Safer Surgery part 46 ppsx

Rather than defining CRM and developing training programmes for aviation, our lab’s efforts at that time were focused on in-flight data collection – trying to understand what worked and

met with resistance Like many physicians, I had prided myself on believing I was competent (and I think I actually was competent…), and, again, like many physicians, I was not overly keen to delve into human error in medicine and team performance in healthcare For many of us, that topic feels just a little too close

to home, at least at first take Rather, I focused most of my interest and efforts on our work in aviation safety I learned about CRM training, which by that time had ceased to be a controversial topic in aviation and by then had become the standard

of practice for any good airline

Rather than defining CRM and developing training programmes for aviation, our lab’s efforts at that time were focused on in-flight data collection – trying to understand what worked and what did not in the cockpit; on what practices the good pilots demonstrated, and what we thought the rest should try and emulate These were the early days of LOSA – the Line Operations Safety Audit The University of Texas LOSA programme involved sending observers from our lab group out onto aircraft flight decks to watch crews at work as they flew routine flights, recording crew behaviours and errors, and noting their responses to safety threats (Helmreich et al 2002) Our experience was showing us that when LOSA audits went ahead without management support, then resources were scarce and the projects tended to stall When senior management pushed for an audit, but the pilots were mired in labour disputes or felt they were being used as scapegoats for problems on the flight line, observers from our lab were greeted with suspicion in the cockpit and again, safety audits stalled When everyone in the organization was

on board, and when both senior management and pilot unions were enthusiastic supporters of the safety audit, the process was typically a major success, and the organizations would devour the findings produced by the audit There was a sense that everything was moving forward as it should, and that we were all contributing

to something valuable

I was fortunate to be a part of those efforts We all had the sense we were doing something worthwhile Despite the difficulties associated with research and the challenges in producing empirical validation, few in our lab group or in commercial aviation for that matter seemed to doubt the effectiveness of CRM, or the value of trying to improve it During this time, many of the first efforts in trying to bring CRM to healthcare were underway David Gaba at Stanford had already started his Anesthesia Crisis Resource Management training programme (Gaba et al 1992), which was receiving positive reviews in the safety community Bob Helmreich had been working with Swiss collaborators to bring CRM to operating room teams

in that country (Helmreich et al 1994) MedTeams, a commercial training group out of Boston, had produced a consulting and training product and had brought their version of healthcare CRM to several sites in the United States (Morey et

al 2002) By the late 1990s, Rhona Flin and colleagues in Scotland had started work on the Anaesthesia Non-Technical Skills project, an empirically derived, non-technical skills rating system (Fletcher et al 2003) that remains one of the stand-out efforts to date in our growing field (see also Chapter 12 in this volume)

In the US, healthcare team training (or CRM, or non-technical skills programmes)

is offered at a number of simulation centres, and such courses tend to be focused

on the operating room, the intensive care unit or cardiac arrest management Training is also offered through professional consulting organizations providing

a range of related leadership training, organizational assessment, culture change, and team training services Around 2003, Bob Helmreich and I wrote some of our impressions and thoughts in a paper entitled ‘Team training and resource management in healthcare: current issues and future directions’ (Musson and Helmreich 2004) Details of these early programmes are described in that paper, along with some worries about how things were proceeding Our concern at that time was primarily that CRM was becoming a private consulting project in many quarters, and that the open, collaborative environment that fostered the growth and success of CRM in aviation was almost nowhere to be found Thankfully, this

is changing, as demonstrated by the behavioural markers researchers meeting in Edinburgh, 2007 that was organized by Rhona Flin and that spawned this book However, there is still a nagging discomfort in the back of my mind that has been present since I first became aware of the potential promise of CRM to improve healthcare delivery That discomfort stems from the sense that there are fundamental differences between healthcare and aviation, and that these differences stand to undermine the many efforts underway that are trying to improve how teams work

in critical healthcare settings This chapter, hopefully, articulates some of those concerns and helps shed light on how some of us should proceed on this important, though sometimes frustrating path

CRM in Aviation

There is some value in briefly revisiting what CRM really is in aviation In that industry, CRM has undergone a long evolution over the past 30 years – this has been described elsewhere, and I will not belabour the chronology of increments and evolutions in this chapter As seen through the eyes of those in healthcare who have looked to aviation for system improvement, CRM has been interpreted as

a set of skills that should be trained in order to improve teamwork and improve safety In a sense this is true, though some key points seem to have been lost

in transition CRM is as much an organizational philosophy as it is a training programme I was not around in the earliest days, but if I had to guess, I would imagine that this has not always been the case CRM started as a means of training better cockpit leadership skills, but soon became integrated with human factors training in general – a more comprehensive training movement that dealt with the risks posed by the ways humans operate in complex settings For example, good CRM courses include didactic teaching or small group workshops that focus

on such things as the effects of fatigue on concentration, memory and decision-making; curricula include discussions on how family stressors can serve as distractions and how telling your crewmates of such stressors helps alert everyone

to the potential impact of those stressors in the cockpit on that day Such material

serves not only to add to the base of knowledge essential for understanding how good CRM works, it also serves to shift attitudes among trainees from one of autonomous independence to one of team-centred interdependence The concept

of safety as an underlying fundamental (or super-ordinate) goal that serves to unify team members’ motivations and behaviours is stressed as a fundamental principle

of crew management

Over time, as new pilots are indoctrinated into CRM and adopt its principles

of crew management and as the majority of pilots in various airlines adopt a team-centred approach to daily operations, the principles expounded by CRM seem to have permeated the senior ranks of commercial aviation and the very culture of flight operations This is not surprising, as senior pilots tend to fill both middle and upper management positions at most airlines It is not uncommon to hear pilots describe management’s actions and decisions in terms of ‘good CRM’ or ‘bad CRM’

All that is CRM, of course, has taken root in the pre-existing operating environments of aviation and over the pre-existing cultures of piloting Cockpits are small, both in terms of space and in terms of crew numbers – always at least two

in number (in commercial aircraft, at least), and seldom more than three Everyone

in the cockpit has essentially the same training, often very common backgrounds, and even similar personality types Pilots did their jobs very well before CRM ever came along, and in that light, CRM can be thought of as the icing on the cake of high-level team performance CRM provided a framework to help highly functioning teams become even better The infrequent mishaps that had occurred

in aviation in the years prior to the introduction of CRM, where miscommunication between or intimidation of crew members contributed to mishaps, became even less common thanks to improved awareness of human factors and to the skills introduced into crew training through CRM It is important to remember that CRM was never brought in at the expense of existing good practices What we used to call good ‘airmanship’ has been expanded to include the fundamental elements and principles of CRM, and the culture has undergone a re-conceptualization

of piloting competency that integrates both technical proficiency and CRM as essential skill sets

CRM in Medicine

As mentioned above, a number of individuals began looking at developing CRM,

or non-technical skills training programs for healthcare in the 1990s In 1999, the

Institute of Medicine (IOM) released its report To Err is Human: Building a Safer Health System (Kohn et al 2000) In it, aviation-based CRM was identified as a

key strategy that held great promise for reducing error in the complex treatment teams that are ubiquitous in modern healthcare This triggered immediate interest

in CRM and the activities of our lab in Texas, and set in motion a growing interest

in the subject that has only gotten stronger with time

But, as I mentioned at the opening of this chapter, I have had a nagging feeling that CRM was not quite the answer that many thought The parallels between the operating room and the cockpit seemed obvious to many and to me as well, but

I thought that there seemed as many differences as similarities Compared to the civilized two-person teams I had seen in cockpits, the operating room had always felt like a jungle to me People came and went throughout each operation As a medical student and intern, I never knew the identities of at least half of the masked people in the room, and I was never sure if anyone could actually name each person who came and went Maybe the circulating nurse knew who they were, but I sure didn’t Sometimes, she would switch out mid-procedure when her shift ended, and

a new person (whose identity was also unknown to me) would come into the room

to take her place without a word being spoken At times the atmosphere was casual and light-hearted, at other times it was tense and sometimes hostile Instruments

do get thrown – that is not an urban legend; I have seen it happen on more than one occasion More often, insults were thrown, usually directed to residents or interns, though also at times they would be cast at entire groups (non-surgical specialties were a frequent target) Eyebrows were used to communicate disapproval and irritation, and could be used to do so quite effectively The humour was at times bawdy, and as the lowly medical student you were not always quite sure when you should laugh and when you should remain quiet It was always safer to just hold the retractor as instructed, though one could never go wrong nodding in silent agreement with whoever was most senior Production pressure was paramount Anything that delayed the completion of the case had the potential to upset the rest of the day’s list and a number of people in the room Everyone seemed to have their own job; there was seldom any sharing of tasks and there seemed little awareness about what others’ jobs entailed The ether screen, suspended between two poles on either side of the patient’s head, served to separate the world of surgery from the world of anaesthesia Sometimes it seemed higher than it needed

to be Maybe it was to protect against flying instruments, I wondered As a doctor

in training, I knew virtually nothing of the world of nurses, except that in the operating room they seemed efficient and key to everything that transpired, though they were typically silent This was my impression of surgical operating teams, and to me, introducing CRM skills like briefing and cross-checking would not necessarily make things run all that much better The idea that CRM would fix everything I had seen in training and later in practice seemed a tall order

Undaunted by the challenge and motivated by a sincere desire to make healthcare safer, a number of parties have forged onward in their attempts to improve the performance of operating room teams, and of teams elsewhere in healthcare through the development and implementation of CRM-like training

At the time of writing this chapter, I have since moved on from Bob Helmreich’s group (and he has retired) and I now oversee simulation and non-technical skills at McMaster University As such, I find myself dealing with the front line issues of integrating CRM or non-technical skills into the postgraduate medical curriculum

at our university, and with integrating simulation and patient safety into a

number of undergraduate programmes Indeed, simulation is by many accounts

a valuable tool in our arsenal as we look for the best ways to improve healthcare team behaviour There are many challenges, such as how we first introduce these concepts and at what level Or, how we educate the practising provider population

so that our trainees do not meet resistance to using their new-found skills as they move on from our educational programmes and into the day-to-day working environment of healthcare? I, like others, am grateful for the work of our Scottish colleagues who have developed the ANTS methodologies, and the more recent Non-Technical Skills for Surgeons (NOTSS) system that you will find described elsewhere in this book (see Chapter 2) I remain convinced that these programmes are on the right track and should be integrated into any efforts to improve operating room team performance

There are a number of us struggling with these same challenges of how best to design, deliver and evaluate CRM or non-technical skills training for healthcare Many efforts in this area have stalled, or have produced less radical change in the day-to-day behaviour of operating room teams than some had hoped Anecdotally, it is common to hear frustrations from those who have attempted

to implement such programmes Beginning with early programmes, such as MedTeams, and progressing to the current day, trainers and course developers lament the difficulty of getting the simplest of interventions to be adopted, though often these frustrations are voiced in private since many of these efforts involve either commercial consulting groups or academic centres where project failure is not well regarded Efforts to bring team skills training to healthcare are resource intensive and expensive When clinical champions and institutional leaders have fought hard to bring in expensive training programmes into their local institutions, challenges are not usually discussed openly and outright failures are sometimes denied

So, why does this training sometimes seem less successful than we would like? Why is there resistance among highly competent professionals to adopt practices that we think make perfect sense? Presumably these individuals are interested

in delivering quality care, regardless of what other competing demands may

be present Aviation had its difficulties and challenges for sure, but either the challenges in healthcare are greater or the standard for success is higher Possibly both are factors The threshold for determining success in healthcare is frankly more rigorous than it ever was for aviation Decision-makers want hard evidence

of success before scant resources are directed towards CRM and team training courses A poorly known (and seldom communicated) fact of aviation safety is that evidence for the success of CRM has actually been quite elusive Eduardo Salas at the University of Central Florida has written extensively and thoroughly

on issues related to the validation of CRM training, and in particular on the challenges of validating such training in the complex operational environments of healthcare and aviation (for detailed reviews of CRM evaluation, see Salas et al

1999, 2006) In this chapter, however, we will assume that improving teamwork, sharing expectations associated with the task at hand, informing others of one’s

plans, improving communication in general, task redundancy, reducing needless variability and having team members monitor each other to improve reliability are all good things, and that programmes to encourage these behaviours should have

at least some positive benefit on team performance in healthcare

In this chapter, I want to examine what it is that seems to be standing in the way of many sincere and diligent efforts to improve team performance Take the example of the ‘surgical time out’ or ‘surgical pause’ (WHO 2008) This is the practice of ensuring everyone is present at the start of a surgical case, where the identity of the patient is confirmed, along with the site of surgery and confirmation

of the specific nature of the procedure This was introduced to prevent wrong-site, wrong-patient surgical errors It can also serve as a tool to communicate expectations between team members, brief potential contingencies and possible complications, and provide an opportunity to clarify everyone’s mental model of what is about to transpire This is what those of us in aviation safety would call

‘basic CRM’, and is an example of how we would get team members to ‘share their mental model’ amongst each other It is current best practice for surgical care, and in North America is encouraged or required by agencies such as the Joint Commission, the Institute for Healthcare Improvement (IHI), and the Canadian Patient Safety Institute To most of us in the error/CRM/non-technical skills world, the value of the surgical time out is obvious, and any downsides are almost impossible to identify Yet, accounts of difficulties in implementing this simplest of practices abound Some surgeons refuse to do it, others roll their eyes, while yet others are reported to ridicule the resident or nurse who reminds them that the practice be followed In other centres, certainly, the practice is adopted and enthusiastically supported The question remains, why the difference and why would anyone resist? It is a simple behaviour The theoretical basis for it is strong The amount of effort is minimal Is it because it is being forced, and anti-authoritarian tendencies cause some to rebel? Is it seen as a loss of professional autonomy? Do they not believe that it makes any sense? Is there a perceived loss

of efficiency in the operating room? Surely, if such a simple practice meets with resistance, more complex and less concrete practices are also doomed, at least in some settings

Let’s start with the basics CRM, or non-technical skills programmes, involve the process of describing the behaviours of highly competent, safe individuals

A current approach in healthcare is to develop a comprehensive list of such behaviours and develop a training programme around that list Surely ANTS and NOTSS are excellent examples Those systems have been empirically derived, agreed upon by a consensus of experienced practitioners, and the face validity of their component elements is strong Good training programmes may also involve a significant amount of supporting theory, didactically delivered and well founded in psychology and experience Some programmes even involve significant coaching with ongoing reinforcement Yet the desired behavioural changes in team members have not been consistently observed following training and even in well-designed programmes, resistance is not uncommon

There are certainly examples of poorly run training programmes, some lasting only an afternoon, without opportunity to practise skills or provide feedback, and without a plan for reinforcement over time Some programmes are simply copies

of aviation programmes, with little domain specificity, and we would not expect such programmes to result in major changes in team behaviour But, some courses seem extremely well designed, and much effort has gone into their delivery and implementation Yet, still, many of these programmes have failed to produce the desired outcomes

Are we right to be focusing on behaviours? The term in our field is behavioural markers, and it refers to the explicit, observable actions of team members Our

thinking to date has largely been to identify the optimal behaviour set employed

by ideal practitioners, usually arrived at through consensus methods, and teach everyone to practise those same behaviours Seems straightforward But, what are human behaviours? Why do people behave the way they do? Why do good team players naturally share their plans with their team members, even without being told to do so? Why do some people resist changes even when they seem to make sense? If we think of behaviour as stemming from our cognition – action from thought, as some would say – then the question becomes: what are they thinking and why? If we are going to change the way people behave in the operating room,

or elsewhere in healthcare for that matter, we need to be examining why they do what they do

Behind the observable behaviours of an individual lie the various processes

of human cognition This includes all of the things that influence our moment-to-moment and day-to-day thinking, working away in our minds, often below the surface and out of sight: our values, attitudes, perceived responsibilities, memories, and even our own personality characteristic tendencies Furthermore, we can ask what has led us to have those attitudes and beliefs In our work settings, this may

be the professional cultures into which we have been acculturated, or the many interactions we have had with others over our careers, or even the national and organizational cultures that surround us at home and work All of these factors influence who we are and how we think You can picture an iceberg, with the base being the social structures, cultural backgrounds and organizational milieu

in which we live lying deeply below the surface of the water Examples of these deep-seated influences may include pre-existing social attitudes about gender and roles, or more concrete factors like the lounge that allows surgeons, but not nurses, to relax and make telephone calls between cases and the messages that this gives us These factors serve as the foundation for the middle layer, which lies just below the surface: our day-to-day thinking; the attitudes, values and cognitive processes The top of the iceberg, rising above the surface, represents our observable behaviours; the only thing others can see from the outside I have drawn this below in Figure 25.1

This chapter is about behavioural markers, training and learning from aviation,

so let’s go back to aviation for a minute CRM had its challenges, to be sure, but the healthcare experience, I believe, is proving more problematic and the road

more uneven Why did CRM seem to work more easily in aviation, or at least why

is it more readily accepted now? If we examine the nature of aviation teams, what

do we find? Captains and first officers, as I have mentioned, are similar – similar backgrounds (flight school), similar interests (airplanes), similar frustrations (Air Traffic Control), and even similar haircuts They share their jobs – often alternating who is in command and who is monitoring on each successive flight There is little confusion about the goal – a smooth flight and safe landing The only major barriers to communication are usually hierarchy, experience and sometimes a tendency to work as an individual and not as a team CRM was designed to address these barriers; hence, much of its focus is on overcoming hierarchical barriers to communication, sharing plans for the purpose of mutual understanding and the importance of coordinating tasks in cockpit crews

An important question to ask is this: do surgical teams encounter the same challenges as those encountered by pilots? By this I am not referring to flap settings vs intubation difficulties; obviously the technical challenges are different But, are the barriers to the fluid flow of information due to the same issues of command hierarchy? Sometimes, perhaps, but is this always the case? Are there other barriers? Interprofessional friction, for example? Is there a perception that the job of the anaesthesiologist is separate from that of the surgeon? Do surgeons, anaesthesiologists and operating room nurses have similar personalities, similar experiences and identical goals? Professional subgroups, or occupational

Figure 25.1 An iceberg model for observed behaviours

subcultures as some call them, are everywhere in healthcare Doctors, nurses, medical sub-specialists, technicians and therapists – all see themselves as groups distinct from each other They relax in different lounges, use language and jargon specific to their subgroups, and wear trappings and symbols of their group membership There are hierarchical barriers within disciplines (residents/registrars and consultants) and between disciplines (who is in charge in the operating room: anaesthesia or surgery? Asking this can start a brawl…) and of course, between professions (doctors, nurses and others)

Each sub-group or discipline has its own perceived strengths and roles Some see themselves as doing the primary job at hand (such as surgery), while others may see themselves as risk mitigators (such as anaesthesia) Each believes they are doing their job to the best of their ability; the surgeons are typically technically competent, the anaesthesiologists maintain stability of the patient, the nurses ensure order in the room, produce equipment for the surgeon as needed without delay and count sponges to make certain nothing is left behind Friction between sub-groups and sub-cultures is common Humour may be directed at one group or another, and disparaging generalizations about one profession or another, or about one specialty or another are not rare

If we return to our iceberg diagram, we can picture a schism or a fault in the base – a rift between groups, or dysfunctional professional cultures The problem may be specific to one team, or characteristic of a given culture in an entire hospital or teaching centre It may be the doctors-only lounge that was mentioned earlier This fault in the foundation of team structure leads to dysfunctional attitudes, biases and differing values within those teams, and eventually manifests

as poor team behaviours – perhaps a tendency toward individualistic behaviour

or a reluctance to help out with heavy workload An example of such behaviour would be a reluctance to ask for help with a busy taskload, either because mutual support is not part of the culture, or because a practitioner could be self-conscious about appearing to not be able to cope with his or her workload A particular work setting may well evolve its own fixes and informal countermeasures to deal with perceived risks to safety or deficiencies in team performance These may take the shape of unofficial rules, or things nurses do without the physicians’ awareness

to try and ensure safety and quality The visible behaviours resulting from deep-seated fractures within the team structure can be more egregious: insults, disrespect

or open hostility

Anecdotes of team dysfunction are rampant in healthcare, though systematic analysis is seldom found in the literature These are stories shared in the nurses’ or residents’ lounges or over drinks with colleagues on a Friday night Few of us would expect that CRM training or non-technical skills courses would likely eradicate these problems, and resistance to change can come from either a perception that the new skills offered will undermine existing practices, or because the underlying team structure is so dysfunctional that no brief training programme is likely to repair the existing degree of damage

So, back to aviation Is there anything that the aviation industry can teach

us about how to implement changes in team behaviour? Our experience with LOSA, as you might remember from earlier in this chapter, was that without both senior management and workforce buy-in, our efforts often proved futile

In healthcare, this would mean getting senior administrative personnel to support team improvement efforts (specifically, the chief executive officer, the chief of medical staff and the chief nursing officer, at a minimum), and in the case of the operating room, the heads of surgery, anaesthesia and nursing Why is this important? Without the support of the senior executive of an organization, resources will not be adequate and those trying to implement change will find institutional resistance acting as a major barrier to their efforts It strikes me that I have not defined ‘support’ By support, I mean money (which is rare), not a letter

of support (which is more common) These projects require resources They may require operating rooms to close for training, which means loss of revenue Senior management in one institution may choose to pay staff to attend training, while in other institutions they may be expected to attend on their own time Without

buy-in from key physicians and nurses, medical and nursbuy-ing staff are unlikely to role model and encourage the proposed changes, and desired behaviours and practices will likely disappear after training, despite best intentions

Our experiences in healthcare CRM, however, suggest that top-level and practitioner support alone is not likely to be enough Many of us in this field often say that healthcare is more complex than aviation, but what does that mean? This belief really relates to the nature of our work groups more than it does to the actual work itself Teams in healthcare are unstable; their members come and go through the course of the week, the day and even the procedure Multiple professions and disciplines, as discussed above, must work together, and often must deal with unusual stresses and sources of friction It is no secret that in many institutions, bad behaviour on the part of some senior staff is tolerated The growing numbers

of formal codes of conduct currently appearing in our hospitals attest to this

fact, as institutions try to find administrative tools to deal with the problem of disrespectful and offensive behaviour Such issues must be dealt with if any attempt

to improve team performance is going to succeed Our experience in aviation was that disruptive and abusive pilots were strong resistors of CRM and actively tried

to subvert those programmes when they first appeared

Will CRM or non-Technical Skills Training Work in healthcare?

There is probably little doubt that in well-functioning operating rooms teams (and for teams elsewhere in healthcare), CRM and non-technical skills training can raise reliability and safety to a higher level The important question is how

do we go about implementing this, or what else needs be done? Paul Uhlig, another participant at the Edinburgh meeting in 2007 and contributor to this book (see Chapter 26), has written and spoken extensively about the need to reform