Lessons Learned from CRM
“More than a Feeling...”
Jeffrey R. Hill, MS
The path to safety . . .
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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
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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 . . .
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Inherent human limitations
Complex, unsafe systems
Safety is often assumed, not assured
Culture of the expert individual
Leonard, 2008
Crew Resource Management
(CRM)
Rate = .0314
Fatalities = 0
Boeing, 2012
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
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Leadership
Teamwork
Communication/Coordination
Situation Monitoring
Mutual Support
Team based Learning/Improvement
Implementation Challenges
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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
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Sharing the Mental Model?
Preparing for surgery?
Communication?
Contingencies?
Nurse-Physician Communication
• Interviewed
– Physicians
– Nurses
– Patients
n
301
310
229
• Patients
– Expected nurse & physician to discuss their care daily
89.0%
O’Leary, et.al.,2010
Nurse-Physician Communication (con’t)
Physician
Nurse
100%
80%
70.6%
61.5%
60%
40%
50.3%
35.9%
20%
0%
Knew name
Communicated
O’Leary, et.al.,2010
Quality of Teamwork across 28 organizations:
Differences between Physicians & Nurses
Quality of Teamwork
5
4
3
2
1
Nurse rates Physician
Physician rates Nurse
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" <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
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
Shared Mental Model
Did we have a Common
understanding of what was
happening?
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
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.
Shared Mental Model
Common understanding of what is
happening and what team members
can expect
The basis for all effective
communication
Managing a Culture
Safety Culture Survey
n=1032/472,397
100%
80%
80%
75%
72%
72%
66%
Positive
60%
64%
63%
62%
58%
57%
45%
44%
40%
20%
0%
AHRQ, 2011
Safety Culture Survey
2007
2008
2009
2010
n=1032/472,397
100%
80%
Positive
60%
40%
20%
0%
AHRQ, 2011
Safety Culture Survey
Mgmt
Physician
Asst/CP
Nurse
n=1032/472,397
100%
80%
Positive
60%
40%
20%
0%
AHRQ, 2011
Why do I need a checklist?
June 12, 2010
221 nm
2hrs + 29 min
Cessna Checklist
Dipstick is missing!
This is why I need a checklist
Pre Procedural Briefing
Precaution Level
Adverse Patient Hx
Procedure Announced
Patient Allergies
Invitation to Speak Up
Briefing Initiated
Ready ?
Pt Name Announced
Checklist Used
W.Board Complete
Procedure Confirmed
Pt Name Confirmed
0%
20%
40%
60%
80%
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
n=1032/472,397
100%
80%
76%
63%
Positive
60%
47%
40%
20%
0%
Will freely speak up
Free to question decisions of
more authority
Not afraid to ask questions
AHRQ, 2011
Communication Openness
Mgmt
Physician
n=1032/472,397
100%
Positive
80%
60%
40%
20%
0%
Will freely speak up
Free to question decisions of
more authority
Not afraid to ask questions
AHRQ, 2011
Communication Openness
(by staff position)
Mgmt
Physician
Asst/CP
Nurse
Tech
n=1032/472,397
Asst/Sec
100%
Positive
80%
60%
40%
20%
0%
Will freely speak up
Free to question decisions of
more authority
Not afraid to ask questions
AHRQ, 2011
Leadership
United 232
DEN – ORD
July 19, 1989
United 232
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#2 engine fan disintegrates
Loss of primary flight controls
Crew gains partial control
Aircraft diverts to Sioux City, Iowa
Aircraft crashes
Sioux City, Iowa
July 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
– Expectation
Invitation toof
Speak
Up Up
Speaking
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.
“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.
Haynes, 1991
Tools (a.k.a. “Processes”)
“Dad. Can I borrow the Car?”
“Sure son… just be safe.”
“OK Dad.”
Tools?
Checklists
Boeing Model 299
Oct 30, 1935
Why Checklists?
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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
100%
88.7%
80%
58.7%
Positive
60%
53.7%
52.8%
50.7%
Consultations
Primary Dx
Med Changes
40%
20%
0%
Planned
Procedure
Planned Tests
O’Leary, et.al.,2010
House Staff Survey
(quality of handoffs)
• n=161
– 108 = Internal Medicine
– 53 = Surgery
• Concerning most recent inpatient rotation…
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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)
100%
Positive
80%
60%
40%
20%
0%
The two most useless phrases in
healthcare
“Safety is our first priority”
“We need to communicate better”
The path to safety . . .
•
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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