Original debrief protocol
1. Define the communit(ies) for your project and explain why each is a stakeholder for your study.
The UC Office of the President (UCOP) is the primary stakeholder/grant funder. UCOP and the Center for Health Quality and Innovation partnered with the Office of Risk Management to identify the services within the UC medical schools that were the highest cost. Ortho or neurosurgical services were targeted for quality improvement interventions for this reason. Each of the UC medical centers’ CMOs recognize the need to demonstrate improvements in cost while maintaining or improving the quality of these high impact services.
Each UC medical center has staff and faculty at multiple levels that are the communities and stakeholders of this project. These include the site leads of the grant, administrative leadership such as the CMO; IT; the Chair of Neurosurgery (NSG); NSG faculty, residents and fellows; anesthesia attendings and residents; neurophysiologists; OR nurses; perioperative leadership and staff; and circulating nurses.
Each of these levels of staff have an interest in improving team communication, coordination, and improving efficiency of their work, while improving patient outcomes.
The five UC medical center sites have formed a collaborative to share information, successes and barriers in implementing this intervention.
2. Describe your plan for approaching potential community partners to ask for their involvement.
In order to implement the post-operative debrief, we are approaching NSG leadership for buy-in and support in disseminating the principles and mechanisms of the intervention. We are attending NSG faculty meetings to solicit feedback on the intervention and what components are necessary to keep NSG attendings engaged and involved. We are reaching out to other UCSF services that have implemented their own post-operative debrief in the past to gain insights on successes and barriers.
We have included nursing at these meetings to build trust and partnership because the major work load will fall on nursing staff. We have established small working groups with nursing QI to help develop the work flow and process improvement segments of the intervention. They in turn are communicating with pod leaders and other nursing stakeholders to guarantee all nursing feedback included. We will be conducting training sessions with nurses after the intervention is vetted by nursing leadership.
We engaged the NSG residents by proposing this initiative as their annual quality improvement project required for their completion of their program. The residents voted to take up the post-op debrief and help champion the effort. Because it is their QI requirement, they have additional incentive to guarantee success of the project.
We have presented at grand rounds, MnM, and other staff lectures to highlight the importance of the project and network with people with previous experience or vested interest in the intervention.
IT has been approached about modification to the OR templates for documentation of the post-op debrief. They are being kept up to date on the pilot’s progress, iterations, and refinement so that when the debrief is rolled out to all services, they will be ready for the build.
3. Identify which stages of your project you'll incorporate community input, and describe what types of input you'll solicit.
The development of the post-op debrief content requires input from all team members: NSG attendings and residents; anesthesia; neurophysiologists; and OR nurses. This is done within UCSF, and at each UC medical center. Feedback is shared with the collaborative and consensus reached on the minimum content of the debrief.
The data collection requires intensive input from nursing staff, as they are the primary data collectors for the project. Since this data collection must be incorporated into already busy work flows, it is imperative that there is additional value to the data beyond the grant purposes. Nursing leadership is using the opportunity to collect information on OR inefficiencies so that problems can be identified, triaged to appropriate units, communicated, and resolved.
4. Name three ways you plan to share your results, beyond writing an academic article or presenting at an academic conference.
Compliance with the debrief will be shared directly with NSG and OR leadership staff. Any problems identified and resolutions implemented will be communicated with the surgical team. Success of this pilot will be shared with the UCSF OR committee in order to plan staged roll out to other services within UCSF. Successful implementation of this post-op debrief can be shared with patient experience units as demonstration of improved teamwork and communication of the surgical team.
Mapping the Post-op Debrief
1. Identify a patient or community group that contributes to or is involved in the principal behavior you are attempting to improve with your intervention.
Attending neurosurgeons.
2. Using any of the individual explanatory theories in “Theory at a Glance”, develop an explanatory model for the target behavior (above) that you will be attempting to influence with your intervention. This can be an extension/based on expected findings (or previously published literature) from your answers to Homework #3. Figures are always very useful... keep it simple.
Using the Theory of Planned Behavior (TPB):
Targeted behavior: Performing the post-op debrief before the attending leaves the OR.
Attitudes towards behavior: Although the fundamental quality and safety benefits behind the post-op debrief are readily
acknowledged by nearly all surgeons, many feel that the never-events the debrief is meant to prevent are too rare. Within one institution, too many debriefs would have to be performed to collect enough data to show meaningful change in never events within a reasonable timeframe. Attendings do feel like there are more common efficiency concerns that could be highlighted by the debrief, and stand a better chance to improve than the never events.
Subjective norm: Attending surgeons are concerned about the beliefs of key people (e.g. the NSG Chair) and are motivated to comply with the behavior both out of the concern of belief of respected others, and the desire to do as well (or better) than others (their colleagues).
Perceived behavioral control: Attending surgeons are being asked to champion the debrief effort. It is agreed (by surgeons, and especially by perioperative nursing leadership) that they are in control of whether the debrief is performed or not. Attendings perceive the power to perform the debrief rests with them.
3. Identify how one or more of your specific interventions will target one or more of these key factors contributing to the behavior of interest.
In order to increase the buy-in and liklihood attendings will perform the behavior, the debrief is being framed as a mechanism to address OR inefficiencies rather than never events. A process improvement system is being created with the input of all community stakeholders to address identified problems and solutions will be communicated back to the surgical team. This intervention addresses the attending surgeons' attitude towards the behavior (performing the debrief) that a lot of time and effort is invested with little or no return (reduction in never-events).
Compliance with the post-operative debrief will be tracked, including percentage completion of items. These results will be de-identified and posted in comparison to other attending surgeon performance within UCSF, and compared to the other 4 UC medical center campuses. This addresses the subjective norm of attending physicians who are concerned with how well they perform compared to colleagues.
4. Create a framework that draws upon a socio-ecological framework to orient your target behavior within a larger context. ie, what are some of broader, external forces that influence the individual behavior of interest...see Figure 2 of “Theory at a Glance.”
Although performing the post-operative debrief is an individual behavior (on the part of the attending surgeon), it is nested within establishing a system for the debrief among the surgical team. The surgical teams are among a community of other surgical teams within the NSG service. These in turn are nested within a quality improvement committee established to address problems identified by the debrief and feed back information to surgical teams. These activities are supported by NSG and UCSF leadership. And these participate in a collaborative of the other four UC NSG and executive leadership.