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

1. Lessons Learned from CRM“More than a Feeling...” Jeffrey R. Hill, MS

2. 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”?

3. 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

4. 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

5. Human error is inevitable because . . . Inherent human limitations Complex, unsafe systems Safety is often assumed, not assured Culture of the expert individual Leonard, 2008

6. Crew Resource Management (CRM)

7. Rate = .0314Fatalities = 0 Boeing, 2012

8. 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

9. 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®

10. CRM focus Leadership Teamwork Communication/Coordination Situation Monitoring Mutual Support Team based Learning/Improvement

11. Implementation Challenges Managing Teams Sharing a Mental Model Managing a Culture Developing Psychological Safety Understanding of Leadership Responsibilities Instituting new Tools and Processes Communication

12. Managing Teams

13. 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

14. 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.“

15. 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?

16. 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

17. Nurse-Physician Communication (con’t) O’Leary, et.al.,2010

18. Quality of Teamwork across 28 organizations:Differences between Physicians & Nurses Quality of Teamwork Sexton, 2008

19. Sharing the Mental Model

20. DOMESTIC VIOLENCE IN PREGNANCY RELATIONSHIPS TO PREGNANCY OUTCOMES AND IMPACT ON OBSTETRICAL CARE Courtesy of Nancy C. Chescheir, MD

21. From: "Hill, Jeffrey R" <Jeff.Hill@Vanderbilt.Edu> Sent: Fri 12/2/05 11:45 am To: "Chescheir, Nancy C" <nancy.c.chescheir@Vanderbilt.Edu> 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/R Jeff Hill

22. From: Chescheir, Nancy C Sent: Friday, December 02, 2005 1:04 PM To: Hill, Jeffrey R Subject: 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

23. Shared Mental Model Did we have a Common understanding of what was happening?

24. From: "Hill, Jeffrey R" <Jeff.Hill@Vanderbilt.Edu> Sent: Fri 12/2/05 2:14 pm To: "Chescheir, Nancy C" <nancy.c.chescheir@Vanderbilt.Edu> Subject: RE: RE: CRM Thanks. I was really asking about the image on your slides. Jeff Hill

25. From: Chescheir, Nancy C Sent: Friday, December 03, 2005 1:04 PM To: Hill, Jeffrey R Subject: 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.

26. Shared Mental Model Common understanding of what is happening and what team members can expect The basis for all effective communication

27. Managing a Culture

28. Safety Culture Survey n=1032/472,397 Positive AHRQ, 2011

29. Safety Culture Survey n=1032/472,397 Positive AHRQ, 2011

30. Safety Culture Survey n=1032/472,397 Positive AHRQ, 2011

31. Why do I need a checklist?

32. June 12, 2010 221 nm2hrs + 29 min

33. Cessna Checklist

34. Dipstick is missing!

35. This is why I need a checklist

36. Pre Procedural Briefing

37. 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

38. The Spectrum of Disrespectful Behavior Disruptive behavior Humiliation and degrading put-downs Passive-aggressive behavior – refusal to comply, ignore calls, negative comments Passive disrespect – poor team players, don’t participate in QI, always late Dismissive treatment of patients Leape, 2012

39. The Spectrum of Disrespectful Behavior • “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

40. Communication Openness n=1032/472,397 Positive AHRQ, 2011

41. Communication Openness n=1032/472,397 Positive AHRQ, 2011

42. Communication Openness(by staff position) n=1032/472,397 Positive AHRQ, 2011

43. Leadership

44. United 232DEN – ORDJuly 19, 1989

45. United 232 #2 engine fan disintegrates Loss of primary flight controls Crew gains partial control Aircraft diverts to Sioux City, Iowa Aircraft crashes

46. Sioux City, Iowa July 19, 1989 111 Fatalities 185 Survivors 172 Injured

47. United 232 Expectation of Speaking Up • Leadership • Team formation • Personal identification • Establish rapport • Sharing a Mental Model • Goals/Objectives • Defining Roles & Responsibilities • Normal situations • Contingencies • Invitation to Speak Up

48. Roles of Leadership Learn Model behaviors Mentor Motivate Hold accountable Encourage feedback *Ensure the success of team members *Leonard, 20XX

49. Leadership “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. “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

50. Tools (a.k.a. “Processes”)