Lessons Learned from CRM “More than a Feeling...”

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 Te

amw

ork

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

Superviso

r Exp

ectations

Manager S

upport

Organiza

tional Le

arning

Overall Perce

ption

Feedback

about Erro

r

Freq of E

vent R

eporti

ng

Comm Openness

Teamwork acro

ss 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

Positi

ve

Safety Culture Survey

Teamwork w

/in Unit

Superviso

r Exp

ectations

Manager S

upport

Organiza

tional Le

arning

Overall Perce

ption

Feedback

about Erro

r

Freq of E

vent R

eporti

ng

Comm Openness

Teamwork acro

ss Units

Staffing

Handoffs/Transiti

ons

Nonpunitive Response to

Error

0%

20%

40%

60%

80%

100%

2007 2008 2009 2010n=1032/472,397

AHRQ, 2011

Positi

ve

Safety Culture Survey

Teamwork w

/in Unit

Superviso

r Exp

ectations

Manager S

upport

Organiza

tional Le

arning

Overall Perce

ption

Feedback

about Erro

r

Freq of E

vent R

eporti

ng

Comm Openness

Teamwork acro

ss 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

Positi

ve

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

Positi

ve

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

Positi

ve

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

Positi

ve

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

Positi

ve

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%

Positi

ve

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”?

Thank You

Jeffrey Hill, MS