Principles in Crisis Resource Management (in Disasters)

1. Principles in Crisis Resource Management(in Disasters) Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg April 16, 2012 MDH MBFI Hall Pre-convention Workshop on Crisis Resource Management in Disasters Philippine College of Emergency Medicine, Inc. MDH Emergency Medicine

2. Workshop on Crisis Resource Managementin Disasters Objectives At the end of the workshop, participants should be able to: Define Crisis Resource Management and know its importance and uses. Understand the basic principles of Crisis Resource Management. Apply the principles of CRM in a simulation activity. Identify one’s and the team’s areas of improvement and strengthening.

3. Principles in Crisis Resource Management(in Disasters)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)

4. Principles in Crisis Resource Management(in Disasters)Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgFacilitator Contents Outline Crisis Resource Management Concept Importance Uses Basic principles Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital)

5. 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.

6. Crisis Resource Management - Concept 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)

7. Crisis Resource Management - Concept History CRM - first developed by aviation industry late 1970s Original term used - Crew Resource Management Another term used - Cockpit Resource Management

8. Crisis Resource Management - Concept 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

9. Crisis Resource Management - Concept 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)

10. Crisis Resource Management - Concept 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.

11. Crisis Resource Management - Concept

12. Crisis Resource Management - Concept 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

13. Crisis Resource Management - Concept 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

14. Crisis Resource Management - Concept 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.

15. Crisis Resource Management - Concept 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.

16. Crisis Resource Management - Concept In medicine, CRM - not limited to anesthesia Anesthesia CRM Emergency Medicine CRM Pediatric CRM Critical Medicine CRM Others

17. To repeat for summary and retention! 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.

18. To repeat for summary and retention! Crisis Resource Management - Concept 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)

19. 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 with emphasis on optimal teamwork (communication, coordination, collaboration), prevention of errors and safety promotion.

20. 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.

21. Crisis Resource Management – Basic Principles

22. 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.

23. Crisis Resource Management – Basic Principles CRM is a management system. Management system includes crisis preparedness and response plans and exercises to enhance optimal responses during an actual crisis.

24. Crisis Resource Management – Basic Principles 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.

25. Crisis Resource Management – Basic Principles 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.

26. Crisis Resource Management – Basic Principles 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).

27. Crisis Resource Management – Basic Principles Seven key behaviours as originated from Crew Resource Management: Know your environment Prepare and plan Call for help early Take a leadership role Allocate attention wisely and use all available resources Prioritize and distribute the workload Communicate effectively

28. Crisis Resource Management – Basic Principles Gaba added more key behaviours in anesthesia CRM (see Nos. 8 to 15). 8. Use all available information 9. Prevent and manage fixation errors 10. Cross (double) check 11. Use cognitive aids 12. Re-evaluate repeatedly 13. Use good teamwork 14. Allocate attention wisely 15. Set priorities dynamically

29. Crisis Resource Management – Basic Principles 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

30. Crisis Resource Management – Basic Principles 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.

31. Crisis Resource Management – Basic Principles 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

32. Crisis Resource Management – Basic Principles In simple and most basic terms, non-technical skills in health-care industry CRM can consist of: Non-technical skills Behavioural skills Leadership Communication Team working (communication, coordination, and collaboration) Cognitive skills Situational awareness Planning Decision making Task management

33. Crisis Resource Management – Basic Principles 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.

34. Crisis Resource Management – Basic Principles To simplify things, I suggest using the following package or framework: Leadership Situational awareness Planning Decision making Communication Coordination Collaboration Task management

35. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital)

36. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital)

37. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital)

38. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital)

39. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital)

40. 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.

41. Crisis Resource Management – Application in a simulated activity (a simulated 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.

42. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital) To plan for the conduct of the simulation CRM, facilitators should formulate an instructional design or lesson plan.

43. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital) 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).

44. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital) 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.

45. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital) General Steps in Response to MCI based on MDH Response Plan:

46. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital) General Steps in Response to MCI based on MDH Response Plan:

47. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital) General Steps in the Control of Disasterin Response to MCI based on MDH Response Plan:

48. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital) General Steps in the Control of Disasterin Response to MCI based on MDH Response Plan:

49. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital) 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.

50. Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital) 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.