CRM / SA…You’re Not Bourne With It

EMT Refresher 2018James Temple

LESSON OBJECTIVE

▪ • Define Crew Resource Management (CRM)

▪ • Explain the benefits of CRM to EMS

▪ • State the guiding principles of CRM and briefly explain each

▪ • Explain the concept of communication in the team environment using advocacy/inquiry or appreciative inquiry

▪ • State characteristics of effective team leaders

▪ • State characteristics of effective team members

▪ • Explain how the use of CRM can reduce errors in patient care

IOM 1999“To Err is Human”

▪ “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.”

Why Aviation?

▪ Commonalities between aviation and healthcare– High risk environment

– Highly skilled professionals

– Failures in teamwork can have deadly effects

▪ What aviation has learned…– Most crashes involve teamwork failure rather than mechanical

failure

– Accident rate reduced since the introduction of CRM

Are you Chuck Norris?

The Error Chain

▪ A series of event links that, when considered together, cause a mishap

▪ Should any one of the links be “broken,” then the mishap probably will not occur

▪ It is up to each crewmember to recognize a link and break the error chain

Aeroflot Flight 593

▪ Airbus A310-300

▪ Moscow – Hong Kong

▪ March, 1994

▪ Pilot allowed his kids (12 and 16) to sit and “control” the plane (1)– Autopilot engaged, no real control of plane

– Older boy actually disengaged auto pilot with pressure on the stick

– No one realized this disconnect

▪ Non-audible warning light (pilots not familiar with this particular plane)

▪ The aircraft rolled into a steep bank and near-vertical dive. Despite managing to level the aircraft off, the pilot over-corrected the attempt to pull up, causing the plane to stall and then crashed into the hillside.

If all pilots would have left the control stick alone trying to save the dive, autopilot would have made the necessary corrections – avoiding the crash.

Air Florida flight 90

De-icing issues / Impatience with delayCommunicationPre-occupation with gauges

United flight 173

Landing gear indicator “problem”

Eastern Airlines flight 401

Everglades – midnight

101 fatalities

Avianca flight 52

73 fatalities

Human Factors

▪ Fatigue

▪ Reliance on technology

▪ Reliance on memory

▪ Loss of situational awareness

▪ Distraction: Interruptions, emotions, environmental noise

▪ Mindset

▪ Automatic behaviors

Why CRM?

▪ Properly trained aircrew members can collectively perform complex tasks better and make more accurate decisions than the single best performer on the team

▪ An untrained team's overall performance can besignificantly worse than the performance of itsweakest single member

▪ We will cover behavior and attitudes of teamworkand communication among team members

How Do We Know It Works?

▪ 5th Generation in Aviation Industry

▪ U. S. Marine Corps Adopting as Basic Operating Philosophy

▪ Significant Reductions in Injuries and Error– Commercial Aviation Industry

– U.S. Coast Guard

– U.S. Navy

– U.S. Air Force

– Veterans’ Administration Hospital System

What Is CRM?

▪ Force multiplier

▪ Uses all resources

▪ Enhances supervision

▪ Improves safety

▪ Raises level of

awareness for

those engaged

CRM Overview

Communication

Secure authority

Assertiveness with respect

Sharing information

Standardization

Work processes

Standards of care

Workload Management

Clear roles and accountability

Contingency staffing plans

Recognizing vulnerabilities regardless

of workload

Concepts

▪ Everyone makes mistakes

▪ Being highly skilled and professional isn’t enough to prevent error

▪ Everyone on the team shares responsibility for patient

How Does It Work?

Five Principles

– Communication

– Decision-Making

– Task Allocation

– Teamwork

– Situational

Awareness

– Debrief*

DAM CLAS

▪ Decision-Making

▪ Assertiveness

▪ Mission Planning

▪ Communication

▪ Leadership

▪ Attitude

▪ Situational Awareness

Situational Awareness

Point where perception and reality collide

▪ Reality always wins

▪ Beware of loss factors– Ambiguity (Avianca flight 52)

– Distraction

– Fixation (Eastern Airlines Flight 401)

– Overload

– Complacency

– Unresolved discrepancy

Situational Awareness (SA)

▪ Know what is going on around you at all times

▪ Requires:– Good mental health

– Good physical health

– Attentiveness

– Inquisitiveness

Where Did It Come From?

▪ Aviation Community

▪ Air Crashes Dominated Industry Attention

▪ Technology Only Went So Far

▪ 1970’s –Dr. Robert Helmreich and CVRs

Cooper’s Colors

WHITE

A person who is in white is unaware, oblivious and pre-occupied. They can be described as daydreaming and what I call “living in a bubble”.

You will often see them looking down while they walk, they can often be unresponsive when you try to get their attention and are often not prepared for their actions in daily life.

This is a very dangerous state of mind to be in, regardless of the threat level that you live in.

YELLOW

Someone who is in this stage is relaxed, but alert to their surroundings. They are not focusing on any specific person or thing in particular but are difficult to surprise because you are assessing the world around you.

This is a very good level to live daily life at, as it does not induce the stress levels commonly associated with orange, red or black but you can respond quickly and efficiently because you have already formulated thoughts about what may happen.

ORANGE

This is a heightened alert level, generally associated with a specific threat or focal point. The only real difference between yellow and orange is the specificity of threat being assessed.

In yellow, you are simply analyzing everyone and everything, but here you are now focused on one threat and are already making decisions about how to react. This is a good level to take action at because it can allow you to avoid an engaged altercation beforehand.

The primary reason that yellow is a better day to day level is because you are not tunneled in on just one potential threat as you are here in red.

RED

This is the Fight or Flight stage. At this point you are either engaged in a struggle or taking action to (either mentally or physically). It is important at this point that you take the physiological effects of the adrenaline dump into consideration.

Ensure that you diligently avoid common reactions such as auditory exclusion, tunnel vision and other physical responses that occur in high stress incidents.

Some of this will be unavoidable, but with proper training and preparation it can be minimized.

BLACK

▪ BLACK – Blind Panic/Psychological Shutdown and sometimes in a state of comatose. You have succumbed to the panic and stress of the incident to the point that you cannot react or respond to stimuli.

▪ This paralysis was most likely brought on because of a lack of mental preparation in any other state of awareness discussed previously.

▪ The most likely of scenarios is that there is someone nearby who can save you or that the conflict will end without harm to you, but this feeling will forever have a lasting impact on you psychologically.

Barriers to Communication

▪ Hearing– The biological function of receiving sounds, converting them to electrical

impulses, and having the brain interpret them

▪ Listening– Correctly identifying what the sender has sent in their message

Communication

Barriers and bias block effective communication

BARRIERS

Physical

Mental

BIAS

Influences

Barriers to Communication

▪ Distracters–Physical/Mental: Noise, static,

simultaneous transmissions; fatigue and stress

–Wording: Incomplete or ambiguous message, too complex or uses unfamiliar terminology

–Personal: Boring, lack of rapport or lack of credibility

Advocacy and Inquiry Communication

Appreciative Inquiry

a. Four steps to using inquiry/advocacy or appreciative inquiry to improve communication among teams

i. Alert the other members of the team to a situation or action of concern

ii. State the problem as it is seen

iii. State a solution or alternative

iv. Obtain agreement among the team to alter plan or action

AI Question Strength

Yes/no Which Who When Where What How Why* What If

WEAK STRONG

Communication

▪ Secure authority– “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– Team members speak up regardless of hierarchy– Use of SBAR: situation, background, assessment,

recommendation

Skill Development

▪ Conscious awareness / practice

▪ When you walk out of somewhere, notice how many people are now in your field of view…just to keep your brain engaged!–Coworkers, kids, etc– Jason Bourne-like observation habits– Just to get them / you in the yellow zone – active

participants!

Decision Making

i. Life threatening vs. non-life-threatening

ii. Entire team should be aware of all necessary information

iii. Collective team knowledge and experience should be utilized to make a decision

iv. Team leader is ultimate authority on final decision but relies on input from all members with equal weight, incorporating experience and knowledge of team

Task Saturation

▪ Too much information at one time

▪ Too many tasks to accomplish in a given time

▪ Usually occurs when an individual is confronted with a new or unexpected situation and loses SA

Task Saturation

▪ Keep your workload to an acceptable level

▪ If you feel overwhelmed, tell the others before becoming saturated and losing you situational awareness

▪ Watch your team members for signs of saturation

Task Allocation

▪ Know your limits

▪ Know your crew’s limits

▪ Capitalize on strengths

▪ “Eat the elephant one bite at a time”

Identification of Resources

▪ External and internal

▪ Identify your resources, know where to find them, and how to use them to accomplish the mission

Crew Coordination

▪ Understand and execute your assignments

▪ Communicate

▪ Question

Standardization

▪ Standardized work processes

▪ Standardized care (e.g., Acute MI, CVA, Sepsis, Trauma)

▪ Allows team members to:– Anticipate what comes next

– Recognize and question the unexpected

– Recognize “workarounds”: address the process

Technical Proficiency and Training

▪ Are Foundations of Paramedic response. CRM cannot overcome a lack of proficiency or training

▪ On the other hand, technical proficiency and training alone do not guarantee safe operations in the absence of effective crew coordination.

Teamwork

Leadership

▪ Authority– Mandated by rank

– Derived through respect

▪ Mentoring– Lead by example

– Admit mistakes

– Be technically competent

– Share knowledge

▪ Conflict Resolution

▪ Mission Analysis

Followership

▪ Self-Assessment

▪ Respect authority

▪ Promote leader success

▪ Ego in check

▪ Balance assertiveness

▪ Accept orders

▪ Admit errors

▪ Provide feedback

▪ Adapt

Maintaining SA

▪ Periodically check:

– What do I know that they need to know?

– What do they know that I need to know?

– What do we all need to know?

– Develop checklists.

Hazardous Attitudes

▪ Anti-authority

▪ Impulsiveness

▪ Invulnerability

▪ Macho

▪ Resignation

Loss of SA

▪ Strength of an Idea

▪ Hidden agenda

▪ Complacency

▪ Accommodation

▪ Sudden Loss of Judgement

Symptoms of Loss of SA

▪ Fixation

▪ Ambiguity

▪ Complacency

▪ Euphoria

▪ Confusion

▪ Distraction

▪ Overload

Regaining SA

▪ Reduce workload: Suspend the mission.

▪ Reduce threats:– Get away from the ground and other obstacles (e.g., climb to a safe

altitude).

– Establish a stable flight profile where you can safely analyze the situation.

▪ Remember: “Aviate, Navigate, Communicate”

How do we get it back?

▪ Trust your gut feelings

▪ “Time Out,” “Abort,” or “This is Stupid.”– Pilot establishes aircraft in a safe and stable configuration, and then

discuss the problem

▪ Sterile Cockpit– Limit talk to the minimum necessary for safety.

– Taxi, takeoff, departure, low-level flying, approach, landing

Effects of using Crew Resource Management to reduce errors in patient care

a. Increased communication among crew (team leader and team members) can reduce potential safety concerns for the crew

b. Increasing patient safety, mitigation or elimination of errors, and increasing the overall effectiveness of a team are benefits of increased communication and effective communication techniques, such as:

i. The process of identifying a potential or actual error,

ii. Supplying information,

iii. Suggesting alternative actions,

iv. Agreeing on a new plan,

c. Team members experience a safe environment in which to identify human errors and suggest ways to mitigate or eliminate errors.

d. Routine training and practice of CRM can increase self-awareness and self-efficacy for all personnel.

Summary

▪ Successful missions hinge on each and every crewmember

▪ Learn how to use the procedures and tools available to you, and use them correctly

▪ Never stop learning

▪ Don’t be afraid to ask questions

▪ Never criticize someone for asking questions

▪ Anyone can call “Time Out,” “Abort,” or “This is Stupid”

▪ Remember that the Mission Pilot must make the final decision based on the crew’s input.

Summary

▪ Pay close attention to all briefings

▪ Understand the “big picture”

▪ Watch for task overload in yourself and other crewmembers

▪ 67% of air transport accidents occur during 17% of the flight time - taxi, takeoff, departure, approach and landing. Keep casual conversation and distractions to a minimum during these phases of flight.

▪ Begin critical communications with instructions, then explain

Enjoy the Rest of your day…”Stay classy Davenport”