Principles in Crisis Resource Management (in Disasters)

1
Principles in Crisis Resource Management(in
Disasters)

• Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
• April 16, 2012
• MDH MBFI Hall
• Pre-convention Workshop on
• Crisis Resource Management in Disasters
• Philippine College of Emergency Medicine, Inc.
• MDH Emergency Medicine

2
Workshop on Crisis Resource Managementin
Disasters

• Objectives
• At the end of the workshop, participants should
  be able to
•  
• Define Crisis Resource Management and know its
  importance and uses.
• Understand the basic principles of Crisis
  Resource Management.
• Apply the principles of CRM in a simulation
  activity.
• Identify ones and the teams areas of
  improvement and strengthening.

3
Principles in Crisis Resource Management(in
Disasters)Reynaldo O. Joson, MD, MHA, MHPEd,
MSc SurgFacilitator

• Help you understand
• what crisis resource management is, its
  importance, its uses, its basic principles
• Give you tips on
• how to apply the basic principles in a simulation
  activity (a simulated mass casualty incident in
  Manila Doctors Hospital)

4
Principles in Crisis Resource Management(in
Disasters)Reynaldo O. Joson, MD, MHA, MHPEd,
MSc SurgFacilitator

• Contents Outline
• Crisis Resource Management
•  
• Concept
• Importance
• Uses
• Basic principles
• Application in a simulated activity (a simulated
  mass casualty incident in Manila Doctors
  Hospital) 

5
Crisis Resource Management - Concept

• As currently being used,
• crisis resource management (CRM)
• broadly defined as
• a management system
• which makes optimum use of all available
  resources people, procedures, equipment
• to promote safety and enhance efficiency of
  operations
• during a crisis situation.

6
Crisis Resource Management - Concept

• A simulated training of a group or groups of
  people
• in handling commonly encountered and anticipated
  high-risk activities, emergencies and disasters
• with the end goals of effective and efficient
  accomplishment of the needed operations and
  responses
• with emphasis on optimal teamwork (communication,
  coordination, collaboration), prevention of
  errors and safety promotion.
• (ROJosons synthesized concept statement)

7
Crisis Resource Management - Concept

• History
• CRM - first developed by aviation industry late
  1970s
• Original term used - Crew Resource Management
• Another term used - Cockpit Resource Management

8
Crisis Resource Management - Concept

• Crew Resource Management / Cockpit Resource
  Management
• - about after analysis of plane crashes in US
  showed human error involved in 85 of events
• - essentially a training program that resulted
  in reduction of human errors and therefore, less
  airplane crashes

9
Crisis Resource Management - Concept

• In the 90s,
• David Gaba, American anesthetist, training as a
  pilot,
• recognizing similarities in high stake
  environments of the operating theatre and
  cockpit,
• developed Anesthesia Crisis Resource Management
  (Anesthesia CRM)

10
Crisis Resource Management - Concept

• In 1999,
• publication - To Err is Human, Building a Safer
  Healthcare System - Institute of Medicine in US
• brought CRM into focus as healthcare community
  began to realize extent of medical error.
• publication suggested that it was the faulty
  systems, processes and conditions that led people
  to make mistakes or fail to prevent them.

11
Crisis Resource Management - Concept
12
Crisis Resource Management - Concept

• Crisis Resource Management (not Crew Resource
  Management)
• currently a buzzword in
• avoiding human factor errors and promoting safety
  
• during emergencies and other high stake
  environments or critical activities

13
Crisis Resource Management - Concept

• CRM encompasses concepts of crew or cockpit
  resource management of aviation industry.
• Usage not limited to emergencies and disasters
• Can be and is used in non-medical and medical
  industries in training people to avoid error and
  improving safety

14
Crisis Resource Management - Concept

• Essentially a training to promote safety by
  addressing behavioural and cognitive skills
• needed to effectively manage all available
  resources, especially during a crisis situation.
  
• Accomplished through development of superior
  non-technical skills
• such as
• leadership, situational awareness,
  communication, and teamwork.

15
Crisis Resource Management - Concept

• Although technical and non-technical skills are
  important,
• CRM puts more emphasis on the non-technical
  skills
• with assumption that people on the job have the
  technical skills to start with.

16
Crisis Resource Management - Concept

• In medicine,
• CRM - not limited to anesthesia
• Anesthesia CRM
• Emergency Medicine CRM
• Pediatric CRM
• Critical Medicine CRM
• Others

17
Crisis Resource Management - Concept
To repeat for summary and retention!

• As currently being used,
• crisis resource management (CRM)
• broadly defined as
• a management system
• which makes optimum use of all available
  resources people, procedures, equipment
• to promote safety and enhance efficiency of
  operations
• during a crisis situation.

18
Crisis Resource Management - Concept
To repeat for summary and retention!

• A simulated training of a group or groups of
  people
• in handling commonly encountered and anticipated
  high-risk activities, emergencies and disasters
• with the end goals of effective and efficient
  accomplishment of the needed operations and
  responses
• with emphasis on optimal teamwork (communication,
  coordination, collaboration), prevention of
  errors and safety promotion.
• (ROJosons synthesized concept statement)

19
Crisis Resource Management - Importance

• To promote effective and efficient accomplishment
  of the needed operations and responses
• by a group of people
• in commonly encountered and anticipated high-risk
  activities, emergencies and disasters
• with emphasis on optimal teamwork (communication,
  coordination, collaboration), prevention of
  errors and safety promotion.

20
Crisis Resource Management - Uses

• In commonly encountered and anticipated high-risk
  activities, emergencies and disasters in medical
  and non-medical industries
•  
• In medical industries
• In hospital and ambulatory centers
• In departments with high-risk activities, such as
  emergency medicine, critical care medicine,
  operating theatres, etc.

21
Crisis Resource Management Basic Principles
22
Crisis Resource Management - Concept

• As currently being used,
• crisis resource management (CRM)
• broadly defined as
• a management system
• which makes optimum use of all available
  resources people, procedures, equipment
• to promote safety and enhance efficiency of
  operations
• during a crisis situation.

23
Crisis Resource Management Basic Principles

• CRM is a management system.
• Management system includes
• crisis preparedness and response plans
• and
• exercises
• to enhance optimal responses during an actual
  crisis.

24
Crisis Resource Management Basic Principles

• Exercises
• - small-scale (such as drills and table-top
  exercises) or full-scale simulation of crisis
  situation.
• - computer-aided and /or aided by simulated
  patients, props and manikins.

25
Crisis Resource Management Basic Principles

• Simulated exercises form the backbone of CRM.
• - must bring out behaviors or non-technical
  skills necessary for an optimal teamwork
  (communication, coordination, collaboration),
  prevention of errors and safety promotion.

26
Crisis Resource Management Basic Principles

• CRM follows a particular educational doctrine
• that has been derived from the aviation industry
  Crew Resource Management (CRM)
• and
• introduced to health sector via the doctrine of
  David Gaba in Anaesthesia Crisis Resource
  Management (ACRM).

27
Crisis Resource Management Basic Principles

• Seven key behaviours as originated from Crew
  Resource Management
• Know your environment
• Prepare and plan
• Call for help early
• Take a leadership role
• Allocate attention wisely and use all available
  resources
• Prioritize and distribute the workload
• Communicate effectively

28
Crisis Resource Management Basic Principles

• Gaba added more key behaviours in anesthesia
  CRM (see Nos. 8 to 15).
•  
• 8. Use all available information
• 9. Prevent and manage fixation errors
• 10. Cross (double) check
• 11. Use cognitive aids
• 12. Re-evaluate repeatedly
• 13. Use good teamwork
• 14. Allocate attention wisely
• 15. Set priorities dynamically

29
Crisis Resource Management Basic Principles

• In Emergency Medicine CRM, one institution added
  the following three key behaviours to the seven
  key behaviours derived from aviation industry
• Triage / prioritization
• Efficient management of multiple patients
• Effective coping with disruptions / distractions

30
Crisis Resource Management Basic Principles

• There are various packages of
• non-technical skills, behavioural skills,
  cognitive skills,
• so called key principles,
• and they vary from one situation to another.
• These just have to be spelled out by the
  facilitators for the individual situations.

31
Crisis Resource Management Basic Principles

• Although there are variations,
• in a Delphi study performed in 2009 to help
  determine key training areas for health-care
  teamwork competency,
• the following were generated
• communication
• task management
• situational awareness
• decision-making
• leadership

32
Crisis Resource Management Basic Principles

• In simple and most basic terms,
• non-technical skills in health-care industry CRM
  can consist of
• Non-technical skills
•  
• Behavioural skills
• Leadership
• Communication
• Team working (communication, coordination, and
  collaboration)
• Cognitive skills
• Situational awareness
• Planning
• Decision making
• Task management

33
Crisis Resource Management Basic Principles

• It must be emphasized that no one key behaviour
  sits in isolation from each other but rather they
  are all interrelated and there are overlaps.
• A good team working involves excellent
  communication skills, task management, planning,
  and leadership.
• Likewise good situational awareness relies on
  communication, team working, and decision making.

34
Crisis Resource Management Basic Principles

• To simplify things, I suggest using the following
  package or framework
•  
• Leadership
• Situational awareness
• Planning
• Decision making
• Communication
• Coordination
• Collaboration
• Task management

35
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)
36
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)
37
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)
38
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)
39
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)
40
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• Let us say that
• MDH has decided to conduct a crisis resource
  management simulated training
• to enhance optimal response during a mass
  casualty incident in Manila Doctors Hospital.
•  
•  

41
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

•  
• The prerequisites for the conduct of CRM are
• the presence of the MDH MCI preparedness and
  response plans and
• that all key players have read and understood
  their roles and responsibilities
• whenever there will be an MCI and an activation
  of Code White (MDH response code for surge of
  patients disaster) by the MDH Chief Safety
  Officer.
•  

42
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

•  
• To plan for the conduct of the simulation CRM,
• facilitators should formulate an
• instructional design or lesson plan.
•  

43
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

•  
• Facilitators should decide
• whether full-scale or small-scale simulation
  exercise (small-scale means portions of the whole
  response plan and using drills and table-top
  exercises).

44
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

•  
• Facilitators also decide
• who are the key players to focus on for the
  training
• and
• what are the non-technical skills to bring out
  among the players.

45
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• General Steps in Response to MCI based on MDH
  Response Plan

Steps in the Response to MCI (Surge of Patients) MDH Response Plan Key Players Key Non-technical Skills to Practice and Enhance
Creation of an incident command Persons authorized to create the incident command (ERO, Hospital Chief Safety Officer, Hospital Director) and members of the incident command (Medical Director, Nursing Director, Communication Officer, Security Officer, etc.) Leadership Situational awareness Planning Decision making Communication Coordination Collaboration Task management
46
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• General Steps in Response to MCI based on MDH
  Response Plan

Steps in the Response to MCI (Surge of Patients) MDH Response Plan Key Players Key Non-technical Skills to Practice and Enhance
Control of disaster Heads and members of disaster response and control teams (triage teams, medical teams, evacuation teams, transport teams, operating room teams, communication teams, traffic control teams, security teams, etc.) Leadership Situational awareness Planning Decision making Communication Coordination Collaboration Task management
47
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• General Steps in the Control of Disaster in
  Response to MCI based on MDH Response Plan

Steps in the Response to MCI (Surge of Patients) MDH Response Plan Key Players Key Non-technical Skills to Practice and Enhance
Triage Staff trained and assigned to do triaging at the ER and at the holding areas (Green, Yellow, and Red Areas) Leadership Situational awareness Planning Decision making Communication Coordination Collaboration Task management
48
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• General Steps in the Control of Disaster in
  Response to MCI based on MDH Response Plan

Steps in the Response to MCI (Surge of Patients) MDH Response Plan Key Players Key Non-technical Skills to Practice and Enhance
Treatment Staff assigned to do the medical care of the injured patients (physicians, nurses, institutional workers, recorders, etc.) Leadership Situational awareness Planning Decision making Communication Coordination Collaboration Task management
49
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• After mapping out essential steps in response and
  control plans in MCI, key players who will
  undergo training, and key behaviour and cognitive
  skills to teach, enhance and practice,
• facilitators then determine what are considered
• good, effective and efficient
• leadership, situational awareness, planning,
  decision-making, communication, coordination,
  collaboration, and task management in general
  terms and in each specific step in the response
  and control plans.

50
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• After the criteria of quality have been
  determined,
• facilitators then formulate specific
  teaching-learning strategies and activities
• (such as drills, table-top exercises, or
  full-scale exercises)
• that will give participants to develop and
  enhance the key behavioural and cognitive skills.
  

51
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• Checklists
• that can be used to teach and evaluate different
  behavioral and cognitive skills
• - very helpful

52
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• Checklist Leadership (Example)

Parameters and indicators - Leadership Yes / No / () Remarks
There was a clearly identified and recognized team leader.
The team leader knew the mission of his team.
The team leader demonstrated skills in situational awareness.
The team leader demonstrated skills in problem-solving and decision-making.
The team leader demonstrated skills in planning for the response (inclusive of contingency plans).
53
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• Checklist Leadership (Example)

Parameters and indicators - Leadership Yes / No / () Remarks
The team leader was calling the shots (was in command).
The team leader demonstrated skills in effective communication with his team members.
The team leader demonstrated skills in coordinating his team members.
The team leader demonstrated skills in making his team members collaborate with each other.
The team leader was able to accomplish his mission effectively and efficiently through optimal teamwork.
54
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• Checklist Leadership (Example)

Parameters and indicators - Leadership Yes / No / () Remarks
The team leader was able to accomplish his mission effectively and efficiently with minimal errors.
The team leader was able to accomplish his mission safely.
Other parameters and indicators of good leadership that were needed and observed. (Add here.)
55
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• Checklist Task Management (Example)

Parameters and indicators Task Management Yes / No / () Remarks
All the members of the response team knew their primary tasks even before the response.
Tasks were planned guided by the situational awareness.
Tasks were communicated effectively to all concerned members of the response team.
Tasks were properly distributed to all members of the response team.
Tasks were accomplished effectively and efficiently through optimal teamwork.
56
Crisis Resource Management Application in a
simulated activity (a simulated mass casualty
incident in Manila Doctors Hospital)

• Checklist Task Management (Example)

Parameters and indicators Task Management Yes / No / () Remarks
There was coordination among the members in the accomplishment of the task.
There was collaboration among the members in the accomplishment of the task.
Tasks were accomplished effectively and efficiently with minimal errors.
Tasks were accomplished safely.
Other parameters and indicators of good task management that were needed and observed. (Add here.)
57
Principles in Crisis Resource Management(in
Disasters)Reynaldo O. Joson, MD, MHA, MHPEd,
MSc SurgFacilitator

• Contents Outline
• Crisis Resource Management
•  
• Concept
• Importance
• Uses
• Basic principles
• Application in a simulated activity (a simulated
  mass casualty incident in Manila Doctors
  Hospital) 

58
Crisis Resource Management - Concept

• A simulated training of a group or groups of
  people
• in handling commonly encountered and anticipated
  high-risk activities, emergencies and disasters
• with the end goals of effective and efficient
  accomplishment of the needed operations and
  responses
• with emphasis on optimal teamwork (communication,
  coordination, collaboration), prevention of
  errors and safety promotion.
• (ROJosons synthesized concept statement)

59
Principles in Crisis Resource Management(in
Disasters)Reynaldo O. Joson, MD, MHA, MHPEd,
MSc SurgFacilitator

• Help you understand
• what crisis resource management is, its
  importance, its uses, its basic principles
• Give you tips on
• how to apply the basic principles in a simulation
  activity (a simulated mass casualty incident in
  Manila Doctors Hospital)

60
Principles in Crisis Resource Management(in
Disasters)

• Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
• April 16, 2012
• MDH MBFI Hall
• Pre-convention Workshop on
• Crisis Resource Management in Disasters
• Philippine College of Emergency Medicine, Inc.
• MDH Emergency Medicine

Thank you for your attention! For
queries rjoson2001_at_yahoo.com / Facebook 0918-
804-03-04 Website http//hospitalsafetypromotiona
nddisasterpreparedness.wordpress.com/2012/04/09/pr
inciples-in-crisis-resource-management-in-disaster
s/
61
Principles in Crisis Resource Management(in
Disasters)

• Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
• April 16, 2012
• MDH MBFI Hall
• Pre-convention Workshop on
• Crisis Resource Management in Disasters
• Philippine College of Emergency Medicine, Inc.
• MDH Emergency Medicine