Crew Resource Management

1
Crew Resource Management

• Donna Moore, RN, MBA, CPHQ
• Commercial licensed pilot
• Project Leader, Ohio KePRO

2
Objectives

• Describe Crew Resource Management
• Discuss optimizing heart failure care using Crew
  Resource Management
• Summarize Crew Resource Management and its
  application

3
History and Background

• Faulty construction vs faulty turns 1911
• 47 accidents and 3 fatalities 1909
• 101 accidents and 28 fatalities in 1910
• Faulty construction - approximately 50
• Mistakes of the pilot
• State of the weather
• Fault of the public

4
Errors

• Aviation accidents investigation by FAA and
  NTSB
• Results in cause factors, public reports,
  remedial actions
• 70 involve human error
• Medical errors no standard method of
  investigation,
• documentation, and dissemination
• IOM Between 44,000 and 98,000 die from medical
  errors
• Medical errors cost 37.6 billion annually
• 17 billion is lost in preventable errors
• Litigation and new regulation seen as a threat

5
Errors

• Causes of error include
• Fatigue
• Workload
• Poor communication
• Imperfect information processing
• Flawed decision making
• Teamwork required
• Team breakdown action or inaction leading to
• deviation from team or organization intention

6
History and Background

• Crew Resource Management (CRM)
• Focus on the effective use of all available
  resources
• including human resource, hardware, and
• Information
• Workload management, situational awareness,
• communication, leadership role, crew coordination
• Not a single task but a set of skill competencies

7
History and Background

• Aviation Crew
• Dispatchers
• Cabin crewmembers
• Maintenance personnel
• Air traffic controllers
• FSS - weather

8
History and Background

• Healthcare crew
• Intensive care units
• Physician Nursing personnel
• Clerical Ancillary departments
• Surgical suites
• Surgeon Anesthesiologist
• CRNA Resident staff
• Nursing staff Ancillary departments
• Emergency departments
• EMT Emergency physician
• PCP Nursing
• Ancillary departments

9
History and Background

• Helmreich study (Healthcare)
• Communication attitudes in hierarchy ¼
  reported they are not
• encouraged to report safety concerns
• 1/3 said safety concerns are handled
  inappropriately
• Errors committed during patient management are
  not
• important as long as the patient improves

10
History and Background

• Helmreich study (Healthcare) (cont.)
• 1/3 did not acknowledge they make errors
• More than ½ find it difficult to discuss mistakes
• Personal reputation
• Threat of malpractice
• High expectations of the patients family or
  society
• Possible disciplinary actions by licensing
  boards
• Threat to job security
• Egos of other team members

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History and Background

• Helmreich study (Healthcare) (cont.)
• Most common suggestion ICU to improve care More
  staff
• Most common suggestion in OR to improve care
  Improve
• communications
• Surgeons are most supportive of steep hierarchies
  where junior
• staff do not question

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Crew Resource Management (CRM)

• Similarities to aviation
• Complexity
• Training intensity
• Time constraints
• Scrutiny
• Teamwork dependency
• Why we do CRM
• To overcome inevitable human error patient
  safety
• To capture and improve best practice team
  effectiveness
• To encourage collaboration and cross check
  safety and effectiveness
• To improve teamwork safety, effectiveness,
  staff satisfaction
• To harness brainpower effectiveness

13
Crew Resource Management (CRM)

• Perception of poor teamwork by one member is
  enough to
• change dynamics of team
• Effective teamwork has several positive sides
• Fewer and shorter delays
• Increases in morale
• Increase in job satisfaction
• Increase efficiency

14
Crew Resource Management (CRM)

• Changing behavior and attitudes
• Situational awareness anticipation and
  recognition of current
• events or events likely to occur
• Improved decision making team leader had
  shared
• information

15
Crew Resource Management (CRM)

• CRM Principles
• Command exercise of duties associated with the
  person in
• charge
• Responsibility
• Authority
• Accountability
• Team coordination

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Crew Resource Management (CRM)

• Leadership exercise of a team members rights,
  obligations
• and responsibilities to ensure a safe, efficient
  and successful
• outcome
• Team climate
• Mentoring
• Professionalism
• Conflict resolution

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Crew Resource Management (CRM)

• Communication exchange of ideas, information
  and
• instruction in an effective and timely manner so
  messages are
• correctly received and clearly understood
• Team communications
• Inquiry
• Advocacy
• Barriers

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Crew Resource Management (CRM)

• Situational awareness level and accuracy of
  knowledge
• about the past, present and future state of the
  environment
• Review
• Monitor
• Predict
• Workload management organizing tasks to ensure
  equitable
• workload distribution
• Planning and prioritizing
• Workload recognition
• Delegating

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Crew Resource Management (CRM)

• Decision making process of determining and
  implementing a
• course of action and evaluating the outcome
• Styles
• unilateral, consultative, collaborative
• Problem solving
• Decision making
• Review/critique

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Crew Resource Management (CRM)

• Resource management optimal use of all
  available
• information and other forms of assistance both
  internal and
• external to the team
• Identification
• Prioritization
• Application

21
Crew Resource Management (CRM)

• Measurement
• Days between wrong site surgeries
• Safety occurrences
• Employee satisfaction survey
• MM
• Process measures
• Risk management case files opened
• Performance assessment

22
Crew Resource Management (CRM)

• Implementing Healthcare CRM
• Survey of the organizational safety culture, the
  patient flow process, and a review of any
  internal safety concerns
• CRM team training, which discussed command,
  leadership, communication, situational awareness,
  decision-making, resource management, and
  workload management
• Newly formed teams apply the knowledge gained to
  job specific case studies and simulations through
  targeted workgroups
• Organizational change agents

23
Crew Resource Management (CRM)

• Implementing Healthcare CRM (cont.)
• Measure CRM skills in real time through debriefs
  following
• actual procedures
• Coaching where briefings and checklists are
  reviewed.
• Error reporting systems are examined or created
• Reports the outcomes established as a result of
  CRM

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Crew Resource Management (CRM)

• Link to JCAHO Safety Goals
• Improve the accuracy of patient identification
• Improve the effectiveness of communication among
  caregivers
• Eliminate wrong site, wrong patient, wrong
  procedure
• Improve the effectiveness of critical alarm
  systems
• Reduce the risk of health care-acquired
  infections
• Leapfrog Culture of Safety
• Train all staff in techniques of teamwork based
  problem solving and
• management
• Provide professional training and practice in
  teamwork techniques

25
Risk Elements

• Pilot in command Surgeon, Emergency physician
• Aircraft Equipment available
• Environment Emergency Department could include
  other patients
• Operation Task being performed

26
Aeronautical Decision Making (ADM)

• Aeronautical Decision Making (ADM)
• A systematic approach to the mental process by
• aircraft pilots to consistently determine the
  best
• course of action in response to a given set of
• circumstances

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Five Elements of ADM

• Pilot in command responsibilities physician
• Communication ability to clearly convey
  information
• Workload management
• Resource use
• Situational awareness

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Self Evaluation

• Illness
• Medication
• Stress
• Alcohol
• Fatigue
• Eating

29
Hazardous Attitudes

• Anti-authority Disregard rules
• Impulsivity Do not stop to consider the best
• alternative
• Invulnerability Adverse outcomes happen to
  other
• Macho Prove they are better than others
• Resignation Do not see themselves making a
• difference

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Workload Management

• Ensuring that workload management that
• essential operations are accomplished for
• planning, prioritizing, and sequencing tasks to
• avoid work overload
• Checklists
• Dealing with distractions
• Maintaining situational awareness of operational
• and environmental factors

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Threat and Error in Medicine

• An effective model should
• Capture the context of patient treatment
  including expected and unexpected threats
• Classify the types of threats and errors
• Classify the processes of managing threat and
  error and the outcomes
• Lead to identification of latent systemic
  threats
• Robert Helmreich Ph.D
• David Musson, M.D.
• University of Texas

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Threat and Error in Medicine

• A model of the error process will aid in
• identification of
• Types of errors
• Deficiencies in training and knowledge
• Ineffective, lacking or potential error
  detection strategies
• Effective error mitigation or management
  strategies
• Threat detection and management strategies
• Systemtic threats

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Definitions

• Threats format that increase the likelihood of
  an error being committed environmental,
  physician related, staff related, patient related
• Latent Threats aspects of the hospital or
  medical organization that are not always easily
  identifiable, but that predispose errors or overt
  threats

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Definitions

• Error types
• Communication
• Procedural
• Proficiency
• Decision
• Violations of formal policies or procedures

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Definition

• Threat and error management behavior actions
• taken by team to reduce errors
• Monitoring
• Effective decision making

36
Threat and Error in Medicine

• Latent threats what exists in the organization
• Overt threats what was present on that day
• Human threats what was done wrong
• Error management how was the mistake handled
• Outcomes did a change in the patients health
  result from the error and how was it managed

37
Threat and Error in Medicine

• For each error ask
• What were the conditions present that HELPED
  this error to occur
• For each error analyzed
• Identify one or more specific threats
• Analysis of many errors or incidents
• Lead to identification of systemic threats and
  deficiencies

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Robert Helmreich Ph. D David Musson, MD
University of Texas
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Case Review

• 8 yr. old boy admitted for elective surgery on
  eardrum
• Anesthetized and ET inserted with internal
  stethoscope and temperature probe
• Anesthesiologist did not listen for chest sounds
  after inserting ET
• Temperature probe connector was not compatible
  with monitor
• Anesthesiologist failed to connect the
  stethoscope
• Surgery began at 0820 CO2 levels began to rise
  after 30 minutes
• Anesthesiologist stopped entering CO2 and pulse
  on chart
• Nurses observed anesthesiologist nodding in
  chair, head bobbing
• Nurses did not speak to anesthesiologist because
  afraid of being yelled at
• At 1015 surgeon heard gurgling and realized
  airway tube disconnected

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Case Review

• Problem was called out to anesthesiologist who
  reconnected it
• Anesthesiologist did not check breath sounds
• At 1030 patient breathing rapidly and surgeon
  could not operate alerted anesthesiologist that
  respirations were 60/minutes
• Anesthesiologist did nothing after being alerted
• At 1045 monitor showed irregular heartbeats
• Around 1100 anesthesiologist noted irregular
  heart rate and asked surgeon to stop surgery
• Patient given xylocaine and condition worsened
• At 1102 cardiac arrest, anesthesiologist called
  code
• ET removed and found 50 obstructed by mucous
  plug
• Emergency team anesthesiologist noticed that
  airway heater had caused the breathing circuits
  plastic tubing to melt
• Patient temperature was 108 F
• Patient died

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9 Errors

• Anesthesiologist
• Decision initiated anesthesia without
  temperature monitor
• Procedural failure to auscultate after initial
  ET insertion
• Decision failure to connect internal
  stethoscope
• Nurse
• Decision failure to awaken anesthesiologist
• Anesthesiologist
• Violation failure to maintain anesthetic
  record
• Procedural failure to maintain alertness,
  monitor patient and notice ET disconnection
• Procedural failure to confirm ET placement
  after reconnection
• Decision failure to act promptly on elevated
  respiratory rate
• Surgeon
• Decision failure to act on inadequate response
  from anesthesiologist

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Interventions from Error 1

• Review training to ensure competency and currency
• Peer monitoring/self assessment with respect to
  limitations due
• to fatigue
• Standardized induction protocols that mandate
  temperature
• monitoring
• Checklist to ensure compliance with this protocol
• Periodic review of monitor and equipment during
  procedures
• Safeguards in airway heaters that prevent
  unregulated heating

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Latent Factors Error 1

• Lack of either proficiency or alertness by
  anesthesiologist
• Lack of standardized induction protocol that
  specifies
• mandatory temperature monitoring
• Lack of checklist
• Lack of periodic review of monitors and equipment
• Airway heater continued to apply heat without
  temperature
• monitor

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Overt Threats from Case

• FDA certification
• Airway heater functions without temperature
  probe
• Organizational
• Change in brand of temperature probe without
  notification of staff
• Failure to act on reports of anesthesiologists
  behavior
• Lack of procedural requirement for patient
  monitoring
• Lack of policy for cross checking other team
  members
• Lack of training for teamwork in the OR
• Organizational and Professional
• Pressure to perform when fatigue
• Professional
• Willingness to tolerate peer misbehavior without
  taking action
• Denial of fatigue
• Culture the nurses role in dealing with
  physician

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Error Tolerant Culture

• An error tolerant culture accepts errors but
• does not tolerate violation of formal rules
• especially those validated as error avoidance or
• mitigation strategies
• Confidential error reporting system
• Individuals should not be held responsible for
  errors unless
• Formal rules are violated
• When available countermeasures against error are
  not employed

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Error Tolerant Culture

• Errors are due most often to the convergence of
• multiple contributing factors. Blaming an
  individual
• does not change these factors and the same error
  is
• likely to occur. Preventing errors and
  improving
• safety for patients require a system approach in
• order to modify the conditions that contribute to
  
• errors

To Err is Human Building a Safer Health System,
p. 42
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Error Tolerant Culture

• The Patient Safety and Quality Improvement Act of
• 2005
• Breakthrough in the blame and punishment culture
• that had literally held a death grip on
  healthcare
• When caregivers feel safe to report errors,
  patients
• will be safer because we can learn from these
  events
• and put proven solutions into place (Dennis
  OLeary,
• MD)
• Improve patient safety by providing caregivers
  the same types of legal
• protections long available to airline pilots and
  ATC

48
Error Tolerant Culture

• Changes the legal framework to support reporting
  incidents
• Policies and procedures that encourage reporting
• Clear definitions of the roles and
  responsibilities of the people
• required to implement and maintain a just culture
• Feedback to users and community rapid, useful,
  accessible,
• and intelligible feedback
• Professional handling of investigations

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Error Tolerant Culture

• Human error will never be eliminated, only
  moderated
• Four types unsafe behavior
• Human error when there is general agreement that
  the individuals should have done something
  different
• Negligent conduct falls below the standard
  required as normal in the community civil and
  criminal liability
• Reckless conduct taking a conscious
  unjustified risk
• Intentional willful violation

50
Safety Reporting

• Paying strict attention to near miss is critical
  to
• prevent accidents

51
Reporting

• Aviation Safety Reporting System (ASRS)
• CALLBACK, NASA, ASRS, 319, June/July 06
• Situation 1 We were in a diving right turn
• While focusing on cockpit communications duties,
  this flight
• instructor experienced a disorienting problem
• We departed on a dual instructional flight on a
  Tower Enroute control IFR flight plan.
• The IFR student was flying the aircraft. I was
  working the navigation and
• communication radios. We were level at 4,000 feet
  MSL and my high-time student
• looked comfortable and in control of the
  aircraft. While being vectored into a 180-
• degree turn to intercept the final approach
  course for our destinationwe
• encountered a small amount of turbulence and my
  student over-controlled the
• aircraft... During this time I was reading back
  our new heading and setting the radios
• for the approach. Several seconds passed. When I
  looked over, we were
• in a diving right turn and were well below our
  assigned altitude

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Reporting

• I immediately took control of the airplane and
  recovered from the unusual
• attitude. I found the aircraft out of trim and
  difficult to control from the
• right seat. From my preflight weather briefing I
  knew that we could sort
• out our problems by climbing to VFR conditions on
  top of the clouds. I
• told Approach that we need to climbWe then
  received clearance for
• a climb to 10,000 feet. We broke out of the
  clouds at 8,000 feet MSL and
• were able to verify that all systems were
  functioning properly and
• requested an IFR clearance back to our departure
  airport. After landing, I
• was asked to call the TRACON, which I did, and
  explained my unusual
• attitude and instrument problem.
• The lessons I have learned from this are never
  take your eye off even
• your most competent student and declare an
  Emergency as soon as
• you realize you are having a problem complying
  with the controllers
• instructions and your clearance. The controllers
  did not know what my
• problems were until I could talk to them from the
  ground later. Had I
• declared an emergency, they ATC would have
  understood that I needed
• time and space to reorganize the cockpit for safe
  IFR flight.

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Reporting

• CIRS Critical Incident Reporting System
• www.anaesthesie.ch/cirs/cirsen03.htm

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Summary Questions?
55
216.447.9604 Fax [phone] www.ohiokepro.com
Publication No. 8031-OH-059-072006. This
material was prepared by Ohio KePRO, the Medicare
Quality Improvement Organization for Ohio, under
contract with the Centers for Medicare Medicaid
Services (CMS), an agency of the U.S. Department
of Health and Human Services. The contents
presented do not necessarily reflect CMS Policy.