The American Journal of Surgery (2010) 200, 620 – 623

Association of VA Surgeons

Briefing guide study: preoperative briefing and

postoperative debriefing checklists in the Veterans
Health Administration medical team training program
Douglas E. Paull, M.D.a,*, Lisa M. Mazzia, M.D.a, Scott D. Wood, Ph.D.a,
Max S. Theis, M.P.H.a, Lori D. Robinson, R.N., M.S.N.a, Brian Carney, M.D.b,
Julia Neily, R.N., M.S., M.P.H.b, Peter D. Mills, Ph.D.b, James P. Bagian, M.D., P.E.a

a
Veterans Health Administration, National Center for Patient Safety, 24 Frank Lloyd Wright Dr., Lobby M, Ann Arbor,
MI 48106-0486, USA; bWhite River Junction, VT, USA

KEYWORDS: Abstract
Briefings; BACKGROUND: The purpose of this study was to examine the outcomes of checklist-driven
Checklists; preoperative briefings and postoperative debriefings during the Veterans Health Administration (VHA)
Communication; medical team training program.
Operating room; METHODS: A briefing score (1, never started; 2, started then discontinued; 3, maintained on original
Teamwork; targeted cases; 4, expanded to other services; 5, briefing all cases, all services) was established at 10.1 ⫾ .3
Training months after introduction of the checklist. Outcomes included antibiotic and deep venous thrombosis
prophylaxis compliance rates before and after use of the checklist.
RESULTS: Antibiotic (97.0% ⫾ .1% vs 92.1% ⫾ 1.5%; P ⫽ .01) and deep venous thrombosis
(95.7% ⫾ .8% vs 85.1% ⫾ 4.6%; P ⫽ .05) prophylaxis compliance rates were higher after initiation
of a surgical checklist.
CONCLUSIONS: Checklist-driven preoperative briefings and postoperative debriefings are associ-
ated with improvements in patient safety for surgical patients.
Published by Elsevier Inc.

Teamwork and communication failure are a leading
cause of adverse events in health care, including the oper-
ating room.1 Medical team training (MTT) and use of avi-
ation-based crew resource management (CRM) techniques
has been associated with fewer communication errors, en-
hanced teamwork, and less technical errors.2,3 The use of a
checklist-guided preoperative briefing to verify that the cor-
rect personnel, equipment, and clinical information is avail-
able before surgery has been associated with improvement
in patient outcomes, operating room efficiency, staff satis-
faction, and patient safety indicators.4,5
The purpose of this study was to understand the effects of
checklist-driven preoperative briefings on specific patient safety
measures within the Veterans Health Administration (VHA).

Presented at the Association of VA Surgeons 34th Annual Meeting,

May 9, 2010, Indianapolis, IN.
* Corresponding author: Tel.: ⫹1-734-930-5897; fax: ⫹1-734-930-5899.
E-mail address: douglas.paull@va.gov
Manuscript received April 10, 2010; revised manuscript July 7, 2010
Materials and Methods
The VHA MTT program, as described in detail previ-
ously, includes specific training on the use of preoperative
briefings and postoperative debriefings, checklists, team-

0002-9610/$ - see front matter Published by Elsevier Inc.

doi:10.1016/j.amjsurg.2010.07.011
D.E. Paull et al. Briefing guide study
work, and other CRM techniques.6,7 More than 12,000 op-
erating room, postanesthesia care unit, and surgical inten-
sive care unit providers underwent training. One hundred
thirty facilities conducting surgical services in the VHA
were included between March 4, 2005, and June 17, 2009.
The Briefing Guide (BiG) study focused on 74 (57%) facil-
ities that responded to e-mail and telephone questionnaires
and requests for a copy of their surgical checklist. The BiG
study (2008-110733) was approved by the VA Ann Arbor
Research and Development Committee on January 13,
2009.
Checklist-guided preoperative briefing and postoperative
debriefing compliance was monitored by conducting quar-
terly semistructured interviews with implementation teams
from each facility. Briefing scores were established using a
previously described scale for each facility at the time of the
last follow-up interview (mean, 10.1 mo).6
Patient safety outcomes for the BiG study included an-
tibiotic (surgical infection prevention) and deep venous
thrombosis (DVT) prophylaxis compliance rates. Rates
were compared for the quarter before the date of the MTT
learning session to rates for the quarter 1 year after the date
of the learning session. Antibiotic compliance rates were
determined by quarterly random chart review for patients
having procedures identified as appropriate for prophylaxis
by the Centers for Medicare and Medicaid Services Surgical
Infection Prevention Project. These procedures included
coronary artery bypass grafting; other cardiac surgery,
colon surgery; hip arthroplasty; knee arthroplasty; hys-
terectomy; and vascular surgery.8 Surgical infection pre-
vention compliance rate was calculated as the number of
surgical patients reviewed receiving prophylactic antibi-
otics within 60 minutes of the time of the surgical inci-
sion divided by the total number of selected surgical
patients reviewed (⫻100).
Charts were reviewed for patients identified as appropri-
ate for DVT prophylaxis and included those having the
following procedures: intracranial neurosurgery, general
surgery, gynecologic surgery, urologic surgery, elective hip
replacement, elective total knee replacement, and hip frac-
ture surgery.9 Patients with reasons for not receiving me-
chanical or pharmacologic prophylaxis were excluded from
review. DVT compliance rates were calculated as the num-
ber of surgical patients reviewed who received appropriate
prophylaxis, anytime from 24 hours before to 24 hours after
their surgery, divided by the total number of selected sur-
gical patients reviewed (⫻100). Data, prechecklist versus
postchecklist, were compared using a 2-tailed, paired Stu-
dent t test. A P value of less than .05 was considered
significant.
Results
Facility and surgical checklist demographics are shown
in Table 1. Surgical checklists were developed by an im-
plementation team at each facility during the course of the
MTT program. The most common elements listed among
621
Table 1 Facility and checklist data
Characteristic Data (%)
Facilities, n 74
Inpatient and outpatient surgical services 65 (88)
Outpatient surgical services only 9 (12)
Acute care beds (for inpatient facilities) 199 ⫾ 35
Staff trained per facility 96 ⫾ 7
Follow-up period, mo 10.1 ⫾ .3
Briefing score at last interview* 4.4 ⫾ .1
Number of facilities that started MTT project
with briefings on all surgical services 20 (27)
Number of facilities briefing all cases, all
services at last interview 37 (50)
Number of cases briefed per month 201 ⫾ 19
Type of checklist
Paper 58 (78)
Sliderboard** 5 (7)
Poster 4 (5)
Whiteboard 4 (5)
Electronic 1 (2)
Other 2 (3)
Checklist elements 19.5 ⫾ .7
*Briefing score established at final follow-up interview: 1, never
started briefings; 2, started but discontinued; 3, maintained briefings
on originally targeted service; 4, expanded to other services; 5, brief-
ing all cases on all services.
**Sliderboard is an acryllic whiteboard with red/green sliders (not
confirmed/confirmed) next to surgical checklist elements.
the 74 submitted checklists included were as follows: pa-
tient identification (68), procedure (68), equipment (67),
position (65), imaging (65), antibiotics (65), blood avail-
ability (62), allergy (61), site (61), implants (59), DVT
prophylaxis (58), and postoperative disposition (58). Based
on this aggregate analysis, a VHA surgical checklist was
developed, piloted, and finalized (Fig. 1).
The type of checklist (coefficient (r) ⫽.04; 95% confi-
dence interval, ⫺.44 –.52; P ⫽ .87) and the number of
checklist elements (r ⫽ .006; 95% confidence interval,
⫺.02–.04; P ⫽ .68) were not correlated significantly with
final briefing scores. From the quarterly semistructured in-
terviews with facility implementation teams, checklist-
guided briefings did not wane during the study (unpublished
Medical Team Training Status Update, June 1, 2009).
Checklist-guided briefings occurred in 92% and 98% of
facilities at the time of the first and fourth interview, re-
spectively.
Reviews for prophylactic antibiotic compliance were
performed for a mean of 78 ⫾ 12 charts/facility: 45 ⫾ 7
charts/facility before, and 33 ⫾ 6 charts/facility after check-
list implementation (P ⫽ .21). Similar data for DVT pro-
phylaxis included 60 ⫾ 6 charts/facility: 28 ⫾ 4 charts/
facility before, and 32 ⫾ 4 charts/facility after the checklist
(P ⫽ .47). Antibiotic and DVT prophylaxis compliance
rates were higher during the 12 months after initiation of the
surgical checklist compared with the 12 months before
initiation (Fig. 2).
622 The American Journal of Surgery, Vol 200, No 5, November 2010
Figure 1 VHA surgical checklist.
Comments
Teamwork and communication failure are a major cause
of medical errors, including those that occur in the operating
room.10 Large organizational databases confirm communi-
cation errors as a leading cause of sentinel events, including
wrong-site surgeries.11 Aviation-based CRM techniques
and tools, adapted for health care, appear to address these
communication errors.3,12 Preoperative briefings guided by
a checklist have been associated with improved teamwork
and communication.13,14
The current study showed improvements in antibiotic
and DVT prophylaxis associated with the initiation and
expansion of checklist-driven preoperative briefings. Even
though the chart review confirmed that the patient actually
received proper prophylaxis, it is possible that the improve-
ment noted was simply better documentation. Facility compli-
ance improvement also could be a consequence of the perfor-
mance measures being introduced during the study period.
Nonetheless, these results, showing a potential patient safety
benefit using the checklist for the VHA as an entire organiza-
tion, are corroborated by those previously published by a
single, large VHA facility.5 The postchecklist VHA antibiotic
prophylaxis compliance rate of 97.0% ⫾ .1% compares favor-
ably with the 81.7% ⫾ .3% reported for non-VHA facilities
during a similar time period.15
A limitation of the study was the lack of morbidity (eg,
wound infection and venous thromboembolism rates, and mor-
tality outcome data). This study measured changes in proce-
dural compliance to assess the effectiveness of MTT within the
VHA. The World Health Organization reported a decrease in
D.E. Paull et al. Briefing guide study
Figure 2 Antibiotic and DVT prophylaxis compliance rates be-
fore and after use of the surgical checklist. *P ⫽ .01, **P ⫽ .05,
2-tailed, paired, Student t test.
unadjusted mortality (1.5% to .8%) and morbidity (11% to 7%)
associated with using the surgical safety checklist.4 Efforts are
ongoing in studying the relationship between MTT checklist-
driven surgical briefings, and adjusted surgical morbidity and
mortality as captured in the VHA Surgical Quality Improvement
Program (VASQIP) database.16
The MTT program has been successful in embedding
checklist-guided preoperative briefings and postoperative de-
briefings into the VHA patient safety culture. Checklist com-
pliance is a useful measure because it shows effective under-
standing and implementation of core CRM principles. Our
results show that an integrated approach, such as that taken in
the MTT program, which combines the use of checklist, brief-
ings, debriefings, team communication, and culture change,
can lead to a positive, sustained improvement in patient safety.
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