Nursing Crew Resource Management: High Reliability Behaviors for front Line Nurses Gary L. Sculli MSN, ATP Director of Clinical Training Programs VHA National Center for Patient Safety Objectives 1. Compare and contrast cultures high reliability and professional nursing 2. Explain a cultural analysis of VHA nursing as an impetus for a Crew Resource Management (CRM) initiative 3. Present a Nursing Crew Resource Management (NCRM) program overview 4. Discuss specific CRM based behaviors that nurses can implement to reduce the level of risk for hospitalized veterans 5. Outline specific outcomes found on nursing units that have implemented NCRM within the VHA Vision National Center for Patient Safety Institute of Medicine (IOM) establish team training programs using proven methods such as crew resource management training techniques employed in aviation Culture Shock High Reliability Team training (CRM) Human factor awareness Regulatory protection High degree of standardization (SOP) Briefings Culture Shock High Reliability Checklist Discipline CVR / FDR Incentivized non punitive reporting (anonymity / immunity) Highly formalized perpetual training Performance checking via simulation Culture Shock Nursing Front Line Hierarchical Relationships (Nurse Physician) Human Factors not emphasized Expectation to complete non nursing functions Varying degrees of standardization Fear and Shame in reporting errors Haphazard recurrent training Absence of performance checking via simulation 1
VA Patient Safety Culture Survey 2009 Mean Scores Front- Line Nursing and All VHA LPN RN Level 1 RN Level II Overall Perceptions of Safety Non- Punitive Response to Error Nursing Assistant Teamwork within Hospital Units Teamwork across Hospital Units Mean Scores RNI, RN II and LPN, Nursing Assistant Mean Scores RNI, RN II and LPN, Nursing Assistant RN I & RN II Lower Shame Teamwork Across Hospital Units Feedback & Communication about Error LPN & N/A Lower Communication and Openness Teamwork Within Hospital Units Tenerife March 1977 (Fatalities 583) (CRM) Crew Resource Management Originated in a 1979 NASA workshop 2
(CRM) Crew Resource Management NCRM - Program Layout Reduce error through better use of human resources Manage error by employing specific safety behaviors Logistics & Pre-work 2 months prior Project Implementation Consultation 12 months Training on site 1 week Refresher Training At 1 year = Clinical Questionnaire Projects Program reception at front line? 1. Mitigating Distractions 2. Checklist development and Implementation 3. Team Briefings / Debriefings 4. Situational Awareness Countermeasures 5. Fatigue Management Percent of respondents that agreed or strongly agreed I would recommend this program to a friend or co-worker Overall, the program was worthwhile I will be able to use my new skills/knowledge in my regular work assignment I developed new skills/knowledge as a result of my participation in the program Baseline (N=478) Follow-up (N=207) Program objectives were relevant to my professional needs/interests 0 20 40 60 80 100 16 Systems NCRM Foundation Human Error Systems Behaviors James Reason Swiss Cheese Model Published (2000) 3
Zero error is NOT realistic Zero error is NOT realistic? Fault Tolerant System system tolerates errors but still functions successfully The Error Pyramid Fault Tolerance MITIGATE CONSEQUENCES of ERROR TRAP ERROR AVOID ERROR Leadership Style Dictator Leader Behaviors Building the Team Complete Control Input not welcome Autocratic Intimidating Rude Hostile ISMP Survey on Workplace Intimidation (2003, 2005, 2008) 75% Nurses and Pharmacists use avoidance techniques ISMP, 2005 4
Team Building Behaviors Leadership Grid (x,y) 1. Interpersonal skills 2. Invite and Expect Participation 3. Use Open Ended Questioning 4. Set Acknowledgement Expectation 5. Briefings 6. Debriefing Sender Receiver Concern for People (y) 9 8 7 6 5 4 3 2 1 1,9 Country Club Style 1,1 Horrible Leader 0 0 1 2 3 4 5 6 7 8 9 Concern for Task (x) 9,9 High Motivation, Morale, Teamwork 9,1 Produce or Perish Independent Critical Thinkers Assertive Advocacy Followership Passive Followers Advocacy Active Dependent Non-Critical Thinkers Assertive Advocacy Air Florida Flight 90 January 1982 January 13, 1982 Fatalities 79 15:59:58 - F/O God, look at that thing. That doesn't seem right, does it?...uh, that's not right. 16:00:09 - CA Yes it is, there's eighty 16:00:10 - F/O Naw, I don't think that's right Ah, maybe it is. Avoiding Hint and Hope Communication Standardized Tools 5
3 W s 3Ws Case Study 1. What I see 2. What I m concerned about 3. What I want A procedure is about to begin in the operating room on a patient having several laryngeal polyps removed. The surgeon begins the case. The circulating nurse notices that there has been no discussion of procedures for reducing the risk of an intra airway fire during electrocautery. Assertive Communication Standardized Communication Tools 4 Step Tool 1. Get Attention - Use title or first name 2. State Concern - I m uncomfortable with 3. Offer Alternative - I want you to 4. Pose question - Get resolution Nursing Questionnaire (TW Domain) Baseline 6 Months 11 Months Situational Awareness ***Nurse input about patient care is well received. ***It is difficult to speak up if I perceive a problem with patient care. ***Disagreements in this clinical area are resolved appropriately (not who's right, but what's best for pt). 75% Improvement ***I have the support I need from personnel to care for patients. ***It is easy for personnel here to ask questions when there is something that they do not understand. ***The physicians and nurses here work together as a wellcoordinated team. 29% Improvement 0% 20% 40% 60% 80% 100% *** Statistically significant (p<0.05, t-test) 6
Levels of Situational Awareness Situational Awareness (SA) Significant Challenge for Nurses Level 1 perception THREATS STRESSORS Cognitive Resources Level 2 comprehension Level 3 projection Make Decisions Medication Variance Fall with Injury Wrong Patient Wrong Procedure Failure to Rescue NARCAN, D50 ACLS LOW (SA) Apply the 1,2,3 Rule Immediate Action As soon as POSSIBLE vs. PRACTICAL 1. Step Back 2. Analyze 3. Use Resources Knowing / Recognizing Red Flags Failed Cross Check Failure to meet targets Confusion Not following Policy Fixation Failure to Delegate Not communicating Not addressing discrepancies Team Monitoring & Cross Checking RN Led Briefings PM Pilot Monitoring Staff Monitoring (NM) Short Done by Leader Informative Structured Opportunity for Questions 7
RN Led Briefings Huddle = Briefing RN to Team Briefing Greet Team Follow Policy Invite participation Acknowledgements Clarify roles RN, LPN, N/A Patient Risks Define Team Questions 3C HUDDLE ANY CHANGES SINCE REPORT? IF SO WHAT? ANY DISCHARGES? HOW ARE YOU DOING? DO YOU NEED HELP? CAN YOU HANDLE YOUR ASSIGNMENT? CAN YOU GO TO LUNCH? CAN YOU TAKE AN ADMISSION? WILL YOU BE ABLE TO LEAVE ON TIME? IS THERE ANYTHING ELSE? *THIS TAKES ABOUT 10 MINUTES MAX TO WITH ALL NURSES AND NURSING ASSISTANTS PRESENT. Unit Acquired Pressure Ulcers (UAPU) UAPU Rate FY 10 qtr. 2 = 4 UAPU Rate FY 11 qtr. 1 = 0 Blood Glucose Monitoring 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 0601-0700 1100-1200 1601-1700 2001-2200 May Oct Blood Glucose Related Events 33% 15 in FY10 Q2 to 10 in FY11 Q1). Hypoglycemic Events 71% 24 in FY10 Q2 to 7 in FY11 Q1. Hyperglycemic Events 8
Checklists Support the user Puts knowledge in the world Read and Verify Read and Do Read and Verify Before Takeoff Window Heat..ON HIGH Anti-Ice.ON Flight Instruments & Radios..SET Yaw Damper...ON & CHECKED Flight Controls....CHECKED Stabilizer Trim..SET Flaps / Slats...15 & GREEN Electrical...NO LIGHTS Fuel Pumps...SET FOR TAKEOFF Fuel Heat.OFF Hydraulics..PRESS & QTY NORMAL Elevator & Rudder Lights....OFF Air Cond & Press...SET FOR TAKEOFF EPR & Airspeed Bugs.. SET Transponder...ALTITUDE Take Off Briefing COMPLETE Read and Do Read and Do Checklist Central Line Mishap 4% - 22% Calls to Rapid Response Team 25% - 12% Failure to Rescue Events 25 9
Central Line Removal Checklist Before Removal (Read and Verify) Patient Identification.Confirmed X 2 Supplies..At bedside Supine Position..Confirmed HOB (Slight Trendelenburg or Flat).In position Sutures..Removed Sterile Cockpit Methodologies Reducing Distractions Sterile Cockpit Methodologies Removal (Read and Do) Patient Confirm in supine position Patient Take a deep breath and hold Line Remove.Pull parallel to skin in steady motion Pressure Dressing Immediately apply Patient Exhale After Removal (Read and Verify) Occlusive Dressing Applied Patient...Instructed - Bedrest X 30 minutes Staff and Patient.Instructed - Monitor per protocol Mean Number of Distractions Mean Number of Distractions 2.5 2.5 2 2 1.5 1 0.5 Nursing Hospital Staff Visitor Patient Other 1.5 1 0.5 Hospital Staff Patient 0 1 2 3 4 5 6 7 8 9 10 11 0 1 2 3 4 5 6 7 8 9 10 11 Medication Error Rate Pre Intervention 3.95 / 1000 bed days of care Simulation High Fidelity Simulation Unit Specific Clinical Scenario 36% Post Intervention 2.26 / 1000 bed days of care 10
Clinical Simulation 8 7 6 5 4 Pre Post Discussion Hoeksemer et al., unpublished References Endsley MR. Situational Awareness in Aviation Systems. In Garland DJ, Wise JA, Hopkins VD, eds. Handbook of Aviation Human Factors. Mahwah, NJ: Lawrence Erlbaum Associates; 1999. Fore, A.M., Sculli, G.L., Albee, D., & Neily, J. (2012). Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit based project. Journal of Nursing Management. Gaffney, F. Seddon, R. & Harding, S.W. (2005). Crew Resource Management: The Flight Plan for Lasting Change in Patient Safety. HCPro. Helmreich RL, Merritt AC, Wilhelm JA. The Evolution of Crew Resource Management Training in Commercial Aviation. Int J Aviation Psych. 1999; 9(1):19-32. Nemeth C. Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. Burlington, VT: Ashgate; 2009. Reason, J.. The Human Contribution Usafe Acts, Accidents and Heroic Recoveries. Burlington, VT: Ashgate 2008. Sculli GL, Sine DM. Soaring to Success:Taking Crew Resource Management from the Cockpit to the Nursing Unit. Danvers, MA: HCPro; 2011. Sculli G.L., Fore A.M., Neily J., Mills P.D. & Sine D.M. (2011) The case for training Veterans Administration frontline nurses in crew resource management. JONA, 41(12), 524-530. Sculli G. Nursing Crew Resource Management: Patient Safety for Front-Line Nurses. TiPS. 2009; 9(4): 3. http://www.patientsafety.gov/tips/docs/tips_julaug09.pdf. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44. Smetzer J.L., Cohen M. R., (2005). Intimidation: Practitioners Speak Up About This Unresolved Problem. Journal on Quality and Patient Safety, 31 (10) 594 599. VHA National Center for Patient Safety The Nursing Crew Resource Management Pilot Program: Fiscal Year 2011 Preliminary Report, August 9, 2011. West, P., Okam, N., Fore, A., Neily, J., Mills, P. & Sculli, G. (2011). Improving patient safety and optimizing nursing teamwork using crew resource management techniques. JONA, 41(12): 211-219. 11