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Alliance with Aviation
Using Crew Resource Management
to Improve Patient Safety
Northfield Hospital
The problem…
IOM 1999
“To Err is Human”
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“……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…”
IOM 1999
“To Err is Human”
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“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.”
IOM 2003
“Health Professions Education”
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Medical schools to incorporate new core
competency: Work in interdisciplinary
teams
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“..All team members must have strong
communication skills and a clear
understanding of each other’s roles and
responsibilities….”
IOM 2003
“Health Professions Education”
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“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…”
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
Example….
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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
What we learned…
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The ultrasound tech had the information that
the caregivers needed, but did not have the
authority to convey it
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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
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Now, nurses use a standardized worksheet for
shift-to-shift report, which includes any pending
tests
Why Aviation?
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Commonalities between aviation and
healthcare
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High risk environment
Highly skilled professionals
Failures in teamwork can have deadly effects
What aviation has learned…
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Most crashes involve teamwork failure rather than
mechanical failure
Accident rate reduced since the introduction of
CRM
Finding the Experts
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Northwest Airlines based in our own
backyard
Recruited fleet training captain, recently
retired, “looking for something challenging
and rewarding to do….”
CRM Overview
Communication
Standardization
Secure authority
Work processes
Assertiveness with respect
Standards of care
Sharing information
Workload Management
Clear roles and accountability
Contingency staffing plans
Recognizing vulnerabilities regardless
of workload
Concepts
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Everyone makes mistakes
Being highly skilled and professional
isn’t enough to prevent error
Everyone on the team shares
responsibility for patient
Understanding error
Need basic knowledge of threats and errors as
part of learning CRM
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“Swiss Cheese” model
Sharp / blunt ends
Organizational culture
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Name and blame vs. “just” culture
Authoritarian vs. flattened hierarchy
Human factors
Human Factors
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Fatigue
Reliance on technology
Reliance on memory
Loss of situational awareness
Distraction: Interruptions, emotions,
environmental noise
Mindset
Automatic behaviors
Communication
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Secure authority
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“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
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Team members speak up regardless of hierarchy
Use of SBAR: situation, background, assessment,
recommendation
Standardization
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Standardized work processes (e.g., callbacks for outpt culture results)
Standardized care (e.g., Acute MI)
Allows team members to:
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Anticipate what comes next
Recognize and question the unexpected
Recognize “workarounds”: address the
process
Workload Management
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Requires clear roles and accountability
Task prioritization
“Situational awareness”: use of huddles
Debriefing serious events
Recognizing vulnerabilities
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Heavy: redistribute the work, ask for help
Light: stay alert, focused
Acknowledging fatigue
Program Design
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3-year “phased” program
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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
Training outline
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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
Turbulence
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Some resistance to mandatory training
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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
Challenges
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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
Status Report
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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
At least one life saved…
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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
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”
Staff anecdotal feedback
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“Why go through training if the doctors
still won’t listen to what we have to
say?”
We still have work to do….
Typical timeline for behavior changes
5 years: 50%