American Osteopathic College of Occupational and Preventive Medicine 2015 Mid Year Educational Conference

Transcription

1 1 Disclosure: 2 Crew Resource Management for Healthcare Providers I am an employee of the Federal Aviation Administration The opinions expressed are those of the author, and do not represent the official policy of the FAA, Department of Transportation, or the Federal Government JAMES ELLIOTT, MD, MPH AOCOPM MARCH 2015 Korean Air Flight 801 Guam August 6, KAL Boeing Night approach Heavy rain RWY 6L Glide Slope Inop Crashed into Nimitz hill (660 feet) Killed 228 of 254 on board Pilot elected to continue night visual approach despite limited visibility due to weather May have assumed false signal was glideslope Outdated charts Ignored repeated suggestions from crew including go around call Korean culture and language cited as one causal factor Causes of Air Carrier Accidents 5 Crew resource Management 6 Inadequate Leadership Poor group decision making Ineffective communication Poor management of available resources The effective use of all necessary resources to safely and efficiently complete the flight The sharing of knowledge and best practices to reduce errors (Lisa West, 2012, UAL) P-1

2 Medical practice 7 Medical practice 8 66 y/o female Total hip arthroplasty (posterior approach) Surgeon had difficulty fitting acetabular shell PA asked if they had the correct size, ignored After extensive remodeling of the acetabulum, shell anchored with screws Difficult alignment with femoral component Anterior hip dislocation x 2 in PACU, once on ward Orders for Weight-bearing as tolerated PT concerned, called Dr. to confirm mobility order Progressive weakness and altered mental status H/H <7/20 No post-op CBC on orders Nurses didn t question because Dr. had reputation of being difficult to nursing staff Transfused 2 units RBCs and revision of arthroplasty Causes of Healthcare Errors 9 CRM 10 Inadequate Leadership Poor group decision making Ineffective communication Poor management of available resources Cockpit Resource Management Crew Resource Management Clinical Resource Management Crew resource Management Institute of Medicine Report 12 The effective use of all necessary resources to safely and efficiently complete the flight Or to safely and effective care for the patient The sharing of knowledge and best practices to reduce errors (Lisa West, 2012, UAL) Medical Errors result in 44,000 to 98,000 deaths per year Cost $17 to $29 Billion per year Not the result of individuals or groups Faulty systems, processes, & conditions that lead people to make mistakes or fail to prevent them. Failure of Communication P-2

3 16 years and billions of dollars later 13 Efforts to Reduce Health Care Errors National Patient Safety Foundation--400,000 deaths due to medical errors, making it the 3 rd leading cause of death CDC reported a 37% decline in medical and surgical complications between [MMWR 61(37); 750. CDC 2008: 90,000 Hospital Acquired Infection deaths 10% of hospital patients injured by medical care AHRQ National Healthcare Quality Reports show modest gains There are still 1000s of preventable deaths each year Evidence Based Medicine Reduce variability (CPG, critical pathways, standardized orders) Metrics (HEDIS, etc.) Electronic Medical Record Identity checks Time outs Improved hand hygiene Process Improvement Efforts to Reduce Health Care Errors 15 To Err is Human 16 These are often good programs and have reduced the number of errors. Necessary, but not sufficient to solve the problem. Flawed Assumption: That we can eliminate errors. We can reduce the number of errors But we will never eliminate errors Human beings are not perfect We will continue to make mistakes We can reduce the number of errors, but not eliminate them all together. 17 Types of Errors 18 Perception Misreading a chart, sensory limitations Decision Selecting the wrong course of action Execution Improper performance of an acceptable course of action These are all made worse by fatigue, stress, or time constraints (15 min appointments) P-3

4 19 Classic Decision Making 20 A rational Individual or group will weigh all possible options and select the best one Judgment and decision making Classical decision making 21 Real life decisions 22 Identify the problem Establish criteria for the solution Develop a list of alternative solutions Assess the advantages and disadvantages of each alternative using the criteria Select the best solution Test the effectiveness of the solution Limited or ambiguous information Limited time Typically rely on past experience in similar situations Select an adequate course of action rather than the optimal course of action This requires judgment and experience 23 Types of Errors 24 Perception Misreading a chart, sensory limitations Decision Selecting the wrong course of action Execution Improper performance of an acceptable course of action Judgment comes from experience. Experience comes from bad judgment P-4

5 System Errors Medical errors are simply human mistakes committed within a health care system inadequately designed to catch and neutralize those mistakes in time. 25 If we can t eliminate errors, then what? Develop healthcare teams who will catch and mitigate each other s errors before they cause harm to the patient Multiple Layers of Defense 26 NanceJJ. Why HospitalsShouldFly SecondRiverHealthcarePress. Bozeman,MT. p. 41. Analyze mistakes to determine the casual and contributing factors, take corrective actions, and share the lessons with others (Will probably require tort reform) Reason s Swiss Cheese Model 27 CRM Contributions to Patient Safety 28 Team Building Improved Communication Establishing a Safety Culture 29 Who is our Crew? 30 Building Safer Healthcare Teams P-5

6 TEAM 31 Team 32 A group of people linked by a common purpose or to achieve a common objective A shared sense of identity Commitment to a common objective Patient Safety and quality care A common vision Shared situational awareness Clear delineation of responsibilities Accountability Team Members 33 Is this your practice? 34 Responsible for their performance Trust Mutual respect Value other members contributions Open communication in all directions Mutual support Healthcare Culture Fragmented by profession, practice, and location Often no sense of team identity High power distance and authoritarian structure devalues many staff members and their contribution Poor Communication Focus on business model rather than patient care model Blame legal mentality that encourages us to hide mistakes rather than share them so others may learn P-6

7 Shared Decision Making 37 Empowerment 38 Involve others and listen to them as real team members Value their input None of us has all the answers A suggestion is not an insult or a threat to your competence. Empower others to take action Any team member can call a safety time out Hazardous Attitudes 39 Hazardous Attitudes 40 Halo effect Blind deference to someone because of their position, reputation, or experience Halo effect Blind deference to someone because of their position, reputation, or experience A-hol effect- Disagreeable, disrespectful, intimidating Where are you on the curve? 41 Hazardous Attitudes 42 Do you read nursing and therapy notes? Do you know the ward nurses names? Do you know the names of the spouses and children of your own staff? Do you value suggestions and comments? Do you get angry or defensive when someone questions your decision? Do you treat nurses or other staff as colleagues or as minions? Halo effect Blind deference to someone because of their position, reputation, or experience A-hol effect- Disagreeable, disrespectful, intimidating Complacency Uncritical expectation that everything will turn out well P-7

8 No 43 Leadership 44 Bullying Belittling Insulting Intimidating Disrespect Throwing people under the bus The art and science of influencing and directing people so as to gain their willing cooperation in achieving a common objective The Leadership Spectrum 45 Situational Leadership 46 Leadership style varies based on the situation and the person or people involved Democratic Participative coaching autocratic Final Thoughts on Leadership Leaders become great, not because of their power, but because of their ability to empower others. Communication John Maxwell P-8

9 Failed communication causes errors and prevents effective teamwork 49 How most people view communication 50 Sender Receiver What image comes to your mind when I say the word Tree? Communication Model 53 How to be a better listener 54 Feedback Filter Filter Sender Message Receiver Non-verbal Communication Listen & silent have the same letters Be an active listener Ask questions to clarify Summarize or paraphrase what you heard to be sure you got the correct message Read back critical information Maintain a sterile cockpit in critical phases of flight or medical care no side chatter Environment and Situation P-9

10 How to be a better sender 55 Essential Communication 56 Speak up if you have something important to say Be assertive when you need to be Ensure you have the listener s attention Speak slowly and clearly Ensure the listener understands Every member of the team must be free to communicate with any other member Their comments should be valued and honestly assessed regardless of their position or status You goal is to transmit an idea, not simply spew words How to speak CRM Any member of the team should be able to bring up a safety concern Point out the problem or concern Say I m concerned This is a patient safety issue Call a Safety Time Out Build a Safety Culture Building a Safety Culture 59 Culture of Blame 60 Accept that errors are going to happen Expect them Anticipate where and how future errors will occur Develop safety measures to identify and mitigate them Fight complacency Assume every order and every process contains an error until it is verified safe Use mistakes and near misses as an opportunity for learning and improvement. Investigation focused on who is at fault rather than what went wrong and how to fix it Encourages people to hide mistakes Ignores the system factors that led to the mistake Restricted access limits our ability to learn from mistakes Our culture of blame doesn t fix the problem and won t prevent future errors. We keep making the same mistakes P-10

11 We don t learn from our mistakes 61 Air the Dirty Laundry 62 Indianapolis 2006 NICU Pyxis stocked with adult dose heparin rather than neonate heparin flushes Administered to six infants by at least 5 nurses 3 babies died The same error had occurred in same hospital in 2002 The exact same error occurred in a Southern California Hospital more than a year later. Only by sharing our mistakes and the lessons learned can we help others avoid making the same mistakes. We need better ways to share safety information within the healthcare community Aircraft Accidents 63 Distribution of Safety Information 64 Safety Privilege Information provided for safety investigation should not be used against the person in legal or admin action Investigation by multidisciplinary team over weeks to months Goal is to determine what went wrong and how to prevent it from happening again, not to assign blame Both causal and contributory factors identified Recommendations to prevent similar accidents in the future Results are distributed throughout the aviation community Urgent Safety Bulletins and Tech Order Changes Regular Safety Briefings and Safety Stand downs Safety and Flying Publications Accident reports, themed safety articles I learned about flying from that Lessons and examples are incorporated into recurrent training Debriefing 65 Investigation should lead to prevention 66 Step-by-step performance review of the flight In fighter aircraft may last 4 hours for a 1 hour flight Opportunity for learning from you own and others performance Considered for adverse outcomes, sentinel events, or unusual cases Determine not only what went wrong, but why it went wrong Identify preconditions and contributing factors Correct all contributing factors, not just the root cause Build a better cheese Redesign the process, adjust work practices, add safety checks Make it difficult for the same mistake to happen again or at least to reach the patient P-11

12 Act on the Recommendations 67 SpaceX 68 Safety changes should not die of old age in a hospital committee Establish a safety fast track Any employee can submit a hazard ticket The people who do the work are involved in solving the problem Teams have recommendations within 2 weeks Change tickets implement the recommendations in a uniform manner and require compliance by a specified date Get the information out 69 Learn from the mistakes of others 70 Patient Safety Grand Rounds Medication and product alerts Findings and recommendations from sentinel events Safety newsletters or electronic bulletin boards Reach every employee Share with other medical organizations You won t live long enough to make them all yourself For Additional Information 71 CRM for health care 72 Wiener E, Kanki b, & Helmreich R, Ed. (2006). Crew Resource Management, 2 nd Ed, Waltham, MA. Academic Press Lesage P, Evans B, Dyar J. ( 2009 ). Crew Resource Management Principles and Practice, 11 th ed. Sudbury, MA. Jones and Bartlett Nance J. (2008). Why Hospitals Should Fly. Bozeman, MT. Second River Healthcare Press 2009 ACHE Book of the year P-12

13 73 74 Bartholomew, K. Ending Nurse-to-Nurse Hostility Why Nurses Eat Their Young and Each Other. 2 nd ed. (2014) Danvers, MA. HC Pro. James.r.elliott@faa.gov Aeronautical decision making 75 Line oriented flight training (loft) 76 Sound judgment can be taught Case studies, simulation, and guided discussion can allow pilots to learn from the experiences of others In a crisis, people revert to their training and habits Train like you fly and you ll fly like you train Simulation permits training for infrequent events or emergencies Crew analyzes their own performance and can review video Instructor also debriefs and grades performance Resource management 77 Making optimal use of available resources Inside and outside the aircraft Prioritize tasks and resources Matching the right person or resource to the task Ask for help when it is needed Monitor effectiveness of crew and other resources P-13