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Lessons Learned from CRM“More than a Feeling...”
Jeffrey R. Hill, MS
The path to safety . . .
• Background• How did we get to CRM?• What did we learn from our efforts?• Is it really “more than a feeling”?
How do we protect out patients from harm?
“Medicine used to be simple, ineffective and relatively safe.
Now it is complex, effective and potentially dangerous.”
- Sir Cyril Chantler
Barriers to Safety
• Catastrophic events are rare• “It won’t happen to me”• We measure safety by outcomes• Errors are associated with poor performance• Culture of focus on individuals, not systems
Leonard, 2008
Human error is inevitable because . . .
• Inherent human limitations• Complex, unsafe systems• Safety is often assumed, not assured• Culture of the expert individual
Leonard, 2008
Crew Resource Management (CRM)
Boeing, 2012
Rate = .0314Fatalities = 0
Crew Resource Management
• …the effective use of all available resources for flight crew personnel to assure a safe and efficient operation, reducing error, avoiding stress and increasing efficiency.
• Developed in early 1980s to address crew issues in aircraft mishaps
• Migration into healthcare in early 2000s
Skybrary, 2013
CRM adaptions to healthcare
• Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™)
• Anesthesia Crisis Resource Management (ACRM)• MedTeams®• Medical Team Management• LifeWings®
CRM focus
• Leadership• Teamwork• Communication/Coordination• Situation Monitoring• Mutual Support• Team based Learning/Improvement
Implementation Challenges
• Managing Teams• Sharing a Mental Model• Managing a Culture• Developing Psychological Safety• Understanding of Leadership Responsibilities• Instituting new Tools and Processes• Communication
Managing Teams
Jesica Santillan (1985 - 2003)
• Duke University hospital• Dx
– Restrictive cardiomyopathy– Nonreactive pulmonary hypertension
• 2/7/03– Heart/Lung X-Plant– As surgery is ending, Surgical team is
notified that her new heart/lungs are ABO incompatible
– Immunosuppressive Rx– Placed on transplant list
• 2/20/03– Second Heart/Lung X-Plant
• 2/21/03– Declared brain dead
After Action Report• As soon as [the surgeon] found out that a heart and lungs were available
for Jesica Santillan, he sent a member of his transplant team, [second surgeon], to procure them from the… Organ Bank….
• While he was there, [the second surgeon] was informed of the donor's blood type at least three times. Incredibly, he'd never been told Jesica's blood type, and so he didn't know the organs were a mismatch.
• …Donor Services says [the surgeon] was informed of the donor's blood type. But [the surgeon] has no memory of them talking about it. He did not ask for any blood type information, he says, because "I had satisfied in my own mind that if they had offered the organs for me that she was a match.“
The Team?
• Who… exactly… was on the team?• What was the objective?• Did they have processes for
– Sharing the Mental Model?– Preparing for surgery?– Communication?– Contingencies?
Nurse-Physician Communication
• Interviewed n– Physicians 301– Nurses 310– Patients 229
• Patients– Expected nurse & physician to discuss their care daily 89.0%
O’Leary, et.al.,2010
Nurse-Physician Communication (con’t)
Knew name Communicated0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
35.9%
61.5%70.6%
50.3%
Physician Nurse
O’Leary, et.al.,2010
Quality of Teamwork across 28 organizations:Differences between Physicians & Nurses
Se-ries1
1
2
3
4
5
Nurse rates Physician Physician rates Nurse
Qua
lity
of T
eam
wor
k
Sexton, 2008
Sharing the Mental Model
DOMESTIC VIOLENCE IN PREGNANCY
RELATIONSHIPS TO PREGNANCY OUTCOMES AND IMPACT ON OBSTETRICAL
CARE
Courtesy of Nancy C. Chescheir, MD
From: "Hill, Jeffrey R" <[email protected]>Sent: Fri 12/2/05 11:45 amTo: "Chescheir, Nancy C" <[email protected]>Subject: RE: CRM
By the way, I was intrigued by the background on your slides this morning. I have since been fascinated about what it might be. What is it?
V/RJeff Hill
From: Chescheir, Nancy CSent: Friday, December 02, 2005 1:04 PMTo: Hill, Jeffrey RSubject: RE: CRM
The background is that of a feminist who took care of a pregnant woman once who got terribly beaten by her lover...i realized I knew nothing about this problem and inquiring minds want to know...nothing too dramatic really
Shared Mental ModelDid we have a Common
understanding of what was happening?
From: "Hill, Jeffrey R" <[email protected]>Sent: Fri 12/2/05 2:14 pmTo: "Chescheir, Nancy C" <[email protected]>Subject: RE: RE: CRM
Thanks. I was really asking about the image on your slides.
Jeff Hill
From: Chescheir, Nancy CSent: Friday, December 03, 2005 1:04 PMTo: Hill, Jeffrey RSubject: RE: CRM
The women's pictures are legal evidence photos of women my friend in NC who is a domestic violence advocate there..these were all women she was the respondent from the dv shelters in different parts of the country. She took the pictures. If you meant the video..she lent me that as well. The clip I showed is from a law enforcement teaching video put together by the San Diego P.D.
Shared Mental ModelCommon understanding of what is
happening and what team members can expect
The basis for all effective communication
Managing a Culture
Safety Culture Survey
Teamwork w/in
Unit
Supervisor E
xpecta
tions
Manager Support
Organizational Le
arning
Overall Perce
ption
Feedback about E
rror
Freq of Event R
eporting
Comm Openness
Teamwork across
Units
Staffing
Handoffs/Transiti
ons
Nonpunitive Response to
Error
0%
20%
40%
60%
80%
100%
80%75% 72% 72%
66% 64% 63% 62%58% 57%
45% 44%
n=1032/472,397
AHRQ, 2011
Posi
tive
Safety Culture Survey
Teamwork w/in
Unit
Supervisor E
xpecta
tions
Manager Support
Organizational Le
arning
Overall Perce
ption
Feedback about E
rror
Freq of Event R
eporting
Comm Openness
Teamwork across
Units
Staffing
Handoffs/Transiti
ons
Nonpunitive Response to
Error
0%
20%
40%
60%
80%
100%
2007 2008 2009 2010n=1032/472,397
AHRQ, 2011
Posi
tive
Safety Culture Survey
Teamwork w/in
Unit
Supervisor E
xpecta
tions
Manager Support
Organizational Le
arning
Overall Perce
ption
Feedback about E
rror
Freq of Event R
eporting
Comm Openness
Teamwork across
Units
Staffing
Handoffs/Transiti
ons
Nonpunitive Response to
Error
0%
20%
40%
60%
80%
100%
Mgmt Physician Asst/CP Nurse
AHRQ, 2011
n=1032/472,397
Posi
tive
Why do I need a checklist?
221 nm2hrs + 29 min
June 12, 2010
Cessna Checklist
Dipstick is missing!
This is why I need a checklist
Pre Procedural Briefing
Pt Name Confirmed
Procedure Confirmed
W.Board Complete
Checklist Used
Pt Name Announced
Ready ?
Briefing Initiated
Invitation to Speak Up
Patient Allergies
Procedure Announced
Adverse Patient Hx
Precaution Level
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Psychological Safety
• “a shared belief that the team is safe for interpersonal risk taking”
• “a team climate characterized by interpersonal trust and mutual respect in which people are comfortable being themselves”
Edmondson, 1999
The Spectrum of Disrespectful Behavior
1. Disruptive behavior
2. Humiliation and degrading put-downs
3. Passive-aggressive behavior – refusal to comply, ignore calls, negative comments
4. Passive disrespect – poor team players, don’t participate in QI, always late
5. Dismissive treatment of patients
Leape, 2012
The Spectrum of Disrespectful Behavior
6. “Systemic” disrespect (subtle, accepted, routine)
– Long hours, excessively high work loads– Non-shared decision-making– Limited disclosure, apology– Everyday patient indignities
• First names, “Honey”• Not knowing what is going on• Waiting
Leape, 2012
Communication Openness
Will freely speak up Free to question decisions of more authority
Not afraid to ask questions0%
20%
40%
60%
80%
100%
76%
47%
63%
AHRQ, 2011
n=1032/472,397
Posi
tive
Communication Openness
Will freely speak up Free to question decisions of more authority
Not afraid to ask questions0%
20%
40%
60%
80%
100%
Mgmt Physician
AHRQ, 2011
n=1032/472,397
Posi
tive
n=1032/472,397
Communication Openness(by staff position)
Will freely speak up Free to question decisions of more authority
Not afraid to ask questions0%
20%
40%
60%
80%
100%
Mgmt Physician Asst/CPNurse Tech Asst/Sec
AHRQ, 2011
Posi
tive
Leadership
United 232DEN – ORD
July 19, 1989
United 232
• #2 engine fan disintegrates• Loss of primary flight controls• Crew gains partial control• Aircraft diverts to Sioux City, Iowa• Aircraft crashes
Sioux City, IowaJuly 19, 1989
111 Fatalities 185 Survivors 172 Injured
United 232
• Leadership– Team formation
• Personal identification• Establish rapport
– Sharing a Mental Model• Goals/Objectives
– Defining Roles & Responsibilities• Normal situations• Contingencies
– Invitation to Speak UpExpectation of Speaking Up
Roles of Leadership
Learn Model behaviors Mentor Motivate Hold accountable
Encourage feedback *Ensure the success of team
members
*Leonard, 20XX
Leadership“Up until 1980, we kind of worked on the concept that the captain was THE authority on the aircraft. What he said, goes. And we lost a few airplanes because of that.
“Sometimes the captain isn't as smart as we thought he was. And we would listen to him, and do what he said, and we wouldn't know what he's talking about.
Haynes, 1991
“And we had 103 years of flying experience there in the cockpit, trying to get that airplane on the ground, not one minute of which we had actually practiced, any one of us. So why would I know more about getting that airplane on the ground under those conditions than the other three. “So if I hadn't used [CRM], if we had not let everybody put their input in, it's a cinch we wouldn't have made it.
Tools (a.k.a. “Processes”)
“Dad. Can I borrow the Car?”“Sure son… just be safe.”“OK Dad.”
Tools?
Boeing Model 299Oct 30, 1935
Checklists
Why Checklists?
• Reduce Variability• Share a Mental Model• Anticipate / predict each other’s needs• Resiliency/agility/flexibility
Communication
"It was impossible to get a conversation going; everybody was talking too much."
~ Yogi Berra
Physician-Nurse Agreement
Planned Pro-cedure
Planned Tests Consultations Primary Dx Med Changes0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
88.7%
58.7%53.7% 52.8% 50.7%
O’Leary, et.al.,2010
Posi
tive
House Staff Survey(quality of handoffs)
• n=161– 108 = Internal Medicine– 53 = Surgery
• Concerning most recent inpatient rotation…– 58.3% reported at least one pt experiencing minor harm– 12.3% reported at least one pt experienced major harm– 31.0% reported overall quality of handoffs as “fair” or “poor”– 37.7% unable to provide accurate or complete information because of
a problematic handovers
Kitch, et.al, Oct 2008
Handoffs(Composite Data… single institution)
0%
20%
40%
60%
80%
100%
Posi
tive
The two most useless phrases in healthcare
“Safety is our first priority”
“We need to communicate better”
The path to safety . . .
• Background• How did we get to CRM?• What did we learn from our efforts?• Is it really “more than a feeling”?