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Implementation of surgical debriefing programs in large health systems: an exploratory qualitative analysis
Mary E. Brindle ORCID: orcid.org/0000-0003-3695-34471,2,
Natalie Henrich1,
Andrew Foster3,
Stanley Marks4,
Michael Rose5,6,
Robert Welsh7 &
William Berry1
The role of the "debrief" to address issues related to patient safety and systematic flaws in care is frequently overlooked. In our study, we interview surgical leaders who have developed successful strategies of debriefing within a comprehensive program of quality improvement.
Semi-structured interviews of four implementation leaders were performed. The observations, beliefs and strategies of surgical leaders are compared and contrasted. Common themes are identified related to program success and failure. Quality and safety researchers performed, coded and categorized the interviews and coordinated the analysis and interpretation of the results. The authors from the four institutions aided in interpretation and framing of the results.
The debriefing programs evaluated were part of comprehensive quality improvement projects. Seven high-level themes and 24 subthemes were identified from the interviews. Themes related to leadership included early engagement, visible ongoing commitment and enforcement. Success appeared to depend upon meaningful and early debriefing feedback. The culture of safety that promoted success included a commitment to open and fair communication and continuous improvement.
There were many challenges to the success of debriefing programs. The loss of institutional commitment of resources and personnel was the instigating factor behind the collapse of the program at Michigan. Other areas of potential failure included communication issues and loss of early and meaningful feedback.
Leaders of four surgical systems with strong debriefing programs report success using debriefing to improve system performance. These findings are consistent with previously published studies. Success requires commitment of resources, and leadership engagement. The greatest gains may be best achieved by programs that provide meaningful debriefing feedback in an atmosphere dedicated to open communication.
Since the publication of "To Err is Human" in 1999, medical error has been acknowledged as a major contributor to the burden of illness in the United States (US) [1]. Preventable complications in surgery contribute significantly to this burden. Over the last 17 years, the quality and safety of surgery in the United States has been addressed through several interventions. One prominent tool developed to improve patient safety is the World Health Organization (WHO) surgical safety checklist [2]. The WHO checklist is a communication tool that involves participation of the surgical team to review issues of surgical safety at three time points: at a sign-in prior to administration of the anesthetic, at a time-out prior to the incision and at a sign-out or "debrief" at the end of the case. Implementation of the WHO Checklist was associated with dramatically improved outcomes in an international trial published in 2009 [2]. Since the publication of these findings, the checklist has been broadly adopted and incorporated into US hospital accreditation with the expectation that this would lead to national improvement in surgical safety.
Despite a concerted, national effort, the burden of medical error in the US remains troublingly high [3]. Follow-up studies of the WHO surgical safety checklist were less promising than the initial trial, and the mandated use of the surgical checklist failed to move the needle of surgical morbidity and mortality within large health systems such as that in Ontario, Canada [4]. These findings suggest that strategies that reduce surgical morbidity within the controlled settings of a trial may fail in the complicated real world. Success or failure of the checklist in improving outcomes closely relate to meaningful compliance [5]. Despite widespread institutional reports of high compliance, audits of checklist use reveal that most hospitals fail to complete the checklist, with very few institutions completing a true team-based "debrief" or "sign out" at the end of the checklist [6, 7]. The potential role of the "debrief" to address issues related to individual patient safety and systematic flaws in care is almost always overlooked and undervalued [6, 8].
The "debrief" within a three-part surgical safety checklist is alternatively referred to as a "sign-out". These terms are used interchangeably in most checklists and within this paper. However, the use of the term "debrief" emphasizes additional communication beyond acknowledgement of the tasks performed by the nursing team at the end of the surgical case. This additional communication typically addresses safety, equipment and efficiency issues arising during the case and identifies opportunities for improvement.
In contrast to many hospitals that have struggled with checklist implementation, there are a few notable institutions have used the surgical checklist effectively to improve quality and safety and continue to do so. Many of these successful institutions have specifically focused on the debriefing aspect of the checklist to address systematic issues of safety, efficiency, and communication [9, 10]. In our study, we interview surgical leaders from four centers across the United States who have developed successful strategies of debriefing within a comprehensive program of quality improvement. We examine three institutions that have maintained these programs and one institution where this program has failed.
Through a thematic analysis of these interviews, we explore effective strategies, the role of leadership, barriers and facilitators, as well as contextual factors that present stumbling blocks and opportunities for medical leaders looking to improve system efficiency and strengthen the role of debriefing in their hospital.
This study was reviewed by the Harvard Ethics Board and judged to be exempt from ethics review.
This study presents a thematic analysis of interviews of surgical leaders at four US institutions. The observations, beliefs and strategies of surgical leaders as reflected in their statements are compared and contrasted. Common themes related to program success and failure are identified. Three quality and safety researchers who are not members of the institutions under study generated the study design, performed, coded and categorized the interviews and coordinated the analysis and interpretation of the results. The authors representing the four institutions aided in interpretation and framing of the results.
Selection of target hospitals
To identify four institutions, a series of searches of the grey literature through Google search engine, word of mouth, emails and phone calls as well as searches using medical search engines were performed. The aim of these searches was not to be exhaustive but rather to identify representative programs that had developed a debriefing protocol with a strategy of process improvement in mind. One of the four target hospitals (McLeod) was known to the lead authors of this study (MB, WB). This program was also asked to identify any additional programs they were aware of that had adopted a similar strategy for debriefing.
Four centers that are geographically and administratively distinct were identified: Beaumont (Michigan), McLeod (South Carolina), Madigan (Washington), Memorial Health (Florida). The programs in South Carolina, Washington and Florida reported ongoing success while the program at Michigan had initial success but ultimately failed.
Medical and administrative leaders were contacted by both email and telephone at each site and asked if they would be willing to undergo a formal interview by telephone. We identified one key medical leader from each site.
A script for a semi-structured interview was created through an iterative process. An initial script was generated, piloted on quality and safety research colleagues and revised. The script was used as a guide for the interview but was not rigidly followed to allow for spontaneous discussion of elements not addressed within the script.
The areas of assessment that were targeted in the interviews were defined by two members of the research team (MB and WB). These included: motivation/rationale for the debriefing initiative, contextual factors, role of local leaders, implementation process, functionality, evolution/sustainability, buy-in and reinforcement. In addition, the impact of the debriefing strategy on process and safety outcomes, team-work and communication was assessed. Each interview was performed by telephone using a web-based recording program and transcribed.
Transcribed interviews were reviewed by the primary interviewer alongside the original recording to ensure accuracy.
Using NVivo, a software program designed for qualitative analysis, the transcribed interviews were coded according to themes. These themes were identified through two-stage process including deductive themes based in part on the predetermined questions and inductive themes that emerged from the content of the interviews. Each line of transcribed text was reviewed for ideas, concepts and reflections which were categorized by thematic codes. Each new idea or concept was assigned to an existing thematic code or a new code was created. At the end of coding all the interviews, each interview was reviewed again to ensure consistent coding across interviews. Coding was performed by a single reviewer. After coding, code validation was performed by a second qualitative expert who reviewed the content and coding themes for consistency. If discrepancies in coding were determined, discussion among the authors was performed until consensus was achieved. The coded themes were reviewed and broad categories encompassing these themes were created.
Narratives were collected within thematic groupings. Common observations were reviewed and discussed by the research team including the clinician leaders who had been interviewed from each site. The elements that were commonly linked to success were categorized; the challenges encountered by each program were, likewise, categorized.
The program at Beaumont, Michigan, was examined as a separate case study. The threats to the success of the Michigan program that eventually lead to its collapse were identified.
How these threats might be prevented or mitigated were reviewed and are presented within the discussion.
All narratives are presented as verbatim. Any changes that are provided for clarification are presented in square brackets.
The four implementation leaders interviewed had developed their strategies within four very different health systems.
Madigan is an Army Medical Center in Washington that performs roughly 10,000 surgeries a year and has 220 inpatient beds. Madigan is staffed by 54 surgeons, 12 anesthesiologists and 49 certified registered nurse anesthetists (CRNAs). Dr. Andrew Foster is Chief of Anesthesia at Madigan and was a physician leader who took on a primary role in creating and maintaining the debriefing program at Madigan.
Memorial Health is a large public health system in Southern Florida including five hospitals with a total of 1858 beds and 62 ORs staffed by 545 surgeons, 101 anesthesiologists and 53 anesthesia assistants as well as 112 CRNAs. Dr. Stanley Marks is a surgeon and Chief Medical Officer for Memorial Health, who developed a comprehensive approach to patient quality and safety that has been instituted across Memorial Health.
McLeod Health is a large private health system including seven hospitals in South Carolina. McLeod regional center completes 19,000 cases a year and has 489 beds. The OR is staffed by 125 surgeons, 12 anesthesiologists and 50 CRNAs. Dr. Michael Rose is an anesthesiologist and Vice President of Surgical Services at McLeod Regional Medical Center and has helped lead a state-wide initiative to improve Surgical Safety in South Carolina.
Beaumont is a large public health system including eight hospitals and performing more than 50,000 surgeries every year in Michigan. The system is staffed by 600 surgeons, 84 anesthesiologists and 145 certified registered nurse anesthetists. Dr. Robert Welsh is Vice Chief of Surgical Services at Beaumont Hospital- Royal Oak and developed the program of surgical debriefing for surfacing safety defects at Beaumont Hospital.
In analyzing the interviews of these leaders, seven high-level themes were identified with an additional 24 subthemes that fell within the high-level umbrella themes.
Figure 1 illustrates the broad thematic categories as well as the subcategories.
Themes Identified in Interviews
Implementation of the debriefing program
The clinician leaders we interviewed all adopted primary leadership roles in initiating programs as well as promoting the importance of the program within the clinical teams and executive leadership. These leaders are passionate, articulate and deeply committed.
Each of the four programs we present used a team training approach as the structural framework on which their programs were built. Different programs used different team training platforms. Two of these programs adopted the formal team training program TeamSTEPPS™ (Memorial Health and Madigan) [11] while two program adapted team training programs from non-surgical specialties. McLeod adapted an airline safety model from FedEx while Beaumont adapted the Keystone ICU team-based quality improvement strategy [12]. Common elements to all these programs included a strong focus on teamwork, communication and clinical leadership all with a goal of improved patient safety. Standardization was important both within single centers as well as between centers operating as part of a single health system.
Role of debriefing within a larger program of quality improvement
Although each interviewee reported that debriefing was part of a much larger implementation strategy at their centers, they acknowledged that the debriefing offered a very specific, crucial contribution to quality improvement. For each program, the debrief aims to identify and address flaws in the system and improve patient safety and system function. Education, piloting, stakeholder involvement and feedback are involved at all centers as strategies used to design and implement programs.
Operationalization of the debrief
The operationalization of the debrief differed from site to site. The debriefing is generally run by nurses but sometimes this responsibility rests with the surgeon. Participation of all members of the surgical team is an expectation in all programs. The physical form of the debrief itself is not consistent. While McLeod and Michigan use paper systems, Memorial uses an established electronic system and Madigan is working with an electronic system that is being revamped. Many of these systems rely on an administrator who categorizes the issues identified in the debrief, assigns tasks to address the issues and provides feedback regarding the plan and eventual resolution. These programs have all reported tremendous value from their programs in teamwork and communication, satisfaction and measures of efficiency and patient safety [9, 10, 13, 14].
Factors key to program success: leadership
All four interviewees identified executive leadership as important in both creating and maintaining programs (Table 1). Early leadership participation in establishing and prioritizing the program, ongoing on-site engagement as well as the creation of enforcement measures all represent different ways in which the administrative leadership helped to support programs.
Table 1 How Leadership works to Promote a Successful Debriefing Strategy
Early, aggressive administrative engagement
At each site, the highest levels of administrative leadership played an important role at the outset of implementation. At Madigan and at MacLeod, executive leadership provided the initial impetus for program development, giving clinician leaders an opportunity to create a process with strong administrative support. In Florida, the executive was convinced by local physician leaders and subsequently made the program a priority. In Michigan, there was strong endorsement of a debriefing program that was established by clinician leaders. The leadership commitment required was described by Dr. Stanley Marks: "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".
Executive experience with quality improvement (not necessarily in surgery)
Although some administrators had never set foot in the operating theaters prior to the implementation of these programs of system improvement, many executive leaders had experience in other system-wide quality improvement strategies. Individual experiences ranged from experience in the flight industry, work within the commercial industry as well as direct involvement with medical quality and safety. Dr. Michael Rose described the quality improvement experience of one of their hospital board members:
"His job had been with [a large national manufacturing company… that had a very high work force injury rate and very high workforce turnover from poor morale; and the last major project that he did with [the company] … was coming in and creating a culture of safety…. I think they got up to something like 1,000 days without an injury before they had their first one which was relatively minor but it was the turnaround on their culture of safety and their injury rates, so he was quite an expert in general execution in the cultural aspects and the kind of seriousness and support that you needed from leadership when you took on an effort like this."
Ongoing, visible, on-site administrative involvement
The programs that remained successful all reported strong ongoing engagement of leadership. At McLeod and Memorial health, this engagement took the form of executive staff being physically present in the operating rooms and other areas where clinical care takes place. This physical presence performed two functions, 1) keeping the executive staff aware and more directly connected with the issues faced by the front-line staff, and 2) reinforcing to the front-line staff the genuine commitment of the institution to the process. Dr. Michael Rose summarized the importance of this onsite presence; "the ability to reach out to senior people, up to and 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". In Memorial Health Care and McLeod, the ongoing direct involvement of the highest levels of executive staff remained an important part of the program long after the original implementation.
Institutional mandates
An institutional mandate has helped to maintain the debriefing programs at Memorial Health and at Madigan. At Memorial Health, participation in team training was directly tied to the privileging of staff while the military structure at Madigan allowed reinforcement to be tied to military promotion and discipline. The leadership at McLeod engaged staff participation through repeated and direct communication between administration and frontline staff. Using an institutional mandate as a method of achieving participation was described by Stanley Marks; "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." Dr. Andrew Foster described a similar approach at Madigan "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'."
Factors key to program success: creating a culture of safety
Developing a culture of safety and using meaningful feedback to generate a pattern of continuous improvement are common themes that arose during the interviews (Table 2). Creating and maintaining a "just culture" dedicated to surgical safety involved a focus on empowering surgical nurses and encouraging open communication.
Table 2 Elements of a Successful Debriefing Program: Creating a Culture of Safety
Empowerment and "Leveling the Playing Field"
Each of the leaders interviewed acknowledged that the traditional hierarchical approach to communication posed a threat to patient safety. Leveling the playing field allowed all members to recognize and report threats to patient safety and improve communication. Dr. Michael Rose described this process as giving voice to "a group of people who felt they had the least amount of respect, the least amount of ability to influence events, but once released and empowered, had a huge impact".
Empowering nurses means providing them with support from the highest levels of administration. Dr. Andrew Foster describes the structure of support at Madigan in Washington: "… we have empowered our nurses and techs to say 'hey, we're not bringing this patient back until we've talked; because number one I've been empowered to speak up if I see a safety issue; and number two I'll go to my leadership, I'll go to your leadership as a matter of fact.'"
Creating an atmosphere of open communication was often described as a responsibility that rested with the surgeon; who would invite input from all members on things that could have been done better. To emphasize that everyone's voice was valued, the surgeon would first ask those who were traditionally less likely to speak up. Dr. Robert Welsh is a clinician leader who exemplifies this approach: "Even if it was a medical student in the room, I would ask the medical student [to speak first in the debrief] and half the time they had no clue what we had done; but sometimes they might have seen something; and then it was on to the next level trainee, moving all the way up in to the most experienced people; and I usually went last."
Feedback on debriefing issues to stakeholders
Feedback on the issues raised in the debrief was commonly regarded by the clinical leaders as the cornerstone to successful debriefing. Providing caregivers with early and meaningful feedback on identified problems gave the participants the satisfaction of seeing their problems recognized and prioritized, allowed repetitive issues to be addressed and gave the participants faith that the debrief achieved a purpose. Dr. Robert Welsh reported that even the surgeons who were resistant, became fans of the process: "they were complimentary of the process saying, 'if I put it in the debriefing, I know it's going to get attended to'". Feedback provided to the executive also provided an additional way in which leadership could be further engaged in process improvement.
Focusing a system on continual improvement is a strong part of creating a culture that focuses on surgical safety. The process is described by Dr. Stanley Marks: "you've got to continually move the minimum standard to the right side of the equation so that you narrow your bell curve…. Raising the bar continuously must become an organizational imperative".
Challenges to the debriefing program
Each of the leaders interviewed spoke about challenges that they had encountered in the process of implementing the debriefing program and challenges that pose a constant threat to ongoing performance (Table 3).
Table 3 The Challenges Encountered in Developing and Maintaining a Debriefing Program
The loss of leadership support and resources were concrete threats to the ongoing effectiveness of these programs. In Michigan, Dr. Welsh describes the change in leadership as coinciding with a change in institutional priorities: "the new CEO… came in probably around October of 2008 and just got blindsided by [the economic downturn] 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?'"
In addition, breakdowns in communication lead to the reluctance of disempowered team-members to speak up and lead team members to disengage with the process.
Dr. Stanley Marks provided an illustration of the wide-spread issues with communication in health care systems: "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."
Dr. Michael Rose described the feelings of disillusionment that lead to disengagement in a system that fails to achieve an atmosphere of open communication: "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."
Providing early meaningful feedback was frequently identified as a key to team members valuing the checklist. When feedback was no longer reliably provided, leaders recognized that this represented a great threat to meaningful participation with degeneration of the debriefing and the entire checklist into a "task" or complete abandonment.
Dr. Michael Rose describes the dangers of the lack of meaningful feedback: "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."
Beaumont hospital, Michigan: Why did it fail?
Beaumont hospital faced many of the same challenges that other programs faced. Unlike these programs, the system eventually collapsed. An examination of the processes that eventually led to the program's failure illustrates the fragility of these systems (Fig. 2).
System Collapse at Beaumont, Michigan
Dr. Robert Welsh identified the financial crash of 2008 as being the catalyst for the program's collapse. This occurred at the same time as a change in executive leadership. Although executive leadership had supported the program, their involvement was at more of an arms-length than the other programs we have examined and this leadership change further distanced the leadership from the debriefing program. The economic advantages of a debriefing program were not easy illustrated and operated based on costs saved or avoided rather than revenue generated. Robert Welsh describes how the economic impact of 2008 affected the administration's views on revenue generation and cost-savings:
"They don't see that costs avoided are worth considering as much as…"how did I negotiate a contract or save money?" or "what did I do to increase the income?"… the averted cost was just not something that they were willing to recognize. 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."
The debriefing program was not seen as a priority to the administration in a situation of scarcity and the key position of the quality and safety nurse was gradually phased out. The nurse in this position facilitated assigning responsibility for dealing with debriefing issues and providing feedback. Once this process was no longer performed adequately, those using the checklist no longer saw the value of the process and stopped participating in this. This loss of feedback was regarded by Dr. Welsh as the key aspect that led the program to collapse: "…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."
With the change in the executive leadership, the voiced institutional support of the program was also missing and the clinician leaders of the debriefing program no longer had the support of the administration and the culture of safety was no longer a prevalent force.
Improving surgical safety through debriefing is a complex endeavor. Although the role of debriefing is acknowledged as an important part of surgical safety, debriefing is rarely performed in institutional audits of checklist compliance [5, 7]. We have examined four programs that have effectively instituted debriefing systems to improve patient safety and the overall effectiveness of the health system. The leaders of these systems have commonly identified strong executive leadership involvement, meaningful and early feedback and a culture of safety and continuous improvement as keys to their success. Each program recognizes ongoing threats to the success of their programs. These threats are those of resources (financial and personnel), the loss of meaningful and early feedback, and the perseverance of traditional hierarchies resulting in the failure to achieve fair and open communication. In the case of Michigan's debriefing program, a loss of resources was the catalyst to the eventual collapse of the debriefing program primarily when meaningful feedback was no longer provided to the surgical teams.
Debriefing is well-established in many high-acuity disciplines where it contributes to a culture of communication, reflection and continuous improvement. The American Heart Association strongly promotes the use of debriefing to improve the running of codes [15]. Studies of debriefing after codes demonstrate improved team communication as well as improved performance measures and clinical outcomes. [16,17,18,19]. Similar results are seen when debriefing is applied to trauma care [17, 20]. The four interviewees in our study all pointed to numerous ways in which debriefing in surgery contributed to improved clinical care, patient safety, communication, attitudes and efficiency at their institutions. Although patient safety is the priority for each of these programs, the debriefing also offered an opportunity to improve performance measures related to process- expanding the potential value of the program and acting, in part, as a Trojan Horse to introduce important safety alongside those measures that improve the business-side of surgical systems. Published results from Madigan, Washington specifically show improvement in operating room efficiency [10] while the program at Beaumont found numerous communication and equipment issues that improved with the use of debriefing [9]. In institutional publications and presentations, the Memorial Health System in Florida reported improvements in communication, measures of satisfaction, teamwork and safety culture [14] while McLeod Health reported improvement in surgical mortality, a decrease in patient safety events and an improvement in measures of satisfaction and attitudes surrounding safety [13].
There is no simple answer as to why debriefing is not adopted routinely after surgical procedures. Qualitative studies through surveys and interviews suggest multiple reasons including logistical challenges and a perceived lack of value [6, 8]. The logistical challenges relate to the different times at which team members' roles conclude in surgical procedures and the competing requirements of circulating nurses who are frequently tasked with running the debriefing. The perception that debriefing lacks value relates to the fact that some elements are redundant, other elements may not be directly applicable to the care of the patient and issues arising in the debrief are not addressed or valued by the institution [8].
The lack of a strong culture of surgical safety likely contributes to the devaluing of the debriefing both by the institution and by the team members who directly participate in the care of the patient.
The interviewees from each of the four sites recognized that an immediate tangible value of the checklist would best ensure that the surgical team would participate in debriefing. Often this meant addressing concerns that impacted the teams' ability to perform its job efficiently in addition to other issues related to improving performance. The fact that issues of equipment and process could be corrected and the surgical team could experience the immediate benefits of participation, gave them a greater commitment to the process.
To improve the culture of surgical debriefing and create a meaningful debriefing process, interviewees acknowledged that the institutional approach should be broad-sweeping, targeting all levels of care and administration with a strong focus on empowerment of nurses and those members of the surgical team who have traditionally not had their voices heard. To create a system in which nurses are empowered, the focus needs to switch from individual performance to team success. In most situations, this requires an institutional culture change. Changing the culture of an institution requires a comprehensive strategy in which team training may play a critical role.
When quality and safety tools are applied without an institutional strategy for ongoing implementation, they are likely to fail. This can be seen in studies of surgical safety checklist that do not specifically involve implementation strategies [4, 21]. When the checklist is introduced as a tool to facilitate communication within a broader institutional strategy, the impact can be tremendous [22]. Programs that succeed in developing debriefing programs to improve surgical safety must remain committed to ongoing improvement and a commitment to communication.
There are many threats to the ongoing success. At Beaumont Hospital in Michigan, the loss of resources was devastating to the debriefing program as key positions were defunded. It is possible that if the executive administration valued the program more either economically or within a stronger institution-wide culture of safety, economic scarcity might not have had the same impact. Stanley Marks at Memorial Health in Florida reflected that the value of the program is so engrained within the institutional culture that it is not likely to be impacted by scarcity. But maintaining the institutional culture takes work. Even in programs like Memorial Health, Stanley Marks refers to the constant threat of degeneration into a "task" mentality.
The value of the debriefing systems established by four surgical centers in diverse settings across the United States is tremendous. Even in Beaumont, where the system failed, there remains a strong commitment by clinician leaders to re-establish the program. The fragility of these systems exposed by the collapse at Beaumont underlines the importance of strong executive involvement, a reliable system of meaningful feedback and prioritization of communication within a system designed to constantly improve.
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The authors thank James Sachetta who helped to arrange and record interviews and Ali MacRobie for transcribing the interviews.
This project was done without funding support.
All data generated or analyzed during this study are included in this published article [and its supplementary information files].
Ariadne Labs at Brigham and Women's Hospital and the Harvard TH Chan School of Public Health, Boston, MA, USA
Mary E. Brindle
, Natalie Henrich
& William Berry
Department of Surgery and Community Health Sciences, University of Calgary, Affiliate Faculty, Ariadne Labs, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, AB, T2N0Z6, Canada
Department of Anesthesia and Operative Services, Madigan Army Medical Center, Tacoma, WA, USA
Memorial Healthcare System, Fort Lauderdale, FL, USA
Stanley Marks
McLeod Health, Florence, SC, USA
Department of Surgery, University of South Carolina School of Medicine, Columbia, USA
Beaumont Health-Royal Oak, Royal Oak, MI, USA
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>MB Designed the study, developed the interview scripts, performed the interviews, coded the interviewer responses, analyzed the responses and generated the manuscript. NH Helped develop the interview scripts and the approach to data coding as well as data abstraction, aided in framing the results and revising the manuscript. AF, SM, MR, RW identified key themes and provided information from each of the four centers, they aided in interpreting and framing the results. Each author aided in manuscript revision. WB conceptualized the study and developed the study design. He aided in manuscript revision. All co-authors have reviewed the manuscript and approve of it in its final form.
Correspondence to Mary E. Brindle.
This study was reviewed by the Harvard Ethics Board and judged to be exempt from ethics review as it was judged to be "minimal risk" for participating subjects. Each participant was offered the opportunity for anonymity within the study but each participant asked that they be identified. Informed consent was obtained from all participants prior to being interviewed.
Written informed consent including consent for publication of identifying information was obtained from all participants.
Brindle, M.E., Henrich, N., Foster, A. et al. Implementation of surgical debriefing programs in large health systems: an exploratory qualitative analysis. BMC Health Serv Res 18, 210 (2018) doi:10.1186/s12913-018-3003-3


Benarkin State Forest on the Blackbutt Range is a great spot to picnic, fish, spot platypus or hike or ride on forest trails.
An opulent bronze, marble and sandstone cenotaph has stood in Esk since 1921, even though it took another 58 years for the surrounding park to be proclaimed as a memorial reserve. The foundation stone was laid in December 1920 by Colonel Graham Butler, the original medical officer who landed with the Queensland 9th Battalion at Gallipoli. The Esk Patriotic Committee had started fundraising in 1916. They needed £885, a high price for a community paying a high human cost. Of the 545 men from the Esk district who enlisted, 83 died. All the names are captured on this monument. Fixed bronze plates on the base bear the names of the dead. The others' names appear on huge bronze plates fixed to recessed marble panels. Designed by Georg Brockwell Gill of Ipswich, the stonework was executed by masons Frank Williams & Co. Art metalwork was supplied by Wunderlich Ltd of Sydney. The memorial park, proclaimed in 1979, was extended four years later. It now includes a stone memorial to Captain Patrick Logan, commandant of the Moreton Bay Penal Settlement who was murdered while exploring the Brisbane Valley in 1830, and plaques honouring those who died in WWII and post-1945 conflicts.
The Fernvale Country Markets take place weekly every Sunday at the Fernvale State Primary School located along the Brisbane Valley Highway, Fernvale. Drop in for a spot of Sunday morning shopping and pick up some fabulous locally made gifts and wares as well as some country fresh, locally grown, Somerset produce.
The Fernvale Murals were conceived as a community project to help re-establish pride and confidence in the town after the trauma of the 2011 floods. There are three murals located around the Fernvale Memorial Park along the Brisbane Valley Highway.
Henry Lawson Bicentennial Park, located opposite the state school in the township of Walloon, is just 15 minutes' drive from Ipswich. The park, home to the Babies of Walloon memorial, is one of the key points of interest on the Cobb & Co Tourist Drive. The striking memorial to the lost Babies of Walloon commemorates the tragic drowning at a local waterhole of two school children, sisters Bridget and Mary Broderick. The tragedy became the subject of a poem by Henry Lawson, "The Babies of Walloon", and the text of this haunting poem is carved in railway sleepers placed around the memorial. As well as the memorial, the link to Henry Lawson is strengthened by the annual Poet's Feast which is staged at the park using the bronze Henry Lawson lectern and poet's platform. The park isn't just about poetry however, with other facilities including playground equipment, BMX track, skate park, sheltered barbecue areas and public toilets all being part of the fabulous amenities.


Thanks for the link- good stuff. I was there but never saw the stage. Having been educated at Woodstock I parked on the other side of town and biked in to the track. A good move, but the bike limited my mobility once I got near the venue. I just parked in the woods and listened.
Thanks for sharing! Was my second time seeing The Grateful Dead and first time for The Band and Allman Bros. Was there for the sound check and the next two days. Was amazing!
thanks for sharing! cool story. Anyone notice that the picture of Bob and Jerry seems to show Bob playing a strat style guitar (all the pegs seem to be on top) Unless i'm way off mark he was playing the 345 or SG around this time right?
I love this story. Makes me realize that I was born a few years later then I should have been.
It looks like a strat, but the knobs are weird and there's a rotary switch..
Not 100% sure, but the above photo (Weir playing a Fender) does not look like Watkins Glen Summer Jam 1973.
In fact, the above photo looks doctored.
The Dead's roadies would set up the stage the same way every time, but there would always be slight differences from concert to concert.
To be sure a given photo is from a given concert, you take the bulk of the photos that can be found Online (that match up in general) and go from there.
So, for Watkins Glen, the key identifiers for photos are the strips of tape on Keith's piano combined with the knots of wood on the back wall.
In the above photo, the piano cannot be seen to reveal the strips of tape, but the back wall can be seen.
The knots of wood do not match other photos that show both the piano tape strips and the back wall.
And then there is the phantom in the photo.
+1 I was there and at many subsequent shows of that era and I was thinking the same thing(s) plus there is no electrical tape "X" on any of Phil's speakers! Goods eyes!
Regardless of whether or not it is actually Watkins Glen, any ideas about what the heck that funky guitar is that Bob is playing?
Looks like a Tele neck?
Still looking into this, trying to puzzle it out.
All evidence suggests that the above photo was Watkins Glen Summer Jam 1973. Have found some other interesting evidence and it will take a few days to assemble everything into a coherent timeline understanding.
The above photo, at this point in my understanding, was most likely from Friday, July 27, 1973. On Friday the stage was in constant flux with the Band and the Dead. Stuff was getting placed and moved around constantly. Since this would be the soundcheck, probably the first set, when it was still slightly daylight outside, you can see that things are scattered around to some extent. For example, one of Bill's drum-kit cases is on top of a speaker, and it may be that the guy to his right is a roadie, tightening things on one of his cymbal stands. The headless phantom!
Let me sort this out, and I'll get back with pics. Should be interesting.
Almost looks like a modded Danelectro .


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Alien: Covenant Review
May 7, 2017 admin Artistswork Movies
Ridley Scott's latest Alien movie finally answers some important questions while returning to the series' horror roots.
By Daniel Krupa
Alien: Covenant director Ridley Scott must've heard the screams of frustration as Alien fans left theatres after watching Prometheus in 2012. Like the Prometheus' crew, I'd waited so long and come so close to the origin of it all, yet left knowing so little. What exactly is that aggressive black goo? What did we do to anger our creators to deserve obliteration? Why do experienced scientists think it's okay to poke stuff? With more questions than answers, I felt cold on it – and I wasn't alone.
While Covenant continues to pose new questions, it also provides answers, and does so within a much more immediately enjoyable and rewarding experience. In many ways – stylistically, thematically, structurally – it sits neatly between the existential ponderings of the previous film and the sumptuous horror of the 1979 original. And while it fails to match the original in terms of sheer terror and elegance, Scott nevertheless delivers some imaginative takes on familiar sequences and rich, satisfying answers to Prometheus' lingering mysteries.
Covenant begins, true to form, with a crew emerging from hyper-sleep. They're pioneers; a mixture of engineers, scientists, and pilots transporting colonists in stasis to a distant planet carefully selected to be their new home. But during the long voyage, the crew is lured to what appears to be an even better site for their colony.
From hereon, Covenant delivers a focussed, suspense-driven story as various members of the crew play host to a variety of vicious parasites which burst forth in gruesome fashion. Scott even offers up a grisly new rendition of the infamous chestburster sequence which is an effective and full-on piece of body horror, though it's almost impossible to match the surprise of the 1979 original. It's an early statement of intent: the sterile musings of Prometheus violently give way to splintering ribs and blood-spattered med bays.
Scott initially holds back the classic xenomorph teased in trailers in favour of a pale, haunting creature – already being referred to as the 'neomorph' by fans of the series – which is no less aggressive and, when fully grown, possesses an eerie quality all of its own.
The classic alien is withheld for good reason, and when it finally makes an appearance, it's worth the wait, punctuating the most intriguing and disturbing section of the movie. It remains one of the greatest monsters in all of cinema, though it's still strange to see H.R. Giger's original design brought to life with computer animation and moving with such intense ferocity and speed. It's not badly done by any means, just at odds with how that creature was originally used. In Covenant, you see it so nakedly, performing a variety of actions outside and in full daylight, when before so much of it was cloaked by the Nostromo's shadows, leaving your imagination to fill in its sinister mystery.
Covenant's early action sequences are exciting; even though much of what unfolds has been seen before in the series, it's testament to Scott that he's able to find new and visually striking ways of tackling these set pieces. Covenant is the first film in the series (not counting the awful AvP spinoffs) to take full advantage of outdoor locations adding novelty to what could've otherwise be a staid sequence. One particularly memorable and violent attack takes place in a field at night, with juvenile creatures scurrying between sheaves of wheat by torchlight.
Scott's compositions and visuals benefit from how he dovetails detailed sets with impressive location work. It's like watching an idyllic postcard of New Zealand fade into one of Hieronymus Bosch's hellish landscapes.
The procession of slaughter feels all more heart-wrenching this time around because the crew is composed entirely of married couples. Although it makes plenty of sense for when you need to populate a new planet, it proves to be a less than a good idea when difficult decisions need to be made in fraught situations. It does a better job of justifying why smart, highly-trained people people end up doing such dumb things than most Alien movies.
The cast is strong: Katherine Waterston plays the resourceful Daniels and deftly handles the tricky transition from supporting role to heroine; Billy Crudup perfectly suits the friendly yet out-of-his-depth captain; Danny McBride, meanwhile, does a lot with limited screen time to establish pilot Tennessee as the most likeable crewmate. Of course, the crew is violently whittled down by the end, but each death feels much more impactful because they're mourned by their partners – the person who loved them the most, and with whom they left Earth to start a new life. The person left alive is not only totally alone but in mortal danger themselves. It's yet another effective spin on a familiar set-up.
Towards the end of the movie, however, the invention that dries up to a degree, with Scott delivering what feels like a compressed version of the original Alien. The outdoor scenes are replaced by claustrophobic corridors and pinging motion-trackers. I'm not sure if it's knowing self-homage by Scott or a lack of new ideas for how to end this sort of movie – regardless, it's still a fun conclusion, though slightly cliched next to the invention that precedes it.
Sandwiched between the fresh first act and that somewhat more predictable conclusion, Covenant smuggles in a more thoughtful and philosophical second act; it's where the movie is at its most Prometheus-like in tone – ponderous, even a little pretentious – but unlike the divisive prequel, Covenant has some genuinely satisfying answers.
It's a movie that isn't afraid to ask big questions but, more often than not, it does so by unsubtly spouting them out of the mouths of its characters. While the original had enough uterine architecture and slimy things slipping down throats to raise scholarly eyebrows, Covenant confronts its ideas head-on; it's the sort of movie where characters quote Paradise Lost and listen to Wagner's Das Rheingold to make their points. It's unapologetically bold and brash in its handling of intellectual material, but it sort of works for a few reasons.
For one, the reveal of how and why the xenomorphs were created is rewarding within the terms Scott laid out in Prometheus. And none of this would've worked without the performance of Michael Fassbender, who once again plays the ship's android. He delivers a lot of the stodgier material with ease while gracefully wading through the rising melodrama, conducting Scott's bombastic sci-fi symphony with total conviction. Even when things become faintly ridiculous, he remains utterly compelling.
Ridley Scott returns to the universe he created in ALIEN with ALIEN: COVENANT, the second chapter in a prequel trilogy that began with PROMETHEUS — and connects directly to Scott's 1979 seminal work of science fiction.
Alien: Covenant strikes a more favorable balance between the unwieldy philosophical ideas of Prometheus and the classic horror and suspense of the 1979 original film. Despite continuing Prometheus' questionable line of inquiry into the xenomorphs' origins and occasionally adopting its histrionic tone for entire scenes, Covenant's framework and exciting action put enough new spins on the series' most reliable touchstones that the cast is able to carry it through to a satisfying end.
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