Alliance with Aviation

1
Alliance with Aviation

• Using Crew Resource Management to Improve Patient
  Safety
• Northfield Hospital

2
The problem
3
IOM 1999To Err is Human

• healthcare organizations should establish team
  training programs for personnel in critical areas
  (e.g., ED, operating rooms), using proven methods
  such as the crew resource management techniques
  employed in aviation

4
IOM 1999To Err is Human

• People make fewer errors when they work in
  teams. When processes are planned and
  standardized, each member knows his or her
  responsibilities as well as those of teammates,
  and members look out for one another, noticing
  errors before they cause an accident.

5
IOM 2003Health Professions Education

• Medical schools to incorporate new core
  competency Work in interdisciplinary teams
• ..All team members must have strong
  communication skills and a clear understanding of
  each others roles and responsibilities.

6
IOM 2003Health Professions Education

• Competency in team care .involves learning
  approaches to maximize collaborative work
  ensuring that timely information reaches those
  who need it and managing patient transitions
  across settings and over time

7
Our experience.

• Communication issues are evident in nearly all
  events or near misses
• Miscommunication
• Dropped communication
• Hesitancy to question peer or authority
• Written communication not accessed
• Staff works side by side but not always together

8
Example.

• Pt admitted with syncope / possible seizure
• That evening, new complaints of leg pain
• On-call MD orders ultrasound
• Results extensive DVT
• Teleradiologist FAXed results after no one
  answered the phone. BUT, no one knew the FAX
  machine was malfunctioning
• Results not discovered until the next morning
  treatment was delayed unnecessarily

9
What we learned

• The ultrasound tech had the information that the
  caregivers needed, but did not have the authority
  to convey it
• Now, they give a heads up to the nurse on
  possible abnormal findings
• No process in place to prompt caregivers to
  follow-up on pending diagnostic tests and to
  communicate that to the next shift
• Now, nurses use a standardized worksheet for
  shift-to-shift report, which includes any pending
  tests

10
Why Aviation?

• Commonalities between aviation and healthcare
• High risk environment
• Highly skilled professionals
• Failures in teamwork can have deadly effects
• What aviation has learned
• Most crashes involve teamwork failure rather than
  mechanical failure
• Accident rate reduced since the introduction of
  CRM

11
Finding the Experts

• Northwest Airlines based in our own backyard
• Recruited fleet training captain, recently
  retired, looking for something challenging and
  rewarding to do.

12
CRM Overview
Communication Secure authority Assertiveness with
respect Sharing information
Standardization Work processes Standards of care
Workload Management Clear roles and
accountability Contingency staffing
plans Recognizing vulnerabilities regardless of
workload
13
Concepts

• Everyone makes mistakes
• Being highly skilled and professional isnt
  enough to prevent error
• Everyone on the team shares responsibility for
  patient

14
Understanding error

• Need basic knowledge of threats and errors as
  part of learning CRM
• Swiss Cheese model
• Sharp / blunt ends
• Organizational culture
• Name and blame vs. just culture
• Authoritarian vs. flattened hierarchy
• Human factors

15
Human Factors

• Fatigue
• Reliance on technology
• Reliance on memory
• Loss of situational awareness
• Distraction Interruptions, emotions,
  environmental noise
• Mindset
• Automatic behaviors

16
Communication

• Secure authority
• Flatten the hierarchy
• Leaders acknowledgement of vulnerability to
  error
• Leader sets tone of open communication input
  from all sources explicitly encouraged and
  required
• Dispels discomfort on the part of team members
  who might be afraid of offending, retaliation if
  they speak up
• Assertiveness with respect
• Team members speak up regardless of hierarchy
• Use of SBAR situation, background, assessment,
  recommendation

17
Standardization

• Standardized work processes (e.g., call-backs for
  outpt culture results)
• Standardized care (e.g., Acute MI)
• Allows team members to
• Anticipate what comes next
• Recognize and question the unexpected
• Recognize workarounds address the process

18
Workload Management

• Requires clear roles and accountability
• Task prioritization
• Situational awareness use of huddles
• Debriefing serious events
• Recognizing vulnerabilities
• Heavy redistribute the work, ask for help
• Light stay alert, focused
• Acknowledging fatigue

19
Program Design

• 3-year phased program
• Year 1 ED (Staff, MDs, EMS, pharmacy, lab,
  x-ray, administration)
• Year 2 Inpatient (medsurg, OB, surgery
• Year 3 Outpatient (Rehab, LTCC, HHC)
• 1-year course for each group
• Quarterly newsletters to all employees

20
Training outline

• Four 3-hour sessions 1 session/quarter
• Small groups 10-12 people
• Interdisciplinary doctors, nurses, EMS, HUCs,
  lab, x-ray, pharmacy
• Interactive presentation, conversation, video,
  role playing, OptionPower technology
• Stories from the front line

21
Turbulence

• Some resistance to mandatory training
• Resentment/perception that training leaves
  department short-staffed
• Eeyore syndrome Nothing ever changes anyway
• Defensiveness when assertiveness with respect is
  practiced with someone who is not secure in
  his/her authority
• Mixed reaction re use of titles

22
Challenges

• Training logistics
• Overcoming perception that CRM is just a fad
• Keeping CRM front and center over a long period
  of time
• Leadership / accountability for mentoring the
  right behaviors within departments

23
Status Report

• ED group training completed July, 2005
• Changed from MD-led to Nurse-led ED to improve
  patient flow, patient transports and admissions
  control
• Incorporated periodic Huddles into shift routine
• Standardized nursing handoffs using SBAR
• Standardized nursing protocols for select chief
  complaints to allow for diagnostics / treatment
  before MD sees pt

24
At least one life saved

• Radiology technician performing abd ultrasound on
  outpatient
• In conversation, patient mentions hes also
  scheduled for a stress test later that day
• Radiology tech sees AAA on ultrasound
• Asks on-duty ED physician for advice in what to
  do with information
• Called primary MD test cancelled, surgery
  consult arranged

25
Staff anecdotal feedback

• Theres a gap between those depts who have had
  CRM training and those who haventa different
  style of communication. They write their
  concerns down and submit them. We now resolve
  our issues in the present, knowing we have
  permission to express concerns at the time they
  occur

26
Staff anecdotal feedback

• Why go through training if the doctors still
  wont listen to what we have to say?

27
We still have work to do.

• Typical timeline for behavior changes
• 5 years 50