do you think these three situations have in common?
Yolanda: Wow, that’s pretty broad. I’m not sure where you want to go with this.
Steven: Yeah, I know, it’s kind of a “guess what I’m thinking” type of thing. They’re all opportunities to do a debrief.
Yolanda: So then today’s podcast, folks, is going to focus on the Perspective article on debriefs in teams [link in episode notes].
Steven: That’s right.
Yolanda: So communication in healthcare is a very important aspect of patient care, and there’s lots of evidence in the literature that shows that good communication amongst healthcare providers is a key determinant of patient safety.
Steven: You know, Yolanda, it’s too easy to say: “communicate better”. I mean that’s trite, right? We have to know how to communicate and debriefing is one of those ways to make sure that information is shared to create situational awareness.
Yolanda: So for those not familiar with the term, situational awareness is a cognitive process where you perceive information, interpret it and project it into the future for what it means to the care that you’re providing. And by maintaining that situational awareness and focusing on what we do, or what we just did, we can learn what works well, what doesn’t work, and what could work better as we strive to learn.
Steven: And Yolanda, that’s a key aspect of teams that provide reliable, safe medical care. They continually learn from their experiences.
Yolanda: So in this podcast, we’re going to discuss how routine debriefs can improve patient safety.
Steven: If we think about the three take-home points that we want to bring in here today, Yolanda, I would suggest that the first one would be that team debriefs are easy to implement and actually would have a low impact on the workload of team members.
Yolanda: That might take some convincing, but we’ll see.
Steven: Well, we’ll try.
Yolanda: So debriefing on a daily basis helps improve team performance, communication, and it lowers barriers to people speaking up.
Steven: That’s another very good point. And finally, I think we can also point out the fact that to be effective, debriefs should follow a structured process. They have to have purpose. They have to be done essentially the same way by everyone, every time so that it’s not really done in a haphazard fashion.
Yolanda: So let’s talk about how to implement debriefings. Well, although I thought it would take some convincing, they’re actually pretty easy to implement in the sense that it doesn’t actually require extra resources and not a huge time commitment. The hard part is planning for it to happen and getting the engagement and the buy-in from the various players.
Steven: Absolutely and so my advice here would be to start with the willing and grow it out from there. Chances are that as you start doing it, people will realize their value and pretty soon, people are going to be saying well, I want to do what they’re doing over there. I want to do it like they do.
Yolanda: There’s also a difficulty in creating what people perceive as a safe space and making it effective. So you don’t want people feeling that they’re wasting their time. You don’t want it to turn into a venting session and complaining, but you want it to be productive.
Steven: Absolutely. You have to be clear on the purpose if you’re going to decide to do team debriefing. And the purpose, really, is to learn from your daily experiences on how to provide safe care. It’s almost like mindfulness for caregivers, if you want: taking the time to reflect on things in real time, while the players are still all there.
Yolanda: So as put forward in the IHI framework for improvement [link in episode notes], really, this is quality improvement in action.
Steven: Absolutely. You know, to make this very valuable, to make it work, it’s important to have a policy in place that clearly places post-event huddles in the realm of quality assurance and also firmly establishes the confidential nature of the discussion, to help provide a sense of security for those that are involved.
Yolanda: These events don’t need to be bad events. They could simply be reviewing what took place that day. It doesn’t need to be an adverse event review.
Steven: Absolutely and in fact, that’s the point. When you routinely debrief, whether things went well or unwell, you’re normalizing the process, right? You’re formalizing it to help decrease the challenge of debriefs being done haphazardly or being done in a moment that’s perceived as threatening because they only get done when things go wrong, for instance.
Yolanda: So it speaks again to the importance of creating a safe space, a shared mindset and having a structure in place to do these and identifying when to use these, because when they’re well done, debriefs can be done on a regular basis without increasing the hassle factor in the workload for staff.
Steven: And I would argue, Yolanda, that they actually make people more efficient, because they can apply their learning to the next patient and learn what works and what doesn’t, in order to continually improve the way they do things.
Yolanda: So let’s move on to the impact of debriefs on team communication, team performance, and the culture of speaking up.
Steven: Well, implementing debriefing in your daily routine’s an important factor to improve your work culture and to promote safety in the care you provide. Everyone needs to understand, though, Yolanda, that the objectives of the debrief is not to criticize the care of any team member, or of the team, or to assign blame when things go wrong. The objective of the debrief, is to review what just happened so that you can learn.
Yolanda: That’s so important because we know that teams that debrief on a regular basis perceive fewer barriers to communication and less hierarchy, essentially fostering that safe work culture and that safe care culture, allowing everyone to speak up about concerns.
Steven: And in the end, you know, that enhances patient safety. In fact, we can’t really talk about debriefing without mentioning briefings.
Yolanda: That’s semantics.
Steven: Well, you know, actually there is a difference there. The briefing occurs before the event, right?
Yolanda: I see.
Steven: And that’s where you make sure that everyone’s on the same page, everyone understands what’s about to be done, people actually know each other, people have a shared vision and shared understanding of the potential complications and are similarly prepared for them. The debriefing comes after the event.
Yolanda: After the event. Yeah.
Steven: And that’s where again, you’re doing pretty much the same thing. Now you’re just going back over what just happened. Did it go as it was planned? If not, why did it not go as planned? What can we learn from this? What do we need to do for the next patient? The very next one that’s coming right after, is there something that we can do right now about that to make sure that we don’t repeat the same problems, same mistakes?
Yolanda: So how would this be different from a huddle, for example, that we hear about a lot in many clinical settings?
Steven: Yeah, that’s a very good question. Huddles are more situational. So those, you would use more at the beginning of a shift, where you’re going to discuss together as a team who’s on call, who’s sick, what’s the bed situation in the unit at that point?
Yolanda: So more context.
Steven: Yeah, context that helps you plan for how you’re going to deliver care over a period of time. Also, discussing what other patients are around and how that might impact your unit’s functioning. So, you know, we call this running the board, right? When we all stand in front of the board and we look at the patient list, that’s part of a huddle. We can broaden the huddle to talk about a few more things other than just who’s on the ward.
Yolanda: So then briefings would be more specific to procedures.
Steven: That’s right.
Yolanda: What are we going to do? How are we going to do it? Who’s doing it?
Steven: And what their level of experience is. Have they done that particular procedure before is very important.
Yolanda: What could we expect? What kind of complications?
Steven: That’s right. Do you share the same mindset about why this is going on? Is this urgent or elective? And the issue of shared mindset, shared awareness of what’s going on is really what the briefing is helpful for.
Yolanda: So then, briefings, debriefings and huddles are all important to create situational awareness and can be affected by information uncovered during debriefings.
Steven: That’s right and, so you know, when we talk about, oh, we need to communicate better. That’s actually the way we can communicate better, is to use those three techniques, those three tools.
Yolanda: So let’s move on and figure out how debriefs can be structured for success.
Steven: Well that’s the key, isn’t it? You have to plan for them. You can’t just make them happen all of a sudden. No. I think we have to start by talking about them with our teams and feel them out for their interest and the potential pushback that they might have about the idea.
Yolanda: I suppose that’s a time and an opportunity to get a feel for what’s important to the folks around the table.
Steven: Absolutely. You know, there’s literature that you can review to help you address fears such as the impact on people’s time.
Yolanda: That’s a big issue, right? In high volume, time efficient, pressured settings, we really don’t want to be seen as wasting our time doing something that doesn’t have a purpose.
Steven: And you want to make sure that people see the value or see the purpose.
Yolanda: So I guess you could start out with a small group of converted or engaged or committed people, identifying what key issues should be addressed during a debrief. Did things go as planned? If not, what happened and why?
Steven: Could it have been anticipated, for instance, and what could we learn about that for the future?
Yolanda: So I guess probably the most important thing then, is to act upon the recommendations or the answers to those questions, so that everyone can see learning in action and derive real meaning from that exercise.
Steven: You know what? That’s probably the most important thing. And you know what? That makes me think that’s probably going to be the pearl I’m going to give at the end. Right? This is probably the most important thing we can say about debriefings. Nothing will kill a project like someone who feels they’re wasting their time. So if you actually raise an issue in a debriefing and say this needs to be addressed and it actually doesn’t get addressed and it doesn’t change, you will completely kill the engagement of your team.
Yolanda: You also need to create that psychological safe space, right? For people who want to participate but feel vulnerable or afraid to speak up and are feeling perhaps vulnerable and scrutinized by their colleagues and it becomes a performance anxiety driving exercise.
Steven: We can’t be judgemental and we don’t want to come at it with a blaming frame of mind, we can’t be angry. We have to really focus on the learning. And you know, as I think about this now, the debriefing can have two purposes that are connected but different, right? On the one hand, the debriefing can be about learning from the experience: what can be done better, what went well, what can we keep going with?
The other aspect of the debriefing can be very helpful to help team members share how they feel emotionally about something that happened and so, you know, emergency room teams, for instance, will often debrief after a major trauma or something like that, to make sure that they support one another. That can be another very important role for debrief, but that’s a very different role than the learning role in terms of the provision of clinical care. Both are very valuable, but I felt it was important to point those out.
Yolanda: So I guess this really speaks to having a growth mindset so that when we see mistakes as opportunities to learn and do better from the viewpoint of quality improvement, joy in work, safe patient care, it takes away from blaming ourselves and using words or thoughts like I could have or should have done better.
Steven: You know the growth mindset versus the fixed mindset are very important in promoting physician wellness. The physician who sees themselves as I should have known better, I’m incompetent, I’m a failure, I’m an imposter, has this fixed mindset where they are holding themselves to a standard perhaps that’s unattainable. A person with a growth mindset will say okay, I didn’t do that as well as I thought I could. What can I learn to make this better next time? And if we foster that growth mindset within our team, we’re actually supporting each other and learning and growing together and that benefits patient safety.
Yolanda: I can see how that’ll be a challenge to incorporate in some settings because historically, that’s not been the culture and that’s not been the mindset present in our clinical world.
Steven: But you know what? All it takes is one person to start changing things. And you know, having this culture of “I’ve got your back” is so powerful to create a team that functions effectively in the interest of patient safety. And “I’ve got your back”—don’t get me wrong here, Yolanda—doesn’t mean I’m going to cover for you if you make a mistake.
Yolanda: Or “I’m watching you till you screw up.”
Steven: Absolutely. No, that’s not what it means. “I’ve got your back” is “I’ll be there for you”. We’re a team and I realize that there are times when your performance might not be optimal. I realize there are times when my performance might not be optimal. But together, if we’re looking out for those times, we might be able to intervene if we learn to work well together through our debriefs to help prevent those potential patient safety incidents from happening.
Yolanda: And ultimately provide better patient care.
Steven: That’s what it’s about, right?
Yolanda: So we’re at the end…
Steven: Wow!
Yolanda: …of another podcast, Steven.
Steven: How quickly time flies.
Yolanda: So I guess it’s time for our pearls.
Steven: The pearls, that’s right. Do you want to go first with a communication pearl?
Yolanda: Yes. Let’s start with a communication pearl. So debriefs, when they’re done routinely and with purpose can actually be a safe place for team members to identify concerns and learn to speak the truth to one another in a non-judgemental, non-blaming, and supportive way.
Steven: Wow. I guess the listeners might have to pause here and let that sink in and think about what that means. That’s a powerful statement. So yeah, let’s take a pause and let you do that.
[Podcast pause – instrumental music playing]
Yolanda: So if you did hit pause, welcome back.
So Steven, do you have a documentation pearl for us?
Steven: Documentation, yes. I think that debriefs don’t need to be documented per se. As the article in Perspective points out, if they’re done after a patient safety incident, there should be a note outlining the event in the chart and some thought should be put into initiating a more formal quality improvement review, if need be. But otherwise, if you’re just doing a regular debrief that’s very routine, whether or not things go well or wrong, there’s not a need to document that per se. The key is really to act on the information that was discussed. Sending a note of a needed change in a procedure or equipment to the appropriate person might really be all that’s needed in terms of documentation when the debriefs are more routine.
Yolanda: So that sums up our point of view for today. Thank you, Steven.
Steven: Thank you, Yolanda. This was fun.
Yolanda: On behalf of the CMPA, I would like to thank you for joining us today. If you have any comments, questions or story ideas, we would love to hear from you. Our email address is podcasts@cmpa.org. And remember…
Steven: …when you change the way you look at things...
Yolanda: …the things you look at change.
Steven: Goodbye, everybody.
Yolanda: Should we debrief after this, Steven?
Steven: I think we should. That’s a very good idea.
[Yolanda and Steven start to debrief]
Announcer: These learning materials are for general educational purposes only, and are not intended to provide professional medical or legal advice, nor to constitute a “standard of care” for Canadian healthcare providers.