Safety Matters. Partners for Life! Winter 2010 Volume 3 Issue 1. Using Soft Skills to Manage Risk in EMS Operations By Colin Henry, Director of Safety

Transcription

1 Partners for Life! Winter 2010 Volume 3 Issue 1 Using Soft Skills to Manage Risk in EMS Operations By Colin Henry, Director of Safety In this article the term soft skills refers to the use of Air Medical Resource Management (AMRM)/Crew Resource Management (CRM), Threat and Error Management (TEM), Risk Assessment and Culture. The day to day safe operations of emergency medical transports are dependent on these skills. We spend lots of time on training pilots the skills required to fly aircraft, and medical crewmembers on the clinical skills required to perform their jobs. These are necessary skills that are required to be met in order to function in our positions. We do not however spend as much time on soft skills training. These are the skills that we should have that are not directly required in order for us to function in our positions. In these soft skills we will find those incidents and accidents that have a human factors relationship. These are errors that have occurred because one forgot about a procedure or process that they know, have blatantly disregarded a procedure, or did not have the knowledge to handle the task at hand safely. Sometimes these appear in a National Transport Safety Board (NTSB) final report as controlled flight into terrain (CFIT), loss of control (LOC), pilot error, pilot failed to, etc. These accidents all have some elements of human factors that were never known or understood by those who were affected. Air ambulance accident statistics from 1988 to 2000 have shown that 64.7% were pilot/human related. Experts say that today this number is around 90% in the air medical transport industry. This is an attempt to show that the skills mentioned are very important to the safe outcome of emergency medical service (EMS) operations. AMRM is a derivative of CRM that gained momentum in the Air Medical industry around the mid nineties. It is defined as a method of making optimum use of the capability of the individuals and the systems in an aircraft to achieve the safest and most efficient completion of a flight. Air medical companies felt that there was something missing from their training curricula after there were some accidents with very experienced and highly trained pilots. Although some companies thought some form of aeronautical decision making training for their pilots, that information was usually not shared with medical crewmembers and communications specialists. The EMS industry knew that there was something missing that did not require solely flying the aircraft. Some EMS operators researched practices at airlines to see what they were doing differently. We found out that some had an active CRM process in place. The CRM training in the classroom had transferred into the cockpit. CRM was a working tool that was standard practice. Some air medical companies even sent personnel to the airlines to learn about CRM. After some years of use in the air medical industry by both pilots and medical crew members, an advisory circular was published in This was the Federal Aviation Administration s attempt to focus this training for all air medical service operation team members such as pilots, medical crew members, communications specialists and maintenance technicians. The air medical industry was introduced to human factors related training at all levels. The AMRM training covered several human factors related accidents and spent time discussing assertiveness, communication, team building & situational awareness. We now recognize the importance of reinforcing these principles through recurrent training and feedback. Some later training modules of AMRM have introduced other subjects such as complacency, stress and management of change. Continued on next page W. Dublin Granville Road, Columbus, OH DISPATCH * Business Office * Business Fax

2 Soft Skills continued... Around the mid-nineties Delta Airlines collaborated with University of Texas to study the effectiveness of their CRM process. This collaboration was instrumental in the introduction of threat and error management principles in the airlines and the introduction of a line operations safety audit process. Some airlines and some hospital systems have actively employed TEM since it is a countermeasure for AMRM/ CRM. The TEM countermeasures are planning, execution, and review/modify. For example, these countermeasures can be used to evaluate effective communications in flight. The skills learned in AMRM training can now be more recognized and any inherent threats and errors managed effectively. This is done by using threat/error management tools and procedures to prevent active failures and latent conditions. We want to employ hard and soft safeguards such as night vision goggles, helicopter terrain awareness warning systems, checklists, standard operating procedures, etc. We must take these safeguards that are put in place and effectively manage their inherent threats and errors using the principles of anticipation, recognition, and recovery that are taught in TEM training. MedFlight has actively employed these principles in its day-to-day operations. We have been teaching the importance of hard and soft safeguards and the recognition of mistakes (skilled-based, rule-based and knowledge-based) that all humans make. Our reporting system allows for threats and errors to be reported and to be effectively managed and shared with all partners through cases and lessons learned. We have expanded AMRM theories into workplace realities with emphasis on our human characteristics. We are also now in a position to audit and measure significant threats and errors in the workplace. This is accomplished through the line operations safety audit (LOSA) process. In 2006 the FAA published a notice that addressed risk assessment. They established the fact that helicopter emergency medical services (HEMS) operate in a demanding environment. They went on to say in their FAA Inspector Handbook that risks must be identified, assessed, and managed to ensure that they are mitigated, deferred, or accepted according to the operator s ability to do so within the regulations and standards appropriate to the operation. This concept has forced Part 135 operators to implement some form of risk assessment/risk intervention procedure. At MedFlight we use a risk assessment tool for both ground and air transportation. We are offering a contingency management plan to our partners so that transport strategies can be proactively accounted for and anticipated threats better managed. Continued on next page. SAFETY COMMUNICATION CONTACT INFORMATION 1. Safety Officer Risk Manager Infection Control Officer Website Resources: Safety Awareness Form the link to the form is located under the Safety section Unusual Occurrence Form the link to the form is located under the Forms section then under Crew Resources Page 2

3 Soft Skills continued. Research and experience has shown that these types of contingency planning can account for fewer errors and in some cases even fewer mismanaged errors. Used effectively the tool also allows any program to effectively manage and measure risk in their day to day operations. This process has been around for years in US military operations. None of the items mentioned will work unless your company/program has the right safety culture in place. Dr. Robert L. Helmreich, a well known human factors expert says that culture represents the values, beliefs, and behaviors that are shared by members of a group. Without the right culture, people will never hear the message nor will they be willing to comply with procedures or practices. This is where a company will see a large amount of procedural/rules-based mistakes. For example, checklists will not be used effectively nor will standard operating procedures be followed. The company s Chief Executive must set the stage for the right safety culture by first establishing a Corporate Safety Culture Commitment policy. This message has to be communicated effectively to all personnel in order to lay the foundation for any specific safety culture such as a just Culture. Just Culture is an environment/culture/understanding of how acceptability of individual behavior is to be determined and how accountability is evaluated. It is shared responsibility and a balance between human factors, individual practices and system issues. Some advantages of a Just Culture are: Its value to both justice and safety. It is good for company morale. It shows how people are committed to the organization. It gives people job satisfaction. It allows those persons who are willing to do that little extra to step inside that role. Just Culture adapts a systems view to errors and mistakes: It sees human error as a symptom, not a cause. It sees human error as an effect of trouble deeper inside the system. It turns to the system in which people work. For example, the design of equipment, the usefulness of policies and procedures, the existence of goal conflicts and production pressures. MedFlight strives for a Just Culture and has implemented this culture in its Safety Management System (SMS). We measure the progress of this culture annually for it is very important for the success of safe outcomes. Just Culture and TEM has had increased popularity in both aviation and healthcare. All of these soft skills mentioned should be a part of a company s SMS in order to manage risk at the highest possible level. References 1. Helmreich, RL, Davies, JM. Culture, threat, and error: lessons from aviation. CJA Merritt, A, Klinect, J. Defensive Flying for Pilots: An Introduction to Threat and Error Management. The University of Texas Human Factors Research Project. The LOSA Collaborative Dekker, S. Just Culture: Balancing Safety and Accountability. Aldershot, UK: Ashgate Publishing Limited Federal Aviation Administration. Advisory Circular 00-64: Air Medical Resource Management Federal Aviation Administration. Inspector s Handbook ; Volume 4, Chapter 5, Section 5: Operational Risk Assessment Programs for Helicopter Emergency Medical Services Page 3

4 Electronic Medical Record Project Update By Linda Hines, RN, JD MedFlight has completed a year long project to transition to an electronic patient care record. Go Live date was March 8, The software product is Zoll epcr on a Panasonic Toughbook. Below is an excerpt from the Electronic Medical Record Group charter. This will summarize the project: Electronic Medical Records have become a standard of care; a standard followed by every regional medical center and larger pre-hospital systems. Electronic Medical Records (EMR) have become a standard of care because they drive consistency in clarity and completeness which, coupled with real time reporting, significantly impacts patient safety. Clear, legible, complete electronic medical records reduce risk and insure compliance with regulatory requirements. Electronic medical records also improve the efficiency of the billing process and record keeping which translates to lower overhead cost. Finally, electronic medical records permit efficient data query to support QI (quality improvement), research, and data sharing. Initially, charting with an electronic medical record is expected to take longer than conventional charting. A quality training and implementation plan should mitigate the challenges. The patient record documentation process should achieve comparable efficiencies to manual charting relatively quickly. The gains in quality, risk reduction, safety enhancement, cost savings, and information capabilities are significant. When the project is completed, the implementation of an electronic medical record will enable MedFlight to submit data seamlessly to state and federal agencies that require specific patient and/or run data submission. Patient records in addition to being legible by all will also be required to have all necessary information prior to finishing therefore the records will be ready for accurate billing much quicker resulting in potentially better reimbursements. Finally with data now being captured electronically, the ability for MedFlight to capture quality improvement and research data will be enhanced tremendously. As you can see patient safety was considered. In addition, to also improve patient safety, MedFlight is returning to the process of using a quick sheet as a patient handoff tool and reference for the receiving team while the complete PCR is pending. Safety of equipment during the patient transport is always a concern when a new piece of equipment is added. The MedFlight Standardization Committee is charged with the task of securing/storing the Tough Book. This is still a work in progress but once complete all Configuration and Best Practice Guidance Circulars will be updated. The SOP Mechanics of the Panasonic Tough Book covers the operations process, including the process that all Tough Book air cards are to remain in the off position during all phases of flight. The rotor teams are still able to document in epcr while the air card is off and later merge in the dispatch information. The MICU teams will not need to turn off the air cards, although they may travel through areas that do not have broadband coverage and may later need to merge in the dispatch information. Page 4

5 Concerned Network Ambulance Accident Date: January 20, :03am PST Program: Cal-Ore Life Flight PO Box 1986 Brookings, OR Weather: Clear. Not a factor Team: Two Flight Nurses, Paramedic Driver, Paramedic Attendant, Patient, Family Member. Injuries. Patient on board. Description: While en route by ground, with lights and siren, from the Hillsboro-Portland Airport (HIO) to the Oregon Health & Science University Hospital (OHSU) in Portland, OR, with a patient that had just been transported by our fixed-wing aircraft, the ambulance was struck on the driver s side by a private vehicle while traveling through an intersection. The flight team members attending the patient in the back were unrestrained at the time of the collision. Local EMS, Police, and Fire departments responded to the scene. A second ambulance was sent to the scene and transported the patient, family member, and Cal-Ore crew to OHSU. The Cal-Ore crew and the ambulance paramedics sustained minor injuries and were treated and released. Debriefing: The incident was immediately reviewed and debriefed with the ground ambulance provider and Cal-Ore staff. After a thorough investigation by law enforcement and the provider, it was determined that the ambulance failed to come to a complete stop before traveling through the intersection. Cal-Ore Life flight has followed up with the patient and family member, and to date they have not experienced any ill effects from the collision. Lessons Learned: The investigation is closed with the strong recommendation to all Cal-Ore crewmembers to remain belted at all times, if possible, during ground transport legs. If unable, due to patient care requirements, they need to be positioned and aware of the possibility of sudden stops or other unusual occurrences. Source: Joe Gregorio, EMT-B, General Manager Page 5

6 Hospital Helipad Standards By Colin Henry, Director of Safety Today most hospitals have helipads that are used for medical helicopter take-offs/landings and to transport patients to and from hospitals. These helipads are usually privately owned by the associated hospital system. As such the hospitals may be liable for any accidents or incidents that could occur due to helicopter traffic activity. On May 21, 2008 in Grand Rapids, MI a helicopter s tail rotor struck a tower while lifting from the hospital helipad. This caused serious injury to two persons. Nine days later, in Pottsville, PA a helicopter was substantially damaged after making an emergency landing at a hospital helipad. Three persons had minor injuries. Approximately one month later, two helicopters collided at a hospital helipad in the Flagstaff area fatally injuring seven persons. On July 2, 2009 a helicopter was substantially damaged in Loris, SC when it came in contact with short steel poles aligned adjacent to the hospital helipad. Six months ago in Tucson, AZ another helicopter experienced a loss of tail rotor authority. That aircraft landed hard and had substantial damage. So if we look at the history in the past two years we will see that there are some incidents and accidents occurring at or in the vicinity of a hospital helipad. We have a lot of helicopter traffic operating into and out of an obstacle rich environment such as a hospital helipad. Threats need to be effectively managed if we expect safe outcomes. It is recommended that hospitals utilize the Federal Aviation Administration s (FAA) Advisory Circular (AC 150/5390-2B) on Heliport Design in order to set up Safety guidelines in and around their helipad. This document will cover areas such as location, size, lighting, obstruction clearance, markings and approach paths. Most helipad builders are familiar with this document and will use it if they are contracted to build your helipad. It is also beneficial for hospitals to register their helipad with the State of Ohio and with the FAA. If you need any help with interpreting this document, please do not hesitate to contact me at Lastly, when a helicopter is dispatched to a hospital, it is vital that the pilot and medical crew members have all the information necessary to find and operate safely at that location. Some coordination is required between the hospital, the pilot and medical crew members to make this occur. The communications center plays a major role in coordinating and disseminating this information from the hospital to the pilot and medical crew members. These communications are vital since it plays a major role in MedFlight s threat and error management procedures. We have a chance to get helipad updates from the hospital usually from security, verify that that information mirrors what we have in our records and then share the most updated information with the pilot and medical crewmembers before they land at the helipad. The pilot and medical crewmembers are still required to exercise good threat and error management skills before landing. Inaccurate information given to the pilot and medical crewmembers from the communications specialist can then be immediately updated. So the next time a helicopter goes to that location, it will have the most current and updated information about that location. Page 6

7 Pre-Designated Landing Zones (PDLZ) By Colin Henry, Director of Safety Pre-designated Landing Zones are areas that have been inspected and designated by someone as an approved area for landing an emergency medical service (EMS) helicopter. PDLZs usually meet the requirements of a standard scene landing area but can also be an airport, church parking lot, soccer field etc. These areas should be known areas that the local EMS departments can use to expedite safe transportation. Much debate about PDLZs has caused us to look deeper into this requirement and to set up provisions to make them as safe as possible. Some persons feel that this exercise may take the patient further away for the accident and hence delay transport time. Others have said that it may cause complacency among pilots and medical crewmembers. I do not feel that a PDLZ should be used if it will delay transportation of a patient and a safer, closer area to the patient is identified for patient pick-up. If a PDLZ is used, it should be adequately checked for accurate hazard and landing information at a scheduled time. We can never get away from landing at scenes but we should use a pre-designated area if patient care and safety are not jeopardized. This can be a more efficient use of resources and time with consistent landing zone information. Risk can be significantly reduced if proper threat and error management principles are applied. At MedFlight we are in the final stages of setting up criteria for PDLZs. For example, PDLZs must meet basic scene landing zone requirements and they must be audited annually to be consider a PDLZ. If it is over a year since a PDLZ was last inspected, it should be treated as a regular scene landing zone. Every PDLZ must be assessed by a pilot initially to be considered suitable for designation. A sponsor or person responsible for the upkeep of the PDLZ must be listed as part of the PDLZ information. This person could be the fire chief, EMS coordinator, MedFlight partner, pilot, etc. PDLZ information will be available in the Communications Center and will eventually be a part of the heliport site binder. These PDLZs have to be effectively coordinated with the local EMS in order to make it a valuable asset to our patient s care. Page 7