Why Policy Should Not Precede the Science: The Case of Briefings and Debriefings

• 10/1/2009
• Author: Steven Berman
• Category: The Journal Blog
• 21659 Views
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This week, Sean Berenholtz, the lead author of “Implementing Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center,” which appeared in the July 2009 issue, guests on the Journal blog. Briefings and debriefings involve a discussion among all members of the surgical team before incision and then before leaving the OR. Drawing on 37,113 briefings and debriefings, Berenholtz and his colleagues demonstrated that it was feasible to implement OR briefings and debriefings in a large, busy hospital and that physicians and nurses perceived that briefings and debriefings were associated with improved interdisciplinary communication and teamwork in the operating room (OR). Dr. Berenholtz takes this opportunity to reflect on some of the issues in implementing briefings and debriefings. He and I welcome readers' questions and comments.

Several studies have implicated failures of communication and teamwork as the root cause in a high proportion of sentinel events in the OR. A number of tools have been adopted in health care from the aviation industry, and briefings and debriefings are but one example. 

Although we did not evaluate the impact on clinical or economic outcomes, our study builds on a growing body of literature that suggests that briefings and debriefings in the OR and other structured communication tools may indeed improve patient outcomes. Since the inception of this study, for example, Haynes et al. (Jan. 29, 2009 New England Journal of Medicine) published the results of the World Health Organization (WHO) Safe Surgery Saves Lives program. In the WHO study, investigators prospectively collected data on clinical outcomes from 3,733 consecutive adult patients before the introduction of the Surgical Safety Checklist and 3955 patients undergoing noncardiac surgery after checklist implementation. The checklist was an integral part of a required sign-in before the procedure and a sign-out before leaving the OR. The authors report a significant 47% (1.5% pre to 0.8% post) reduction in mortality and a 36% (11% pre to 7% post) reduction in complications after introduction of the checklist.

Based in large part on the WHO study and other smaller studies, many organizations and professional societies are now advocating the routine use of briefings and debriefings in the OR. While these studies and others evaluating the potential role of briefings and debriefings, including checklists, seem promising, there are many unanswered questions. For example, do briefings and debriefings reduce patient complications and mortality? Frankly, it doesn’t seem plausible that a checklist decreases mortality by nearly 50%. In other words, for every two patients who would have died, one patient did not die as a result of checklist implementation. 

Many other implementation questions also remain unanswered. Who should lead the briefing and debriefing? Who should be included? When should a briefing be conducted relative to timing of patient induction and surgical incision? When should a debriefing be conducted relative to the timing of surgical closure and leaving the OR? Should the briefing and debriefing consist of yes/no questions, open-ended questions, or a combination of both? Should briefings and debriefings be modified based on the patient population and/or surgical procedure? To date, the answers to these questions are not known.

While the pressure to improve perioperative quality and safety is increasing, I would hope that we don’t repeat mistakes of the recent past. Perhaps two lessons from recent announcements that mandated time-outs have done little to nothing to change wrong-sided surgery in the United States are worth mentioning. First, policy should follow the science, not precede the science. More research is needed to inform policies before briefings and debriefings are mandated.  Second, while checklists and other structured tools are an easy answer, this isn’t about checklists. To achieve substantive and sustainable improvements in the quality and safety of patient care, we need to focus on systems of care; engage local interdisciplinary teams to assume ownership of the problem; centralize support for technical work, including robust data collection and data quality control efforts; encourage local adaptation of the intervention, improve culture; and encourage social networking among organizations. Only then will we make progress.