Espresso: Debriefing

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What is a debrief?

  • Conversation involving frontline workers taking part in a patient’s care that occurs shortly after the event takes place.

  • Can be used for a number of purposes:

    • Knowledge or skill attainment (individual learning)

    • Describe threats to patient or worker safety, or threats to team dynamics (systems learning)

    • Provide closure for individuals involved in a clinical situation (therapeutic)

  • Debriefing is not the same as a true “root cause analysis” (RCA) but may be a first-step in performing RCA.

  • Cornerstone of clinical and simulation-based education.

When should a debrief occur?

  • Defining set triggers in which debriefs should occur has been identified as best practice to:

    • Set expectations amongst staff when they should occur, and how frequently

    • Increase frequency of debriefs

    • Promote system-wide goals

  • In OB/GYN, there’s not a standard list of what should generate a debrief; but you might imagine there’s a few major events that we commonly think of as emergencies:

    • Shoulder dystocia, or difficult extraction at cesarean

    • Significant postpartum or surgical hemorrhage events

    • Unexpected newborn complication

    • Unexpected surgical complications or unexpected intraoperative findings

    • Patient injury or serious complication, unanticipated ICU admission, or death

      • Many of these events may be defined locally; and if you don’t have a list defined at your institution, it is worth asking about it and starting one!

      • In general, it is good practice to also have a “staff member request” as a trigger for considering a debriefing to empower any person on the team to review events that may be unusual or uncomfortable.

  • Best practice has identified that the “hot debrief” (i.e., shortly after the event) is helpful to staff immediately involved and provides opportunity to get a very clear clinical picture.

    • “Cold debrief” (i.e., one done much later) will allow for more data to be collected, but worsens recall of participants and also removes some of the other advantages that a hot debrief may enable - i.e., finding time for staff to attend, identifying learning points immediately after event, etc.

    • A cold debrief can certainly be performed later on - in some institutions, this is performed through the “M&M” process with which all residents are likely familiar!

How should a “hot debrief” be done?

  • Three general stages of debriefing:

    • Preparation

    • Delivery

    • Post-Debrief

  • Preparation

    • If a debrief is requested/triggered, all staff should be invited.

    • A time and location should be identified, ideally soon after the event occurred.

    • A facilitator should be named, and a second person can serve as a scribe for documentation (more on that later)

      • Ideally, the facilitator should be a designated person who was not the team leader or heavily involved in the events. 

        • At UW L&D, this is often our charge nurse or another senior nurse who serves to facilitate.

        • This helps to eliminate any issues of hierarchy/power and encourages all voices to speak up.

    • Any other concerns to allow for optimal debrief should be addressed - short time period for cross-coverage by other personnel, for instance. 

  • Delivery

    • Facilitator should set expectations at the start:

      • Aim for brevity of debrief (5-10 minutes ideal)

      • Establish psychological safety - not to blame or punish, but to review and characterize event.

      • Invite the team leader to provide a summary of the case.

        • The facilitator should encourage the team leader to provide an objective case overview at this point - the focus should be on the “actions” that occurred. 

        • Provide reassurance that the next step of the debrief will be to focus on reflection and judgements.

      • After the event summary, the Facilitator should then start conversation according to a specific structure to review the event:

        • Many possible structures, but broadly fall into:

          • Review things that went well.

          • Review opportunities to improve.

          • Identify points for action and “take home” learning points.

        • Your institution likely has a “debrief form” that helps to guide these conversations. However, some of the more significant ones described include:

          • TALK - Target, Analysis, Learning Points, Key Actions

          • INFO - Immediate, not For personal assessment, Fast facilitated feedback, Opportunity to ask questions

          • STOP5 - Summarize, Things that went well, Opportunities to improve, Points to action, Responsibilities

          • Seven Step After Action Review - US Army tool which has been adapted to QI.

          • And many more exist!

  • Post-Debrief

    • Facilitator and scribe can review that action points are recorded.

      • If appropriate, can assign action items to specific individuals for follow up.

    • Documentation should be completed at this time.

      • Again, debrief forms are often present in hospitals for these purposes as part of QI review. Sometimes this may be incorporated into your patient safety reporting system.

    • Medico-legally, debrief processes and forms are most frequently considered protected information through quality and safety structures. 

      • Your legal department can help ensure all pieces are structured to meet this standard.

Additional Info: 

AHRQ https://psnet.ahrq.gov/primer/debriefing-clinical-learning 

Contemporary OB/GYN: https://www.contemporaryobgyn.net/view/debriefing-after-adverse-outcomes-opportunity-improve-quality-and-patient-safety