By Thomas Davis, CRNA, MAE, DNAP candidate

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All too often, opportunity knocks on the door and nobody is home.  Despite our desire to have everything go smoothly and safely with each patient interaction, glitches occur and when they do, opportunities emerge for improving the care that every patient deserves.  Rather than reprimanding the individual involved, insightful leaders respond by opening the door and welcoming the event as an occasion to debrief the entire team and develop a plan to ensure that the incident is not repeated.

“When a test pilot comes off a flight, typically there is another pilot to take it up and he believes in the debriefing.  You don’t keep something to yourself.”

 ~Wally Schirra, NASA astronaut

The act of debriefing has been an important part of military teamwork for decades.  Timely analysis of an event as it is occurring enables soldiers to address mistakes and make changes while on the battlefield.  Debriefing encourages novel approaches to critical situations and has the additional benefit of fostering relationships that promote team learning.  Similarly, the healthcare battlefield must address a never-ending flow of patients with unique needs that require addressing in a timely manner.  Writing in the British Medical Journal, authors Freytag et al. note that teamwork is the key to reducing medical error and recommend regular team debriefing as avenue for proactively developing a collaborative plan that will reduce or eliminate future medical errors.

Debriefing a team does not need to be a punitive or daunting event, rather, it is a format for understanding why the current protocol failed and exploring ways to patch holes to prevent future recurrence.  Leadership and strategy consultant Doug Sundheim proposes a simple four-step process to follow when conducting a team debriefing.  His advice to business leaders is equally applicable in the healthcare community.

Specify a time and place.  Emotions run high when an event occurs or a medical error is made, and knee-jerk responses seldom address the root cause of the incident.  Having a one on one talk to reprimand the person involved destroys morale and does not address the foundational issue.  A better solution is to designate a time and place for the entire team to review the glitch and collaboratively propose a solution.

Create a learning environment.  For the first half of my healthcare career, our department had a monthly morbidity and mortality conference to present a bad outcome and roast the person involved.  Over the years, the M&M conference morphed into a learning experience with the intent of process improvement based on the philosophy of Dr. Peter Pronovost, “every system is perfectly designed to achieve the results it gets.”  Addressing a problem as a system error rather than a personal failure opens the door for the team to find novel ways to design a new system that does not allow the mistake to be repeated.

Gather information.  As the leader, you are privy to information about what happened, however don’t assume that you have all the details of an event.  Those on your team who provide direct patient care are the most knowledgeable about flaws in the system and have insight about correcting them.  When the team assembles, use the time to clarify the following:

• What was the goal?
• What was the outcome?
• Why did we achieve the results that we got?
• What will we do differently in the future?

Develop a plan.  Theory and intellectual understanding are great but they don’t repair a defect in the system.  Take notes as the conversation progresses and use the insight of your team to change the existing system.  The objective is to develop a plan that eliminates the possibility of anyone else repeating the error.

The purpose of debriefing is to modify a system, change behavior and improve outcome.  Until the knowledge gained at the debriefing session is put into action, it is only an academic exercise.  Apple CEO, Steve Jobs knew the importance of follow-up and assigned a designated responsible person for each agenda item prior to a meeting.  Corporate trainer Paul Axtel affirms the importance of after meeting action as an essential part of the process for continuous improvement and makes two recommendations:

• Summarize the meeting notes and distribute them to each person on the team. Written notes creates a document trail and serves as a reminder to each team member regarding the origin of the problem and the consensus for solution.
• Clarify the plan and expected behavior of team members. When items need additional attention, designate who will be responsible and establish a timeline for completion.

The best leaders learn from every experience positive or negative, and constantly seek ways to improve results while promoting individual professional growth.  Medical errors might have devastating consequences or they may create a “near miss” scenario where nobody was injured…but they were at risk.  Glitches represent opportunity knocking on the door and perceptive leaders seize the opportunity to create a learning situation that fixes a defective system, improves safety, and preserves the self-esteem of the team member.  Open the door and welcome a friend.

Tom is a clinical anesthetist, noted author and requested speaker.