Implementation of surgical debriefing programs in large health systems: an exploratory qualitative analysis

Since the publication of “To Err is Human” in 1999, medical error has been acknowledged as a major contributor to the burden of illness in the United States (US) [1]. Preventable complications in surgery contribute significantly to this burden. Over the last 17 years, the quality and safety of surgery in the United States has been addressed through several interventions. One prominent tool developed to improve patient safety is the World Health Organization (WHO) surgical safety checklist [2]. The WHO checklist is a communication tool that involves participation of the surgical team to review issues of surgical safety at three time points: at a sign-in prior to administration of the anesthetic, at a time-out prior to the incision and at a sign-out or “debrief” at the end of the case. Implementation of the WHO Checklist was associated with dramatically improved outcomes in an international trial published in 2009 [2]. Since the publication of these findings, the checklist has been broadly adopted and incorporated into US hospital accreditation with the expectation that this would lead to national improvement in surgical safety.

Despite a concerted, national effort, the burden of medical error in the US remains troublingly high [3]. Follow-up studies of the WHO surgical safety checklist were less promising than the initial trial, and the mandated use of the surgical checklist failed to move the needle of surgical morbidity and mortality within large health systems such as that in Ontario, Canada [4]. These findings suggest that strategies that reduce surgical morbidity within the controlled settings of a trial may fail in the complicated real world. Success or failure of the checklist in improving outcomes closely relate to meaningful compliance [5]. Despite widespread institutional reports of high compliance, audits of checklist use reveal that most hospitals fail to complete the checklist, with very few institutions completing a true team-based “debrief” or “sign out” at the end of the checklist [6, 7]. The potential role of the “debrief” to address issues related to individual patient safety and systematic flaws in care is almost always overlooked and undervalued [6, 8].

The “debrief” within a three-part surgical safety checklist is alternatively referred to as a “sign-out”. These terms are used interchangeably in most checklists and within this paper. However, the use of the term “debrief” emphasizes additional communication beyond acknowledgement of the tasks performed by the nursing team at the end of the surgical case. This additional communication typically addresses safety, equipment and efficiency issues arising during the case and identifies opportunities for improvement.

In contrast to many hospitals that have struggled with checklist implementation, there are a few notable institutions have used the surgical checklist effectively to improve quality and safety and continue to do so. Many of these successful institutions have specifically focused on the debriefing aspect of the checklist to address systematic issues of safety, efficiency, and communication [9, 10]. In our study, we interview surgical leaders from four centers across the United States who have developed successful strategies of debriefing within a comprehensive program of quality improvement. We examine three institutions that have maintained these programs and one institution where this program has failed.

Through a thematic analysis of these interviews, we explore effective strategies, the role of leadership, barriers and facilitators, as well as contextual factors that present stumbling blocks and opportunities for medical leaders looking to improve system efficiency and strengthen the role of debriefing in their hospital.

This study was reviewed by the Harvard Ethics Board and judged to be exempt from ethics review.

The four implementation leaders interviewed had developed their strategies within four very different health systems.

Madigan is an Army Medical Center in Washington that performs roughly 10,000 surgeries a year and has 220 inpatient beds. Madigan is staffed by 54 surgeons, 12 anesthesiologists and 49 certified registered nurse anesthetists (CRNAs). Dr. Andrew Foster is Chief of Anesthesia at Madigan and was a physician leader who took on a primary role in creating and maintaining the debriefing program at Madigan.

Memorial Health is a large public health system in Southern Florida including five hospitals with a total of 1858 beds and 62 ORs staffed by 545 surgeons, 101 anesthesiologists and 53 anesthesia assistants as well as 112 CRNAs. Dr. Stanley Marks is a surgeon and Chief Medical Officer for Memorial Health, who developed a comprehensive approach to patient quality and safety that has been instituted across Memorial Health.

McLeod Health is a large private health system including seven hospitals in South Carolina. McLeod regional center completes 19,000 cases a year and has 489 beds. The OR is staffed by 125 surgeons, 12 anesthesiologists and 50 CRNAs. Dr. Michael Rose is an anesthesiologist and Vice President of Surgical Services at McLeod Regional Medical Center and has helped lead a state-wide initiative to improve Surgical Safety in South Carolina.

Beaumont is a large public health system including eight hospitals and performing more than 50,000 surgeries every year in Michigan. The system is staffed by 600 surgeons, 84 anesthesiologists and 145 certified registered nurse anesthetists. Dr. Robert Welsh is Vice Chief of Surgical Services at Beaumont Hospital- Royal Oak and developed the program of surgical debriefing for surfacing safety defects at Beaumont Hospital.

In analyzing the interviews of these leaders, seven high-level themes were identified with an additional 24 subthemes that fell within the high-level umbrella themes.

Figure 1 illustrates the broad thematic categories as well as the subcategories.

Improving surgical safety through debriefing is a complex endeavor. Although the role of debriefing is acknowledged as an important part of surgical safety, debriefing is rarely performed in institutional audits of checklist compliance [5, 7]. We have examined four programs that have effectively instituted debriefing systems to improve patient safety and the overall effectiveness of the health system. The leaders of these systems have commonly identified strong executive leadership involvement, meaningful and early feedback and a culture of safety and continuous improvement as keys to their success. Each program recognizes ongoing threats to the success of their programs. These threats are those of resources (financial and personnel), the loss of meaningful and early feedback, and the perseverance of traditional hierarchies resulting in the failure to achieve fair and open communication. In the case of Michigan’s debriefing program, a loss of resources was the catalyst to the eventual collapse of the debriefing program primarily when meaningful feedback was no longer provided to the surgical teams.

Debriefing is well-established in many high-acuity disciplines where it contributes to a culture of communication, reflection and continuous improvement. The American Heart Association strongly promotes the use of debriefing to improve the running of codes [15]. Studies of debriefing after codes demonstrate improved team communication as well as improved performance measures and clinical outcomes. [16‐19]. Similar results are seen when debriefing is applied to trauma care [17, 20]. The four interviewees in our study all pointed to numerous ways in which debriefing in surgery contributed to improved clinical care, patient safety, communication, attitudes and efficiency at their institutions. Although patient safety is the priority for each of these programs, the debriefing also offered an opportunity to improve performance measures related to process- expanding the potential value of the program and acting, in part, as a Trojan Horse to introduce important safety alongside those measures that improve the business-side of surgical systems. Published results from Madigan, Washington specifically show improvement in operating room efficiency [10] while the program at Beaumont found numerous communication and equipment issues that improved with the use of debriefing [9]. In institutional publications and presentations, the Memorial Health System in Florida reported improvements in communication, measures of satisfaction, teamwork and safety culture [14] while McLeod Health reported improvement in surgical mortality, a decrease in patient safety events and an improvement in measures of satisfaction and attitudes surrounding safety [13].

There is no simple answer as to why debriefing is not adopted routinely after surgical procedures. Qualitative studies through surveys and interviews suggest multiple reasons including logistical challenges and a perceived lack of value [6, 8]. The logistical challenges relate to the different times at which team members’ roles conclude in surgical procedures and the competing requirements of circulating nurses who are frequently tasked with running the debriefing. The perception that debriefing lacks value relates to the fact that some elements are redundant, other elements may not be directly applicable to the care of the patient and issues arising in the debrief are not addressed or valued by the institution [8].

The lack of a strong culture of surgical safety likely contributes to the devaluing of the debriefing both by the institution and by the team members who directly participate in the care of the patient.

The interviewees from each of the four sites recognized that an immediate tangible value of the checklist would best ensure that the surgical team would participate in debriefing. Often this meant addressing concerns that impacted the teams’ ability to perform its job efficiently in addition to other issues related to improving performance. The fact that issues of equipment and process could be corrected and the surgical team could experience the immediate benefits of participation, gave them a greater commitment to the process.

To improve the culture of surgical debriefing and create a meaningful debriefing process, interviewees acknowledged that the institutional approach should be broad-sweeping, targeting all levels of care and administration with a strong focus on empowerment of nurses and those members of the surgical team who have traditionally not had their voices heard. To create a system in which nurses are empowered, the focus needs to switch from individual performance to team success. In most situations, this requires an institutional culture change. Changing the culture of an institution requires a comprehensive strategy in which team training may play a critical role.

When quality and safety tools are applied without an institutional strategy for ongoing implementation, they are likely to fail. This can be seen in studies of surgical safety checklist that do not specifically involve implementation strategies [4, 21]. When the checklist is introduced as a tool to facilitate communication within a broader institutional strategy, the impact can be tremendous [22]. Programs that succeed in developing debriefing programs to improve surgical safety must remain committed to ongoing improvement and a commitment to communication.

There are many threats to the ongoing success. At Beaumont Hospital in Michigan, the loss of resources was devastating to the debriefing program as key positions were defunded. It is possible that if the executive administration valued the program more either economically or within a stronger institution-wide culture of safety, economic scarcity might not have had the same impact. Stanley Marks at Memorial Health in Florida reflected that the value of the program is so engrained within the institutional culture that it is not likely to be impacted by scarcity. But maintaining the institutional culture takes work. Even in programs like Memorial Health, Stanley Marks refers to the constant threat of degeneration into a “task” mentality.

The value of the debriefing systems established by four surgical centers in diverse settings across the United States is tremendous. Even in Beaumont, where the system failed, there remains a strong commitment by clinician leaders to re-establish the program. The fragility of these systems exposed by the collapse at Beaumont underlines the importance of strong executive involvement, a reliable system of meaningful feedback and prioritization of communication within a system designed to constantly improve.