Team Perfection in Healthcare

Ultimate Goal: High Reliability Organization

Minimization of

Consequences resulting from

CRM errors

Early detection of

Error

Error Avoidance

Chernobyl Nuclear Plant Disaster in 1986

Group Values

Individual Values

Attitudes Perceptions

Competencies

Behavioral Patterns

• According to The FAA (Federal Aviation Administration) Definition: • CRM represents the utilization of all available human,

informational, and equipment resources toward the effective performance of a safe and efficient flight.

• CRM is an active process by crewmembers to identify significant threats to an operation, communicate them to a person in charge, and to develop, communicate, and carry out a plan to avoid or mitigate each threat.

• Misconceptions exist…

– ‘It’s all about teamwork’

– ‘it’s a tool to enhance communication’

– ‘it’s about management of resources…’

• CRM is about and management

Assertiveness Normalization of Deviance

Leadership

Team Debriefings

Human Factors Disclosure

Stress and Fatigue

Team Briefings

Situational Awareness

Decision Making

Error Mitigation

Critical Language

Checklists

Communication

Conflict Resolution

• American deadliest plane crash: Flight 191

• CRM developed for a NASA workshop in 1979

• For more than 2 decades, CRM has gone through 6 generations of evolution: – From a model that targeted individual styles and

correcting deficiencies in human behavior to the current error management model.(2)

– Traditional CRM skills and methods are applied not only to eliminate, trap or mitigate errors but to identify systemic threats to safety (3)

• human error is inevitable but errors can provide a great deal of information for safety improvement(2)

• It took 20 years to yield an observable outcome – the Success…

Does this imply we, the Healthcare Industry, can also achieve the same success in 20-year time?

1990 1999 2001

WHO 2009

AHRQ 2004

• Course development based on safety culture tools recommended by WHO (2009)(4)

– Safety Attitude Questionnaire (Sexton et al, 2006) • 60 item questionnaire which measures dimensions including

teamwork, management, and working conditions. Different versions for intensive care units, operating rooms, wards, clinics, etc.

• It asks workers and managers about their attitudes to safety and perceptions of how safety is prioritized and managed in the work unit or across the organization(4)

– Hospital Survey on Patient Safety Culture: (AHRQ, Sorra & Nieva, 2004)

– The MaPSaF Manchester Patient Safety Assessment Framework (Kirk et al, 2007)

Adult Learning:

Kolb’s Cycle

Progressive Style:

Classroom-based Immersive Simulation

Focus on Debriefings and Self-reflection

28

1

3

1 2 2

1 1

Mixed Specialties

DOM

Operating Room

Surgery

Obstetrics & DeliverySuitesPsychiatry-CPH

Pharmacy

ENT

Workshop Composition Period: 5/13- 5/15

Total: 39 Workshops

• The most popular framework for guiding training evaluations:

Kirkpatrick’s typology Results

Behavior

Learning

Reaction

• Reaction Evidence

Medical Staff 15%

Nursing Staff 74%

Allied Health Staff 7%

Administrator

3%

Others 1%

Categories of Participants Period: 5/13- 3/15

Item Agree %

12) I am overall satisfied with this training program Note: Response rate= 96.4% (563/584)

99.1%

• Reaction and Learning Evidence

Teamwork Climate

† P-value obtained from Wilcoxon signed rank test (non-parametric test for comparing median difference of two related samples).

Safety Climate

• Reaction Evidence

† P-value obtained from Wilcoxon signed rank test (non-parametric test for comparing median difference of two related samples).

Perception of Management

Job Satisfaction

• Learning Evidence

† P-value obtained from McNemar’s test (equivalent to chi-square test for repeated measures).

Learning Evidence

• Behavioral Evidence

– Train-the-trainer program

• Change agents in various departments

– Surgical Safety Checklist

• Mandatory for ALL operations in operating theatres – Both attitude and behavioral changes were observed

• Being followed by procedures done in ward settings

• Behavioral Evidence – Co-organized CRM training workshop

• Different departments took the initiatives

– In-situ simulation drills • Initiated by individual specialties • Co-organized with CRM committee for facilitated debriefings

– AED in-house CRM teaching activities • Further consolidation of CRM concept

– Checklist-guided Briefing and Debriefing Huddles in OR • Nursing Staff, Surgeons and Anesthetists worked as a team to

prepare for the elective operations on the next day • Problems encountered on the day were brought out for

appropriate follow-up actions

• Outcome Evidence

– It is DIFFICULT

– Briefings and Debriefings in OR

• Implemented in 5/2014 on T4 (1 out of 4 Floors)

• Evaluation – 60-item SAQ to all nursing staff, anesthetists and surgeons of

various specialties (pre- and post- exposure)

– Elective Overrun (1-year data pre and post initiation)

– Start-time Delay for 1st Elective Case

– Same-day Elective Cancellation due to un-optimized patient’s status

• Outcome Evidence

– Briefings and Debriefings in OR

• Preliminary results – 60-item SAQ (Score<60:Poor; >75:Good)

» only pre-exposure baseline obtained

» Response rate >60% for all specialties (nursing staff:100%)

» Compared with a benchmark study, BMC (2006):

• Outcome Evidence

– Briefings and Debriefings in OR

• Preliminary results – 60-item SAQ (Score<60:Poor; >75:Good)

» Subgroup analysis

• Doctors vs.. Nurses

• Nurses: Significantly lower scores for all domains

• Job ranking: No significant difference

• Outcome Evidence – Briefings and Debriefings in OR

• Preliminary results – Elective Overrun

» 25-30% reduction in late finish on T4 since the initiation of

briefings (c.f. more or less the same on T2/T3/T5) » Possibly related to more effective list management

OTMS Late Finish: No of Days with Late Finish

• Outcome Evidence – Briefings and Debriefings in OR

• Preliminary results – Start-time Delay for 1st Elective Case

» Mean: 66.7% vs. 78.7% (pre- vs. post-briefing initiation) » Better teamwork and sharing of common goals

Percentage of Zero Start-time Delay for 1st Elective Case

• Outcome Evidence – Briefings and Debriefings in OR

• Preliminary results – Same-day Elective Cancellation due to un-optimized patient’s

status

» CDARS reports for reasons of same day elective cancellation

» Before the initiation of briefing huddles, 15% elective operations being cancelled on the day of OT had a reason stating that “patient’s not fit for OT”

» From 1/5/2014-30/4/2015, only ONE patient had the elective operation cancelled due to poor chest condition

» Discussion of concerns about patients’ status during briefing huddles allows early recognition of patients requiring further optimization, and therefore prevents unexpected same day elective cancellation

• A meta-analysis of the effectiveness of crew resource management training in acute care domains, Postgraduate Medical Journal, 12 2014, O’Dea Angela , O’Connor Paul

– Peer reviewed papers published in English between Jan 1985 and September 2013, 239 articles were found

Reaction evidence Learning evidence

Behavioral evidence

Lack of Outcome evidence

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials; Gordon C S Smith, Jill P Pell ; BMJ. 2003 Dec 20; 327(7429): 1459–1461.doi: 10.1136/bmj.327.7429.1459

• The long term effects of CRM training or the impact on clinical care outcomes is not yet established.

• The healthcare industry could wait for this evidence before further implementation of CRM training, or perhaps the ‘parachute approach ‘ may be more prudent.

Recommendations based on NTWC Data

Teamwork Climate Job Satisfaction:

scored lower than other international

institutes

CRM Training

Nurse:

Lower score in all domains

Major Target:

Nurse

Job Ranking:

No significant difference

Early exposure to CRM teaching

warrants a better grow in safety

culture

Behavioral changes

Reduced Mishaps and

Incidents

Learning

Positive Reactions

1. Cooper, G. E., White, M. D., & Lauber, J. K. (1980). Resource Management on the Flight deck: Proceedings of a NASA/Industry Workshop. (NASA CP-2120). Moffett Field, CA: NASA-Ames Research Center.

2. Robert L. Helmreich, Ashleigh C. Merritt & John A. Wilhelm Department of Psychology; The Evolution of Crew Resource Management Training in Commercial Aviation; Aerospace Crew Research Project;The University of Texas at Austin; International Journal of Aviation Psychology pages 19-32

3. Crew Resource Management: From Patient Safety to High Reliability; David Marshall, SaferHealthcare

4. Human Factors in Paent Safety Review of Topics and Tools; Report for Methods and Measures Working Group of WHO Patient Safety ;April 2009

5. Team Training in the Skies: Does Crew Resource Management Training Work? Eduardo Sa;as et al; Human Factors; Winter 2001; 43; Proquest Health & Medical Complete

6. Improving Patient Safety Using Crew Resource Management Principles Taught Via Medical Simulation. David Gaba’s group at Stanford University – Anesthesia Crisis Resource Management, 1990s

7. Robert Helmreich and Hans Schaefer at University of Texas and Basel – Team Oriented Medical Simulator (TOMS), 1990s

8. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials; Gordon C S Smith, Jill P Pell ; BMJ. 2003 Dec 20; 327(7429): 1459–1461.doi: 10.1136/bmj.327.7429.1459

9. McCulloch P. Intervention to improve teamwork and communication among healthcare staff. Br J Surg 2011;98:469-79

10. Zeltser MV. Approaching the evidence basis for aviation-derived teamwork training in medicine. Am J med Qual 2010;25:13-23

11. Salas Eduardo; Wilson, Katherine A; Burke, C Shawn; Wightman, Dennis C; Does Crew Resource Management Training Work? An Update, an Extension and Some Critical Needs; Human Factors; Summer 2006; 48, 2; Proquest Health & Medical Complete

12. Buljac-Samardzic M.Interventions to improve team effectiveness: a systematic review. Health Policy 2010;94:183-95

13. Rabol Li. Outcomes of classroom-based team training interventions for multiprofessional hospital staff. A systematic review. Qual Saf Health Care 2010;19

14. Weaver SJ. Team training in healthcare:a narrative synthesis of the literature. BMJ Qual Saf 2014;23:359-72

15. O’Dea Angela , O’Connor PaulA meta-analysis of the effectiveness of crew resource management training in acute care domains, Postgraduate Medical Journal, 12 2014,

16. Powell, Stephen M; Hill, Ruth Kimberly; Home Study Program: My copilot is a nurse – using crew resource management in the OR; Association of Operating Room Nurses, AORN Journal; Jan 2006; 83,1; ProQuest Health & Medical Complete

17. Colin Kanschok , Mary Sirois; Flying Lessons: Crew Resource Management in Healthcare; Divurgent

18. Mary David Oriol; Crew Resource Management; Applications in Healthcare Organizations; JONA; Volume 36; Number 9, pp 402-406; 2006 Lippincott Williams & Wilkins, Inc

19. Flin Rhona; O’Connor, Paul; Mearns, Kathryn; Crew Resource Management: Improving team work in high reliability industries; Team Performance Management; 2002; 8, ¾ ; ABI/INFORM Complete p68

20. Salas, Eduardo; Prince, Carolyn; Bowers, Clint A; Stout, Renee J et al; A Methodology for enhancing crew resource management training; Human Factors; Mar 1999; 41,1; ProQuest Health & Medical Complete pg 161

21. Daniel J, France, Renee Stiles; F Andrew Gaffney, MD; Margaret R, Seddon, MD; Eric L Grogan, MD; William R Nixon, Jr; Theodore Speroff; Crew Resource Management training- Clinicians’ reaction and attitudes; Association of Operating Room Nurses, AORN Journal; Aug 2005; 82,2; ; ProQuest Health & Medical Complete pg 214

22. Peter F Kemper; Martine de Brujne, Cathy van Dyck and Cordula Wagner; Effectiveness of classroom based crew resource management training in the intensive care unit: study design of a controlled trial; BMC Health Services Research 2011, 11: 304

23. David G, Lindquist, MD; Improving Patient Safety Using Crew Resource Management Principles Taught via Medical Simulation; Prescriptions for Excellence in Health Care, Issue 7, Winter 2009

24. Daniel J France et al; An Observational analysis of surgical team compliance with perioperative safety practice after crew resource management training; The American Journal of Surgery 195 (2008) 546-553

25. Sylvain Boet MD, M Dylan Bould, MBChB; Lilian Fung MD; Haytham Qosa MD; Laure Perrier, MLIS; Walter Tavares, PhD; Scot Reeves, PhD; Andrea C Tricco, PhD; Transfer of learning and patient outcome in simulated crisis resource management: a systematic review; Can J Anesth (2014) 61: 571-582; DOI 10.1007/s 12630-014-0143-8

26. Clint A bowers, Florian Jentsch, Eduardo Salas; Analyzing Communication Sequences for Team Training Needs Assessment; Human Factors Dec 1998; 40, 4; ProQuest Health & Medical Complete pg 672

27. K Michael Hughes,Ronald S Benenson, Amy E Krichten, Keith D Cllancy; James Patrick Ryan, Christopher Hammond; A Crew Resource Management Program Tailored to Trauma Resuscitation Imrpoves Team Behavior and Communication; Journal of The American College of Surgeons 2014; 219:545-551

28. Johnathan R.B. Halbesleben; Karen R. Cox; Leslie Hall; Transfer of crew resource management training: A qualitative study of communication and decision making in two intensive care units; Leadership in Health Services Vol 24 No 1, 2011 pp 19-28

29. Christopher M Hicks, Glen W Bandiera, Christopher J Denny; Building a simulation-base crisis resource management cource for emergency medicine, Phase 1: Results from an interdisciplinary needs assessment survey; 2008 the Society of Academic Emergency Medcine; DOI 10.1111/j. 1553-2712.2008.00185.x

30. Guy Huller, Philippe Garnerin, Michel-Ange Morales, Ricardo Pfister; Effect of crew resource management training in a multidisciplinary obstetrical setting; International Journal for Quality in Health Care 2008; Volume 20, Novemeber 4; pp 254-263