Team Perfection in Healthcare - Hospital Authority · 2015. 6. 5. · •According to The FAA...
Transcript of Team Perfection in Healthcare - Hospital Authority · 2015. 6. 5. · •According to The FAA...
Team Perfection in Healthcare
Ultimate Goal: High Reliability Organization
Minimization of
Consequences resulting from
CRM errors
Early detection of
Error
Error Avoidance
Chernobyl Nuclear Plant Disaster in 1986
Group Values
Individual Values
Attitudes Perceptions
Competencies
Behavioral Patterns
• According to The FAA (Federal Aviation Administration) Definition: • CRM represents the utilization of all available human,
informational, and equipment resources toward the effective performance of a safe and efficient flight.
• CRM is an active process by crewmembers to identify significant threats to an operation, communicate them to a person in charge, and to develop, communicate, and carry out a plan to avoid or mitigate each threat.
• Misconceptions exist…
– ‘It’s all about teamwork’
– ‘it’s a tool to enhance communication’
– ‘it’s about management of resources…’
• CRM is about and management
Assertiveness Normalization of Deviance
Leadership
Team Debriefings
Human Factors Disclosure
Stress and Fatigue
Team Briefings
Situational Awareness
Decision Making
Error Mitigation
Critical Language
Checklists
Communication
Conflict Resolution
• American deadliest plane crash: Flight 191
• CRM developed for a NASA workshop in 1979
• For more than 2 decades, CRM has gone through 6 generations of evolution: – From a model that targeted individual styles and
correcting deficiencies in human behavior to the current error management model.(2)
– Traditional CRM skills and methods are applied not only to eliminate, trap or mitigate errors but to identify systemic threats to safety (3)
• human error is inevitable but errors can provide a great deal of information for safety improvement(2)
• It took 20 years to yield an observable outcome – the Success…
Does this imply we, the Healthcare Industry, can also achieve the same success in 20-year time?
1990 1999 2001
WHO 2009
AHRQ 2004
• Course development based on safety culture tools recommended by WHO (2009)(4)
– Safety Attitude Questionnaire (Sexton et al, 2006) • 60 item questionnaire which measures dimensions including
teamwork, management, and working conditions. Different versions for intensive care units, operating rooms, wards, clinics, etc.
• It asks workers and managers about their attitudes to safety and perceptions of how safety is prioritized and managed in the work unit or across the organization(4)
– Hospital Survey on Patient Safety Culture: (AHRQ, Sorra & Nieva, 2004)
– The MaPSaF Manchester Patient Safety Assessment Framework (Kirk et al, 2007)
Adult Learning:
Kolb’s Cycle
Progressive Style:
Classroom-based Immersive Simulation
Focus on Debriefings and Self-reflection
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1
3
1 2 2
1 1
Mixed Specialties
DOM
Operating Room
Surgery
Obstetrics & DeliverySuitesPsychiatry-CPH
Pharmacy
ENT
Workshop Composition Period: 5/13- 5/15
Total: 39 Workshops
• The most popular framework for guiding training evaluations:
Kirkpatrick’s typology Results
Behavior
Learning
Reaction
• Reaction Evidence
Medical Staff 15%
Nursing Staff 74%
Allied Health Staff 7%
Administrator
3%
Others 1%
Categories of Participants Period: 5/13- 3/15
Item Agree %
12) I am overall satisfied with this training program Note: Response rate= 96.4% (563/584)
99.1%
• Reaction and Learning Evidence
Teamwork Climate
† P-value obtained from Wilcoxon signed rank test (non-parametric test for comparing median difference of two related samples).
Safety Climate
• Reaction Evidence
† P-value obtained from Wilcoxon signed rank test (non-parametric test for comparing median difference of two related samples).
Perception of Management
Job Satisfaction
• Learning Evidence
† P-value obtained from McNemar’s test (equivalent to chi-square test for repeated measures).
Learning Evidence
• Behavioral Evidence
– Train-the-trainer program
• Change agents in various departments
– Surgical Safety Checklist
• Mandatory for ALL operations in operating theatres – Both attitude and behavioral changes were observed
• Being followed by procedures done in ward settings
• Behavioral Evidence – Co-organized CRM training workshop
• Different departments took the initiatives
– In-situ simulation drills • Initiated by individual specialties • Co-organized with CRM committee for facilitated debriefings
– AED in-house CRM teaching activities • Further consolidation of CRM concept
– Checklist-guided Briefing and Debriefing Huddles in OR • Nursing Staff, Surgeons and Anesthetists worked as a team to
prepare for the elective operations on the next day • Problems encountered on the day were brought out for
appropriate follow-up actions
• Outcome Evidence
– It is DIFFICULT
– Briefings and Debriefings in OR
• Implemented in 5/2014 on T4 (1 out of 4 Floors)
• Evaluation – 60-item SAQ to all nursing staff, anesthetists and surgeons of
various specialties (pre- and post- exposure)
– Elective Overrun (1-year data pre and post initiation)
– Start-time Delay for 1st Elective Case
– Same-day Elective Cancellation due to un-optimized patient’s status
• Outcome Evidence
– Briefings and Debriefings in OR
• Preliminary results – 60-item SAQ (Score<60:Poor; >75:Good)
» only pre-exposure baseline obtained
» Response rate >60% for all specialties (nursing staff:100%)
» Compared with a benchmark study, BMC (2006):
• Outcome Evidence
– Briefings and Debriefings in OR
• Preliminary results – 60-item SAQ (Score<60:Poor; >75:Good)
» Subgroup analysis
• Doctors vs.. Nurses
• Nurses: Significantly lower scores for all domains
• Job ranking: No significant difference
• Outcome Evidence – Briefings and Debriefings in OR
• Preliminary results – Elective Overrun
» 25-30% reduction in late finish on T4 since the initiation of
briefings (c.f. more or less the same on T2/T3/T5) » Possibly related to more effective list management
OTMS Late Finish: No of Days with Late Finish
• Outcome Evidence – Briefings and Debriefings in OR
• Preliminary results – Start-time Delay for 1st Elective Case
» Mean: 66.7% vs. 78.7% (pre- vs. post-briefing initiation) » Better teamwork and sharing of common goals
Percentage of Zero Start-time Delay for 1st Elective Case
• Outcome Evidence – Briefings and Debriefings in OR
• Preliminary results – Same-day Elective Cancellation due to un-optimized patient’s
status
» CDARS reports for reasons of same day elective cancellation
» Before the initiation of briefing huddles, 15% elective operations being cancelled on the day of OT had a reason stating that “patient’s not fit for OT”
» From 1/5/2014-30/4/2015, only ONE patient had the elective operation cancelled due to poor chest condition
» Discussion of concerns about patients’ status during briefing huddles allows early recognition of patients requiring further optimization, and therefore prevents unexpected same day elective cancellation
• A meta-analysis of the effectiveness of crew resource management training in acute care domains, Postgraduate Medical Journal, 12 2014, O’Dea Angela , O’Connor Paul
– Peer reviewed papers published in English between Jan 1985 and September 2013, 239 articles were found
Reaction evidence Learning evidence
Behavioral evidence
Lack of Outcome evidence
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials; Gordon C S Smith, Jill P Pell ; BMJ. 2003 Dec 20; 327(7429): 1459–1461.doi: 10.1136/bmj.327.7429.1459
• The long term effects of CRM training or the impact on clinical care outcomes is not yet established.
• The healthcare industry could wait for this evidence before further implementation of CRM training, or perhaps the ‘parachute approach ‘ may be more prudent.
Recommendations based on NTWC Data
Teamwork Climate Job Satisfaction:
scored lower than other international
institutes
CRM Training
Nurse:
Lower score in all domains
Major Target:
Nurse
Job Ranking:
No significant difference
Early exposure to CRM teaching
warrants a better grow in safety
culture
Behavioral changes
Reduced Mishaps and
Incidents
Learning
Positive Reactions
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2. Robert L. Helmreich, Ashleigh C. Merritt & John A. Wilhelm Department of Psychology; The Evolution of Crew Resource Management Training in Commercial Aviation; Aerospace Crew Research Project;The University of Texas at Austin; International Journal of Aviation Psychology pages 19-32
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8. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials; Gordon C S Smith, Jill P Pell ; BMJ. 2003 Dec 20; 327(7429): 1459–1461.doi: 10.1136/bmj.327.7429.1459
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