CRM / SA…You’Re Not Bourne with It LESSON OBJECTIVE
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EMT Refresher 2018 James Temple CRM / SA…You’re Not Bourne With It 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 delay Communication Pre-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 be significantly worse than the performance of its weakest single member ▪ We will cover behavior and attitudes of teamwork and 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 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 ▪ 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 BIAS Physical Influences Mental 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