Table 3 The Challenges Encountered in Developing and Maintaining a Debriefing Program

The Loss of Leadership Support

“the new CEO… came in probably around October of 2008 and just got blindsided by what happened in November of 2008 so his emphasis now was the bottom line… he’s trying to figure out “how do I keep this boat afloat?” and so if it wasn’t direct patient care they weren’t going to fill those positions” MI

Communication and Cultural Challenges

“I think sometimes surgeons speak one language and nurses speak another and internists speak another and if you magnify that throughout the healthcare enterprise you know maybe there’s 50 languages being spoken in a hospital, all of which is presumed to be English.” FL

“I think we’re really going to have to teach people to communicate especially health care providers at all levels. Because it’s become a huge challenge.” FL

“I don’t think we communicate well with each other. I think that there are a lot of hand-offs in health care. And each one of those handoffs is a potential red flag.” FL

“We had issues of respect and civility in the environment that created some vulnerability and increased the risk because people might be afraid to speak or raise their hand.” SC

“when a person feels that they don’t have voice or their voice is suffocated, I think they fundamentally lack confidence and disengage. Some will just check out, but some people will actively disengage and broadcast how the place doesn’t care about anything that happens, never does anything.” SC

“it was just supposed to be a verbal process, and I can tell you that the managers, it’s very interesting how people don’t want to talk to each other and for some reason the nurse managers were reluctant to do this, and whether they felt it was just another imposition on their time” MI

“we had an education part that would go out to the personnel in the operating rooms. We did not do this with the surgeons, we kind of knew we would have a lot of push back from the surgeons and I thought we’re not going to fight this fight with them” MI

Lack of early, meaningful feedback

“pretty soon, no one is collecting the data anymore, and there’s no question that if you don’t get that data and then give feedback to people, they’ll just stop giving it, they don’t see any value in it anymore.” MI

“if you’re in a workforce and you’re doing critical, complicated, potentially deadly stuff and you see adverse events happening and you experience them two weeks ago and the same thing happened six months ago and you predict it’s going to happen again two months from now, you can see how you begin over time to resent it, feel cynical, feel disempowered, and that you can’t make a difference.” SC

“Now what they will tell you, though, is “well, I put this stuff in and it doesn’t go anywhere” or “I never see that things change” and that’s something that we all struggle with” WA

“the debrief, as I said, is a little bit more out in the cloud, abstract, and we haven’t made a system yet where the feedback is more immediate.” WA

Lack of perceived “value”

“When you go to them and say “look every surgical site infection costs the hospital 11,000 dollars” or whatever number you want to use, they say “yeah, okay that’s nice but did it make any money for us?” and they just couldn’t grasp this.” MI

“I think that there’s value that is hard to parse and be able to show as being more cost effective… it would be hard to do.” WA

“Task” mentality

“we had a wrong sided hip surgery done where everybody was like, “oh yeah we did the briefing, we did the briefing”; and what they did was perfunctory. Nobody was engaged, and so the recognition was that we needed a script that called out to people to actually answer a question.” MI

“So raising the bar continuously must become an organizational imperative. If you don’t do that, you’ll stagnate.” FL

“there’s the drudgery of “do I have to produce this piece of paperwork?” but then yes there’s drudgery that you have to produce this paperwork and it’s another piece of paperwork. If that were the only thing I think that it would be one of those things that we’d have to continuously manage compliance.” SC

“for me, it’s the technological hurdles that you know we are in the military, so we want to make sure that our permission systems are highly secure but that rubs up against our desire to also have ease of access and usability.” WA

Loss of Resources

“people were increasingly asked to take on more responsibilities and in fact beyond the ability to do all of them well.” MI

“when November 2008 came the belt-tightening was significant and so now it was quite common that when somebody left their position to go to another position, their position went unfilled. So we no longer had the glue person.” MI

“So we end up having a replacement for M_ but this person now gets asked to do an audit for this and for that, and a variety of things, so she gets pulled in a multitude of different directions and then she gets another position as well, and the hospital doesn’t see fit to make the replacement” MI