Alliance with Aviation

1. Alliance with Aviation Using Crew Resource Management to Improve Patient Safety Northfield Hospital

2. The problem…

3. IOM 1999“To Err is Human” • “……healthcare organizations should establish team training programs for personnel in critical areas (e.g., ED, operating rooms), using proven methods such as the crew resource management techniques employed in aviation…”

4. IOM 1999“To Err is Human” • “People make fewer errors when they work in teams. When processes are planned and standardized, each member knows his or her responsibilities as well as those of teammates, and members “look out” for one another, noticing errors before they cause an accident.”

5. IOM 2003“Health Professions Education” • Medical schools to incorporate new core competency: Work in interdisciplinary teams • “..All team members must have strong communication skills and a clear understanding of each other’s roles and responsibilities….”

6. IOM 2003“Health Professions Education” • “Competency in team care ….involves learning approaches to maximize collaborative work; ensuring that timely information reaches those who need it; and managing patient transitions across settings and over time…”

7. Our experience…. Communication issues are evident in nearly all events or near misses • Miscommunication • Dropped communication • Hesitancy to question peer or “authority” • Written communication not accessed Staff works side by side but not always together

8. Example…. • Pt admitted with syncope / possible seizure • That evening, new complaints of leg pain • On-call MD orders ultrasound • Results “extensive DVT” • Teleradiologist FAXed results after “no one answered the phone”. BUT, no one knew the FAX machine was malfunctioning • Results not discovered until the next morning: treatment was delayed unnecessarily

9. What we learned… • The ultrasound tech had the information that the caregivers needed, but did not have the authority to convey it • Now, they give a “heads up” to the nurse on possible abnormal findings • No process in place to prompt caregivers to follow-up on pending diagnostic tests and to communicate that to the next shift • Now, nurses use a standardized worksheet for shift-to-shift report, which includes any pending tests

10. Why Aviation? • Commonalities between aviation and healthcare • High risk environment • Highly skilled professionals • Failures in teamwork can have deadly effects • What aviation has learned… • Most crashes involve teamwork failure rather than mechanical failure • Accident rate reduced since the introduction of CRM

11. Finding the Experts • Northwest Airlines based in our own backyard • Recruited fleet training captain, recently retired, “looking for something challenging and rewarding to do….”

12. CRM Overview Communication Secure authority Assertiveness with respect Sharing information Standardization Work processes Standards of care Workload Management Clear roles and accountability Contingency staffing plans Recognizing vulnerabilities regardless of workload

13. Concepts • Everyone makes mistakes • Being highly skilled and professional isn’t enough to prevent error • Everyone on the team shares responsibility for patient

14. Understanding error Need basic knowledge of threats and errors as part of learning CRM • “Swiss Cheese” model • Sharp / blunt ends • Organizational culture • Name and blame vs. “just” culture • Authoritarian vs. flattened hierarchy • Human factors

15. Human Factors • Fatigue • Reliance on technology • Reliance on memory • Loss of situational awareness • Distraction: Interruptions, emotions, environmental noise • Mindset • Automatic behaviors

16. Communication • Secure authority • “Flatten the hierarchy” • Leaders’ acknowledgement of vulnerability to error • Leader sets tone of open communication: input from all sources explicitly encouraged and required • Dispels discomfort on the part of team members who might be afraid of offending, retaliation if they speak up • Assertiveness with respect • Team members speak up regardless of hierarchy • Use of SBAR: situation, background, assessment, recommendation

17. Standardization • Standardized work processes (e.g., call-backs for outpt culture results) • Standardized care (e.g., Acute MI) • Allows team members to: • Anticipate what comes next • Recognize and question the unexpected • Recognize “workarounds”: address the process

18. Workload Management • Requires clear roles and accountability • Task prioritization • “Situational awareness”: use of huddles • Debriefing serious events • Recognizing vulnerabilities • Heavy: redistribute the work, ask for help • Light: stay alert, focused • Acknowledging fatigue

19. Program Design • 3-year “phased” program • Year 1: ED (Staff, MDs, EMS, pharmacy, lab, x-ray, administration) • Year 2: Inpatient (medsurg, OB, surgery • Year 3: Outpatient (Rehab, LTCC, HHC) • 1-year course for each group • Quarterly newsletters to all employees

20. Training outline • Four 3-hour sessions: 1 session/quarter • Small groups: 10-12 people • Interdisciplinary: doctors, nurses, EMS, HUCs, lab, x-ray, pharmacy • Interactive: presentation, conversation, video, role playing, OptionPower technology • Stories from the front line

21. Turbulence • Some resistance to mandatory training • Resentment/perception that training leaves department short-staffed • Eeyore syndrome: “Nothing ever changes anyway” • Defensiveness when assertiveness with respect is practiced with someone who is not secure in his/her authority • Mixed reaction re: use of titles

22. Challenges • Training logistics • Overcoming perception that CRM is just a fad • Keeping CRM “front and center” over a long period of time • Leadership / accountability for mentoring the right behaviors within departments

23. Status Report • ED group training completed July, 2005 • Changed from MD-led to Nurse-led ED to improve patient flow, patient transports and admissions control • Incorporated periodic Huddles into shift routine • Standardized nursing handoffs using SBAR • Standardized nursing protocols for select chief complaints to allow for diagnostics / treatment before MD sees pt

24. At least one life saved… • Radiology technician performing abd ultrasound on outpatient • In conversation, patient mentions he’s also scheduled for a stress test later that day • Radiology tech sees AAA on ultrasound • Asks on-duty ED physician for advice in what to do with information • Called primary MD; test cancelled, surgery consult arranged

25. Staff anecdotal feedback “There’s a gap between those depts who have had CRM training and those who haven’t…a different style of communication. They write their concerns down and submit them. We now resolve our issues in the present, knowing we have permission to express concerns at the time they occur”

26. Staff anecdotal feedback • “Why go through training if the doctors still won’t listen to what we have to say?”

27. We still have work to do…. Typical timeline for behavior changes 5 years: 50%