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

Principles in Crisis Resource Management(in Disasters)

Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgApril 16, 2012

MDH MBFI Hall

Pre-convention Workshop on

Crisis Resource Management in Disasters

Philippine College of Emergency Medicine, Inc.

MDH Emergency Medicine

Workshop on Crisis Resource Managementin Disasters

Objectives

At the end of the workshop, participants should be able to:

1.Define Crisis Resource Management and know its importance and uses.

2.Understand the basic principles of Crisis Resource Management.

3.Apply the principles of CRM in a simulation activity.

4.Identify one’s and the team’s areas of improvement and strengthening.


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)



Contents Outline

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

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.


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.

(ROJoson’s synthesized concept statement)


History

CRM - first developed by aviation industry late 1970s

Original term used - Crew Resource Management

Another term used - Cockpit Resource Management


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


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)


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.


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


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


-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.


-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.


In medicine,

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



a management system




To repeat for summary

and retention!







To repeat for summary

and retention!

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


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.

Crisis Resource Management – Basic Principles



a management system





CRM is a management system.

Management system includes

crisis preparedness and response plans

and

exercises

to enhance optimal responses during an actual crisis.


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.


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.


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).


Seven key behaviours as originated from Crew Resource Management:

1.Know your environment

2.Prepare and plan

3.Call for help early

4.Take a leadership role

5.Allocate attention wisely and use all available resources

6.Prioritize and distribute the workload

7.Communicate effectively


Gaba added more key behaviours in anesthesia CRM (see Nos. 8 to 15).

8. Use all available information9. Prevent and manage fixation errors10. Cross (double) check11. Use cognitive aids12. Re-evaluate repeatedly13. Use good teamwork14. Allocate attention wisely15. Set priorities dynamically


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


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.


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

Crisis Resource Management – Basic PrinciplesIn simple and most basic terms, non-technical skills in health-care industry CRM can consist of:

Non-technical skills

Behavioural skillsLeadershipCommunicationTeam working (communication, coordination, and

collaboration)

Cognitive skillsSituational awarenessPlanningDecision makingTask management


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.


To simplify things, I suggest using the following package or framework:

• Leadership• Situational awareness• Planning• Decision making• Communication• Coordination• Collaboration• Task management

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.



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.



To plan for the conduct of the simulation CRM,

facilitators should formulate an

instructional design or lesson plan.



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).



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.



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.)

LeadershipSituational awarenessPlanningDecision makingCommunicationCoordinationCollaborationTask management



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


MDH Response Plan


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.)




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


MDH Response Plan


Triage Staff trained and assigned to do triaging at the ER and at the holding areas (Green, Yellow, and Red Areas)




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


MDH Response Plan


Treatment Staff assigned to do the medical care of the injured patients (physicians, nurses, institutional workers, recorders, etc.)




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.



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.



Checklists

that can be used to teach and evaluate different behavioral and cognitive skills

- very helpful

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).





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.





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.)


Checklist – Task Management (Example)

Parameters and indicators – Task Management


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.


Checklist – Task Management (Example)

Parameters and indicators – Task Management


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.)



Contents Outline

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



•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)



MDH MBFI Hall





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MDH MBFI Hall





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

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