Table 1.

How Leadership works to Promote a Successful Debriefing Strategy

Theme	Memorial Health, Florida	McLeod, South Carolina	Madigan, Washington	Beaumont, Michigan
Early, Immersive Engagement of Executive Leaders	“I wound up getting all of the executives trained in team training. So people… who had probably never set foot in an operating room were all trained in team training and crew resource management.” “we trained all our senior leaders in the organization…. nobody was excluded.” “[The Crew Resource Management Program is] governed at a pretty high level. It’s governed by the Chief Medical Officer of the healthcare system and the director of crew resource management for the system.” “the army has to be your senior leaders…. the senior leaders have to embrace it and have to continue to train it and live it.”	“Several of our senior leaders were at the IHI… they came back from that meeting with the outlook that the IHI was going to try to attack the issue of improvement in surgery, and so that began the work.”	“we had a couple sentinel events and the executive leadership at our hospital said “you guys need to change something” and the solution they came up with was team STEPS” “The Deputy Commander who really pushed this, is a private pilot, which is really kind of interesting, and so he is very familiar with … CREW resource management and he was really into this” “I think that the big lesson was you know early, getting senior leadership buy-in, really socializing it, and anticipating the kind of push back you’re going to get and addressing those in very detailed manners, you know don’t leave that up to other people’s discretions on how that’s going to go”	“Our CEO… was a pharmacist or a pharmacy tech when he first started out in the world of healthcare, so he had some engagement with personnel and with patients to some degree. He recognized the success of the Keystone ICU project, and so he was willing to endorse the process going into the operating rooms as well. So we really had [support] at the highest level of the hospital.”
Involvement	“The CEO of the hospital makes rounds in their own hospital. The CMO makes rounds, the chief medical officer of each hospital. I expect all my senior-most to make rounds. I don’t need them in their office, I need them out on the floor. And they see me in all of our hospitals.”	“We actually brought our senior leadership group and board members into the operating room, that corridor, to show them what we were finding…. by the time of our annual board retreat that year, some number of months later, we as an organization … said that we were going to attack this issue of safety in surgery with vigour to attempt to get it to zero rate of harm.” “The ability to reach out to senior people, up to including board members and have them engage at that level with staff as a point of emphasis on the importance of the work is part of the secret sauce here” “when you put board members in scrubs in the operating room, observing and talking to staff… that makes a big difference”
Enforcement	“I believe that leadership, number one, mandates it and stands behind that mandate. If a member of the medical staff doesn’t take the course and cooperate with the policies, they can’t operate here.”	“we [the executive leadership] don’t go down and beat people up for not providing it but on the other hand what we will do is we will regularly reach out to people and say “I didn’t get a debrief from your case yesterday”, and when you do that for 2 or 3 or 4 years, there aren’t very many circulating nurses that will fail to submit the debrief.”	“It was very important to us to have senior leaders there that said ‘this is what we are going to do, and it really isn’t an option not to participate in this’ ” “We have an officer evaluation form…. It’s an opportunity for your supervisor and you to sit down and say what are the goals here? What are the expectations?... The expectation is you will fully participate in the surgical brief and debrief…. If you didn’t do that well, you might actually do poorly on your evaluation which can have adverse consequences for getting a bonus or for getting a promotion, specifically in the military.”
Clinician Leadership and Engagement	“I brought to bear the notion of my own experience in the operating room…. And I was able to convince the senior executives, the non-physician senior executives that this was an approach that would make our operating rooms and our procedural areas much safer.”	“this culture owns it because [those of us] that generally live one floor above the action really don’t have to drive this. It is substantially driven by the rank in file staff and their immediate managers who are accountable for doing the fixes.” “a lot of the remedies are in the ingenuity and the creativity of the front line staff.” “we do have a very engaged workforce, I would say that in the final mix of this were physician led, evidence based, data driven”	“our very first day we were there, we had the Chief of Surgery, the Chief of Anesthesia go through each room, if there was a problem we addressed it right then and there” “the other thing I think is really important is surgical leadership…. If you don’t get our surgeons to go along with this, it just won’t happen. We have been very fortunate here; both our Chief of Surgery and our Deputy Commander for Surgical Services are huge components to this. I think that, probably more than anything else has made the biggest difference.”	“My experience had been in the ICU, because I’m also a surgical intensivist, was that the communication piece was the critical component.” “in my room when I’m operating, it’s me-the surgeon-[who leads the debrief] and I generally like to see the surgeons doing that… If the surgeon is taking the time to lead this process, there must be some value to it.” “[Nurse leader in quality and safety] definitely had the respect of the OR personnel, she also had the respect of the surgeons too. She was a little unique in that she was able to walk in both worlds comfortably for her and people accepted her from both the surgeon’s perspective but also from the OR personnel.”

IHI Institute for Healthcare Improvement