Webinar Series 2014/2015 - HealthTechS3...Certificate Number 1319. Subsequently, he assisted the Director of Safety in creation of Columbia’s Safety Management System and has participated

Webinar Series 2014/2015

Stronger Hospitals, Healthier Communities

For more than 40 years HealthTech Management Services® (previously Brim Healthcare) has worked with critical access, district and acute care hospitals across the United States to help them improve financial strength, build professional excellence and grow to meet the needs of their community.

• Founded in 1971 by healthcare pioneer, A.E. “Gene” Brim

• An independent, privately held company

• Headquartered in Brentwood, Tennessee with a regional office in Madison, Wisconsin

• Providing management services to 18 hospitals nationwide

• Providing financial and consulting services, physician recruitment and turnaround services to more than 30 hospitals nationwide

• Expertise with critical access hospitals, district hospitals, acute care hospitals and not‐for‐profit systems

© HTMS Webinar Series 2014/2015 | Slide 2


We turn challenges into opportunities.

Hospital Organizational Assessment Performance Optimization Services

Executive &Management Leadership Development Hospital Contract Management Support Services

Medical Practice ‐ Clinic Assessment & Consulting Strategic Medical Staff Development Planning

Clinical Resource Management Assessment & Consulting Medical Staff Office Assessment & Consulting

Survey Preparation Survey Plan of Correction Assistance

Swing Bed Optimization Policy and Procedure Review

Recruitment and Interim Placement Productivity Education, Consulting & Tool Box

Revenue Cycle Assessment & Consulting Supply Chain Resources

Accounts Receivable Analysis Physician Recruitment

Quality, Performance Improvement and Patient Safety Assessment and Consulting

Business Office Assessment & Consulting

HealthTech Management Services uses a comprehensive approach to assess your hospital’s unique needs and determine the best plan of action to focus on sustainable performance improvement. Once a plan is developed, HealthTech’s team of professionals can lead the implementation of the changes required for your hospital’s optimized performance.

Webinars

HTMS provides webinars as part of its mission to improve healthcare in rural communities.

Today’s webinar is part of our series on Patient Safety.

The power point is posted on the HTMS web site at www.htmsinc.com. The recording will be posted within 2 business days of the webinar.


Upcoming Webinars & Collaboratives

SURGICAL SERVICES COLLABORATIVEBuilding Relationships between Surgery and Central Sterile

February 25, 2015

Speaker: Deborah Spratt, MPA, BSN, RN, CNOR, NEA‐BC, CRCST, CHL

Applying Crew Resource Management Principles to

Healthcare

March 13, 2015

Speaker: Diane Bradley, Regional Chief Clinical Officer HTMS


Instructions for Today’s Webinar

If you are accessing the audio portion of the webinar by telephone, you must enter the pin provided when you logged in if you would like to ask a question.

If you are accessing the audio portion of the webinar by computer audio controls must be enabled if you would like to ask a question.

You may type any questions or comments you have during the webinar in the question box on your computer.

Please take the time to complete the survey at the conclusion of the webinar.

You may contact Carolyn St.Charles after the webinar with questions or comments at carolyn.stcharles@ht‐llc.comOffice Phone: 360‐584‐9868Cell: 206‐605‐3748


Today’s Speaker: Gary Rogers• Gary Rogers has been involved in the maintenance of Boeing tandem rotor helicopters almost continuously since 1966. In April, 1978, he began a 36‐year career with Columbia Helicopters. During that time, he went to Sudan as part of a 21‐man, three‐aircraft Columbia team contracted by the U.S. government to haul food to refugee camps during a famine. Experiences obtained by Rogers as a member of an aircraft recovery crew in Vietnam sparked a lifetime interest in aviation safety. Almost forty percent of the aircraft losses in Vietnam (which included 3300 helicopters destroyed) were due not to enemy fire, but to accidents. Human error, both active and organizational, was most likely a factor in most of those accidents, although there was little systematic study and research into human performance was rudimentary.

• In 2006, he took temporary leave from Columbia Helicopters to complete a six‐week course in Aviation Safety and Security presented by the University of Southern California. The course included Aircraft Accident Investigation, Safety Management Systems, and Human Factors. He holds Certificate Number 1319. Subsequently, he assisted the Director of Safety in creation of Columbia’s Safety Management System and has participated in accident investigations involving the company’s aircraft.

• In 2013, he was awarded the Rolls Royce Excellence in Aviation Maintenance Award at the HAI convention in Las Vegas.

• Although he retired from Columbia Helicopters in 2014, he continues to provide training to the Papua New Guinea Civil Aviation Safety Authority.


Crew Resource Management

Gary RogersFebruary 19, 2015

The Deadly Interface Between Human and Machine


Human Factors/Ergonomics

• Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well‐being and overall system performance.

• Human factors involves gathering information about human abilities, limitations, and other characteristics and applying it to tools, machines, systems, tasks, jobs, and environments to produce safe, comfortable, and effective human use.


Applications of Ergonomics

• Ergonomics developed in parallel with accident investigation.

• In aviation, prior to 1960 the largest contributing factor to aircraft accidents was equipment failure. Thereafter, the increased use of turbine‐engine aircraft, improvements in navigation systems, and better air traffic control resulted in a dramatic decrease in the number of catastrophic accidents.

• Investigators then turned their attention to a new discovery: as mechanical systems became more reliable, they learned that human error became more prominent as a contributing factor in accidents.


Birth of Crew Resource Management

• Accident Investigators discovered that more than 70 percent of air crashes involved human error rather than failures of equipment or weather. A NASA workshop examining the role of human error in air crashes found that the majority of crew errors consisted of failures in leadership, team coordination and decision‐making.

• Investigation of several catastrophic accidents provided the key:


United Airlines Flight 173 – Portland Oregon


United 173 – Breakdown in Cockpit Management

• "The Safety Board [NTSB] believes that this accident exemplifies a recurring problem ‐‐ a breakdown in cockpit management and teamwork during a situation involving malfunctions of aircraft systems in flight… Therefore, the Safety Board can only conclude that the flight crew failed to relate the fuel remaining and the rate of fuel flow to the time and distance from the airport, because their attention was directed almost entirely toward diagnosing the landing gear problem."


Air Florida Flight 90 – Potomac River


Air Florida: Flight Delays and Icy Runway

• After leaving the gate, the aircraft waited in a taxi line with many other aircraft for 49 minutes before reaching the takeoff runway. The pilot apparently decided not to return to the gate for reapplication of deicing, fearing that the flight's departure would be even further delayed. More snow and ice accumulated on the wings during that period, and the crew were aware of that fact when they decided to make the takeoff.

• Even though the temperature was freezing and it was snowing, the crew did not activate the engine anti‐ice system.


Investigators Focus on Group Dynamics

• The National Transportation Safety Board (NTSB) concluded that the root cause of both of these crashes (and others) lay in faulty group dynamics.

– An authoritarian cockpit culture where co‐pilots and flight engineers were discouraged from questioning captains prevented the crew from recognizing the hazards and taking action to prevent disaster.

– Lack of communication, inadequate leadership, and flawed decision‐making were contributing factors to these accidents


Need for Cultural Change Recognized

• Culture is deeply ingrained and very difficult to change. The cockpit culture prevalent at this point in history was a product of decades of aviation development. Generations of pilots were indoctrinated in it.

• Captains (as the title implies) were accustomed to being treated with deference by other crew members. Assertiveness by subordinate members of the crew was actively discouraged. Decisions were not questioned, and input from other members of the crew was not usually solicited.


United Airlines Flight 232 ‐ Iowa Cornfield

• As more airlines implemented CRM training for their crews, the utility of this training quickly became evident.


US Airways Flight 1549 – Miracle on the Hudson

• By 2009, Crew Resource Management had been implemented by all commercial carriers. It had been continually improved over decades, and cockpit culture had been completely transformed.


What is Crew Resource Management?

• "A system not designed to expect and safely absorb human error will constantly suffer from human mistakes."‐ David A. Marshall

• The definition of Crew Resource Managementa flexible, systemic method for optimizing human performance in general, and increasing safety in particular, by (1) recognizing the inherent human factors that cause errors and the reluctance to report them, (2) recognizing that in complex, high risk endeavors, teams rather than individuals are the most effective fundamental operating units and (3) cultivating and instilling customized, sustainable and team‐based tools and practices that effectively use all available resources to reduce the adverse impacts of those human factors.


“Teams, Rather than Individuals…”

“…in complex, high risk endeavors, teams rather than individuals

are the most effective fundamental operating units..”


Communication and Assertiveness

• The primary goal of CRM is enhanced situational awareness, self awareness, leadership, assertiveness, decision making, flexibility, adaptability, event and mission analysis, and communication.

• CRM aims to foster a climate or culture where the freedom to respectfully question authority is encouraged. It recognizes that a discrepancy between what is happening and what should be happening is often the first indicator that an error is occurring.

• This is a delicate subject for many organizations, especially ones with traditional hierarchies, so appropriate communication techniques must be taught to supervisors and their subordinates, so that supervisors understand that the questioning of authority need not be threatening, and subordinates understand the correct way to question orders.


Leadership

• A leader, for our purposes, is someone who other people follow, or as someone who guides or directs others.

• Leadership is organizing a group of people to achieve a common goal.

• Leadership is a set of skills that can be taught.


Crew Coordination

A leader’s responsibilities are to:• Establish a culture of open communication and collaboration.

• Use effective communication skills

• Use cross‐checking tools to capture error and avoid mishaps

• Manage risk by identifying hazards and mitigating them

• Manage fatigue


Decision Making

• Recognize that a problem exists• Define what the problem is• Identify probable solutions• Take appropriate action to implement a solution

In dealing with complex systems, it is best to do contingency planning, publish standard and emergency operating procedures, and create emergency checklists to aid crew members in dealing with problems.Standard operating procedures are the basis for training crews to deal with problems


Risk Management• The first step in risk management is the identification of hazards• The second step is assessing risks in terms of likelihood and severity

• The third step is reducing either the probability or the severity of risk, or both.


RISK ASSESSMENT MATRIX

Severity

Probability

Catastrophic(1)

Critical(2)

Marginal(3)

Negligible(4)

Frequent(A)

High High Serious Medium

Probable(B)

High High Serious Medium

Occasional(C)

High Serious Medium Low

Remote(D)

Serious Medium Medium Low

Improbable(E)

Medium Medium Medium Low

Eliminated(F)

Eliminated

Factors that Affect Decision‐Making: Stress

• In the accident examples we have examined, the crews were under extreme stress, facing imminent death. It is very difficult in such a situation to to apply one’s knowledge and experience to solving a problem.

• Here, intense training and practice of emergency procedures is key. Flight simulators make it possible to expose pilots to virtual system failures.

• In learning to fly an aircraft, instructors often use the mantra: “in an emergency, fly the plane! Fly the plane! Don’t stop flying the plane.” This mantra has saved many lives.


Factors that Affect Decision‐Making: Pressure

• Air crews are under continuous pressure to meet schedules. Delays in rolling back from the gate trigger cascading consequences: missed connecting flights for passengers, aircraft stacked up on taxiways.

• It is a matter of professional pride to make on‐time departures. In the case of Air Florida Flight 90, ice on the taxiway made the aircraft 90 minutes late leaving the gate. Trapped for 45 minutes in a line of aircraft waiting to takeoff, the pilots were acutely aware that a decision to return to the deice station might make them hours late for takeoff.


Factors that Affect Decision‐Making: Fatigue

• The NTSB estimates that fatigue contributes to 20‐30% of transport accidents. Since, in commercial aviation operations, about 70% of fatal accidents are related to human error, it can be assumed that the risk of the fatigue of the operating crew contributes about 15‐20% to the overall accident rate.

• Fatigue degrades every aspect of human performance. Despite duty time restrictions, it continues to be a factor in aircraft accidents.


Factors that Affect Decision‐Making: Complacency

• Modern commercial aircraft can (and often do) fly themselves – including takeoff and landing. There are sound financial reasons to allow automated systems to do the flying: reduced fuel consumption, for example. Consequently, modern pilots spend less time at the controls of their aircraft.

• While very reliable, automated control systems do fail. They depend on air sensing devices for airspeed and altitude information, on gyros for attitude information. When they do fail, the consequences can be disastrous.

• Pilots must remain alert and aware so that they can take over when automated systems fail.


References and Additional Reading

• Normal Accidents: Living with High‐Risk Technologies by Charles Parrow

• Managing the Risks of Organizational Accidents by James Reason

• The Logic Of Failure: Recognizing And Avoiding Error In Complex Situations by Deitrich Dormer

• The Field Guide to Understanding Human Error by Sidney Dekker


Patient Safety Assessment

If you would like someone from HTMS to contact you regarding a patient safety assessment at your

organization, please contact:

Diane Bradley, Regional Chief Clinical Officerdiane.bradley@ht‐llc.com

Office Phone: 585‐671‐2212Cell: 585‐455‐3652


QUESTIONS?


Documents

Webinar Series 2014/2015 - HealthTechS3...Certificate Number 1319. Subsequently, he assisted the Director of Safety in creation of Columbia’s Safety Management System and has participated