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Crew Resource Management: Lessons for Healthcare—Part I

 

By Donna Moore, RN, MBA, CPHQ, Quality Improvement Project Leader

 

 

Hospitals throughout Ohio and the nation are taking a hard look at crew resource management (CRW) as a model for improving quality and enhancing patient safety. CRW has evolved in the aviation industry over the last 30 years, from its inception in the 1970s as “cockpit” resource management to the current terminology, “crew resource management.” The change from “cockpit” to “crew” was a natural progression as researchers realized that there are many roles involved in a safe flight, including but not limited to the performance of pilots, flight attendants, air traffic controllers, flight service, maintenance personnel, and dispatchers. This evolution did not happen overnight. In fact, on October 1, 2006, more changes will be introduced into pilot safety programs. As hospitals look at CRM and its place in healthcare, they must realize that CRM requires a culture change that typically takes years to fully achieve. The aviation industry has been investigating the causes of accidents since the inception of powered flight in the early 1900s. Analysis of airplane accidents in the early years of flight indicated that 50 percent were due to faulty construction of the aircraft. From this regulations evolved into those present today, which include the maintenance of aircraft, including annual inspections.

 

Aviation accidents or incidents make the news, often on the front page if it is a local accident, regardless of the size of the aircraft, number of individuals involved, or the cause. The public and the pilots will openly discuss and analyze what happened. In the aviation arena this is known as “hangar talk.” Accidents are investigated by the National Transportation Safety Board (NTSB), which in turn publishes findings on its Web site at www.ntsb.gov/ntsb/query.asp. Aviation magazines such as AOPA Pilot or Aviation Safety provide a synopsis of the event, along with an analysis of the causes and discussions on prevention or safety initiatives. The Federal Aviation Administration (FAA) encourages pilots to attend free safety seminars where the cause and prevention of accidents are discussed. Today, 70 percent of the accidents involve human error.

 

Comparisons with healthcare

In healthcare, mistakes or “adverse outcomes” are frequently kept confidential. There is no sharing from one individual to another, from one facility to another, from one state to another. In other words, there is no encouragement to learn from the errors of others. There is no standard method of investigation, documentation, or dissemination of information. There is no standardization of practice for error prevention. Very rarely does a healthcare incident make the news. The Institute of Medicine (IOM) has estimated that between 44,000 and 98,000 individuals die annually as a result of medical errors. This makes medical errors the 8th leading cause of death. IOM estimates the cost of preventable errors is $17 billion annually. Healthcare providers and administrators need to question “why?” and “what can be done?” Unfortunately, in healthcare new regulations are viewed with suspicion and often as a threat.

 

Culture change

Adoption of CRM requires a culture change—a change in the way teams work together. Healthcare organizations cannot expect to implement effective CRM in a year. Early critics of CRM in aviation claimed it was theoretical and based on the management techniques of the time. The focus was on role-playing and management theory. This shifted to “Threat and Error” management where the goal is to catch the errors prior to injury. CRM involves changing the attitudes and behavior of the team.

 

It is necessary to understand the human factors involved in healthcare errors prior to implementing CRM. Robert Helmreich, PhD, from the University of Texas at Austin, conducted studies on the reporting of errors and teamwork in healthcare.1 He found that one-quarter of healthcare personnel reported they were not encouraged to report safety concerns and one-third said that safety concerns were not handled appropriately. Pressure exists to cover up mistakes; therefore, opportunities for improvements are overlooked. The individuals questioned agreed that errors committed during patient management are not important if the patient improves. Errors in healthcare are not reported for several reasons including personal reputation, job security, and egos. Other reasons include fear of malpractice suits and disciplinary action by the licensing boards.

 

Helmreich also studied staff perceptions.1 Sixty percent of the medical respondents agreed with the statement, “Even when fatigued, I perform effectively during critical times.” This is a much larger percentage than the 26 percent of pilots who agreed with this statement. Sixty-seven percent of healthcare respondents believe that true professionals can leave personal problems behind when working. Seventy percent of healthcare respondents felt their decision-making is as good in emergencies as in routine situations. Medical personnel downplay the effects of stress and fatigue on their ability, which could lead to increased error. Seventy percent of the respondents do not feel that the surgeon or physician in charge should be questioned. By contrast, 94 percent of the pilots promote flat hierarchies.

 

It is important to understand the background of CRM and the staffs’ perceptions of patient safety, error reporting, and hierarchy prior to adapting this model to healthcare. Through this series of articles we will continue to review CRM in aviation and how its success in this arena can be applied to healthcare settings.

 

Reference:

1. Sexton, J. Bryon, Thomas, Eric J., & Helmreich, Robert L., “Error, Stress, and Teamwork in Medicine and Aviation: Cross Sectional Surveys”, BMJ Volume 320, 3/18/06, pp. 745- 749.

Donna Moore is a commercially-licensed pilot.

 

 

Standardizing Care: Guidelines, Protocols and Pathways

 

By Barbara G. Stiebeling, RN, MSN, Quality Improvement Project Leader

 

Guidelines, protocols and pathways are distinct, interrelated tools. The goal of using them is to provide consistency, continuity and coordination of care. In addition, they must be flexible enough to allow the practitioner to override certain aspects of prescribed care based on his or her knowledge of the patient.

 

Guidelines serve as recommendations that form the skeleton of a plan of care for certain populations, according to Artemis March, PhD, MBA. These are usually developed by professional organizations and describe the “what to do.” Protocols outline the processes and procedures needed to implement the guidelines: They describe the “how to do it.” Finally, clinical pathways provide a road map, which becomes especially important when patients are treated by multiple clinicians/caretakers. They describe, “who is doing what and why.”

 

Barriers to guideline, protocol and pathway usage include:

1. Perception of inflexibility
2. Complexity
3. Not available when needed

Perception of inflexibility

This notion often translates into the perception of loss of autonomy and decision-making. Guidelines are based on the best available science and their implementation should be expected, unless the physician documents a rationale for deviation. Physicians must be encouraged to use their good clinical judgment when the guidelines do not fit the situation, however, these departures from guidelines must also be monitored and discussed. The 2007 pre-publication JCAHO standards for medical staff

address this issue. Read more at: http://www.jointcommission.org/AccreditationPrograms
/Hospitals/Standards/prepub_stds/prepub_stds.htm

 

Complexity

Hospital care is complex and keeping protocols simple is a challenge, but can be done. Logical order, checkboxes whenever possible and limiting the number of pages are just a few ideas to use in implementing user-friendly protocols.

 

Not available when needed

Many hospitals that identify this barrier have developed protocols and pre-printed orders, but for a variety of reasons, they are not used. Some of the reasons are listed below:

1. The responsibility of placing them on the chart is unclear
2. Their location is either not convenient or unknown
3. Change is difficult
4. Telephone admission orders continue

 

Best practices

Most Ohio hospitals are dealing with the above challenges. A few best practices are described below:

 

Mercy Hospital Clermont is a 157-bed Community hospital in Batavia, Ohio. It has developed protocols for the core measure conditions of acute myocardial infarction, heart failure and pneumonia. Since the Emergency Department (ED) is their primary source of admissions, education on the use of pre-printed protocols/order sets is concentrated in this department. Pre-printed order sets are used unless the physician declines. In addition to these measures, concurrent review helps to monitor compliance.

 

At UHHS Geauga Regional Hospital, a 188-bed hospital in Chardon, Ohio, pre-printed orders have been in use for four years. Their acceptance has been gradual, but steady. One of the most successful features of these orders is their simplicity. Another feature is the consolidation of discharge instructions for all conditions on the same form. Although standardization is the rule, flexibility is built in to accommodate clinical judgment.

 

There are many reasons to adopt and adapt these patient care tools. First and foremost, they provide consistency, continuity and coordination of care. These tools are pre-requisites for the adoption of Computerized Physician Order Entry (CPOE). (Please see the accompanying article below.) Their use may also influence a hospital’s reimbursement in pay-for-performance programs. Finally, in an environment of increased litigation, they serve as protection for the hospital, the physician, and most importantly, the patient.

 

Reference:

Artemis March: Quality Matters, The Commonwealth Fund. Volume 19, June 2006. Online at

http://www.cmwf.org/publications/publications_show.htm?doc_id=378546

 

 

The Quality of Health Care Explored in Four-Part PBS Series: Remaking American Medicine™...Health Care for the 21st Century

 

As many as 98,000 Americans die each year in hospitals due to preventable medical errors. One million more are injured. In fact, medical errors kill as many people per year as breast cancer, HIV-AIDS and car accidents combined. These and other equally startling statistics underscore the chaotic conditions within the American health care system.

 

Remaking American Medicine™ Health Care for the 21st Century explores the quality crisis and the innovative solutions being undertaken by providers, patients and their families to transform the care provided by the institutions we all depend on. The four one-hour programs are scheduled to air on PBS on consecutive Thursdays on October 5, 12, 19 and 26 at 10 p.m.

 

 

2006 Crosskeys Media®. Patient safety expert Dr. Peter Pronovost leads rounds with other physicians and nurses in the Cardiac Surgical Intensive Care Unit at Johns Hopkins Medical Center in Baltimore.

 

 

Each program examines critical health care issues facing Americans today including patient safety, medical and medication errors, hospital-acquired infections, family-centered care and effective management of chronic disease. But rather than assign blame for the failings in health care Crosskeys Media® series producer, offers solutions by showcasing the stories of individuals and institutions who are working to ensure better health care for everyone.

 

"We wanted to present detailed and emotionally engaging profiles of people like Dr. Donald Berwick, founder of the Institute for Healthcare Improvement, who are struggling to fix our broken health care system," said Frank Christopher, executive producer, Crosskeys Media. "Remaking American Medicine is their story, told through the eyes of doctors, nurses, administrators and patients, showing their struggles, their setbacks and their victories. We call these people and their institutions Champions of Change."

 

Silent killer

The first program, "Silent Killer," sets the stage for the issues that will be explored throughout the series. The program highlights the efforts of Sorrel King, whose 18-month-old daughter died at one of the most respected hospitals in the world, Johns Hopkins. King has gone from grieving victim to engaged activist, partnering with Johns Hopkins to make safety a top priority at the institution. Says Tony King, Sorrel’s husband, "We never really even heard the term medical error or knew that this was going on."

 

Sorrel has joined forces with Dr. Berwick to save 100,000 lives in American hospitals, the equivalent number of people who die each year from medical errors according to the Institute of Medicine. Notes Dr. Berwick, “What we need is outrage. We need the public to say, 'No, I don’t want a health care system at any price, let alone close to two trillion dollars, which is going to hurt me when it tries to help me.'" "Silent Killer" will be broadcast Thursday, October 5.

 

First do no harm

Program Two, “First Do No Harm,” takes a critical look at the impact of medical errors and patient safety in two hospitals and follows the efforts of physicians who are challenging their colleagues to live up to their oath to “first do no harm.” In Pittsburgh, Penn., Chief of Medicine Dr. Richard Shannon is confronting an epidemic of hospital-acquired infections that are shattering the lives of their victims.

 

In New Jersey, Hackensack University Medical Center is engaged in an effort to completely transform the way the institution delivers care. The imperative for this change is dramatically illustrated in “First Do No Harm” through the needless suffering of 89-year-old Anna Terrano, a victim of a medication error at Hackensack. The introduction of information technology is now being used to prevent patients like Anna Terrano from being harmed from the care they receive. “First Do No Harm” will be broadcast on Thursday, October 12.

 

100 million Americans

The series then moves to the challenge of treating chronic diseases that affect nearly 100 million Americans. “The Stealth Epidemic” examines the human and economic costs of effectively managing diabetes, heart disease and other chronic conditions that consume nearly 70 percent of all health care resources. According to Dr. Ed Wagner, a physician, epidemiologist, and internationally recognized expert on care systems for chronic illness, “If we don’t improve the basic care of diabetic patients, I worry for the financial survival of those systems.”

 

“The Stealth Epidemic” will air Thursday, October 19 and examines the groundbreaking efforts in two very different communities -- Los Angeles and Whatcom County in the state of Washington -- that are fundamentally transforming the physician-patient relationship. These initiatives offer a glimmer of hope for patients struggling with their chronic conditions.

 

Hand in hand

As medicine continues to become more and more technologically sophisticated and the systems that deliver medical care become increasingly complex, the relationship between providers and patients and their families is more important than ever. The final program, “Hand in Hand,” will be broadcast on Thursday, October 26 and tells the story of patients and families who have formed a unique bond in a teaching hospital in Augusta, Georgia.

 

While a number of patients are featured throughout this program, the story of the Moretz family is especially compelling. Daniel Moretz was born with serious heart disease and has had numerous medical procedures, culminating in a heart transplant. Throughout his illness and many hospitalizations, his mother Julie vowed to be by Daniel’s side, something not easily achieved in a hospital. But through Julie’s efforts and the insistence of other families, the Medical College of Georgia (MCG) Health System in Augusta has transformed itself into a nationally recognized facility where partnership among patients, their families and providers has become the guiding vision for the care it delivers.

 

“The media are filled with tragic stories of medical errors and innocent victims who have been killed by the health care system,” says Co-Executive Producer Matthew Eisen, who has been working with Christopher on the series for five years. “What we wanted to do was tell inspiring stories of a wide variety of people–consumers, health care providers, and policymakers who are transforming systems of care. Our goal is to show what is possible when people confront the problems head-on, and work together to reduce harm and save lives.”

 

To help accomplish this, an outreach campaign managed by Devillier Communications, Inc. was developed to engage major health care groups at the national and local level. “We have 46 National Partners and hundreds of local groups including PBS stations, Quality Improvement Organizations including Ohio KePRO, consumer groups, health care providers and businesses participating. With their help, we are creating awareness about health care quality and generating viewership for the series,” said Christopher.

 

In tandem with the series theme, Ohio KePRO is 1 of 15 QIOs nationwide working with the Centers for Medicare & Medicaid Services (CMS) on the Transformational Planning Project to develop a long-range plan for the QIO program that promotes transformational improvement in healthcare quality.

 

“Patient safety is at the vanguard of Remaking American Medicine and transformational change,” said Alice Stollenwerk Petrulis, MD, FACP, Chief Medical Officer for Ohio KePRO and its parent organization, KePRO, Inc. “The compelling nature of this unprecedented series will help advance a patient-centered culture of ensuring care that is safe, effective, efficient, timely, and equitable.”

 

Additional information is available by visiting www.RAMcampaign.org.

 

 

Systems Improvement and Organizational Culture Change (SIOC): The Role of Computerized Physician Order Entry

 

By Patricia Nelson, RN, Quality Improvement Project Coordinator

 

Despite the significant information that is available showing the advantages of using computerized physician order entry (CPOE) for patient care safety and efficiency, there is limited spread of this technology in U.S. hospitals. Although CPOE systems with clinical decision support are shown to decrease medication errors and near misses, wide spread adoption in hospitals remains slow.

 

The Centers for Medicare & Medicaid Services (CMS) has identified the adoption of information technology as a key strategy for transformational change of the health care system. In an effort to move hospitals forward, the Systems Improvement and Organizational Culture Change (SIOC) Identified Participant Group (IPG) is the CMS model being implemented to promote the strategy in hospitals nation-wide.

 

A widely recognized barrier to adopting and implementing CPOE is physician resistance. Overcoming this barrier requires innovative approaches to securing and maintaining physician buy-in. Hospitals recognize the need for a physician to champion the initiative and assist with gaining widespread physician support. However, hospitals still report resistance from the medical staff as the project is rolled out.

 

Variety of approaches

Lehigh Valley Hospital in Pennsylvania used a variety of approaches to gain physician support and increase their use of the CPOE system, according to Donald Levick, MD, MBA, the physician liaison for information services.1 These approaches included the following:

 

• Acknowledgement and recognition
• Tangible incentives
• Increased access to computers
• Leveraging clinical decision support and
• Resident and peer pressure.

Lehigh Valley Hospital did not require physicians to use the CPOE system and 20 months after implementation, CPOE usage was only 30 percent. Reportedly, Lehigh Valley Hospital used radical approaches to “stimulate” physician support. A program that paid physicians over a period of four months was put in place. After the program ended and utilization dropped, a raffle was held for attendance at a CME conference of the physician’s choice. To be eligible, a physician needed to reach a certain CPOE utilization level.1

 

Implementing CPOE is tied to changing physician behavior, which requires paying attention to factors and strategies that will support behavior change.

 

Read more:

Computerized Physician Entry SystemsJason S. Lee, PHD, Academy Health

http://www.academyhealth.org/syntheses/cpoe.htm

 

Glen Falls Hospital Computerized Physician Order Entry (CPOE) Project

http://www.gfhdocs.org/GFH%20CPOE.htm

 

Pain-Free CPOE

Following the right protocol is a critical step for encouraging physician adoption.

George Marshalek and Steve Casey

Health Management Technology, February, 2003

http://www.healthmgttech.com/archives/h0203cpoe.htm

 

Reference

1. You’ve Led the Horse to Water, Now How Do You Get Him to Drink:

Managing Change and Increasing Utilization of Computerized Provider Order Entry

Levick, Donald MD, MBA, et al. Journal of Healthcare Information Management. Winter 2005, Vol. 19, No. 1

 

 

Abstraction: Helpful Hint

 

By Karen Gallagher, RN, Quality Improvement Project Leader

 

The following situation recently was recently presented to the Acute Care Services Team. Here is the solution.

 

Validation Chart Request

Occasionally, a validation chart request will be identified on the Case Selection Report as “received.” The Medical Record Department will not receive a green paper request for this chart because the clinical data abstraction center (CDAC) has it in their possession.

 

What does this mean to you?

The chart was copied and sent to the CDAC for another reason and all the components necessary to pass validation may not have been included.

Example: The original Heart Failure (HF) chart request was for Patient Safety. The CDAC copied this chart for validation. Currently, you use a preprinted booklet addressing the discharge instructions for the HF patient. The booklet covers diet, activity, follow-up, medications, weight monitoring and worsening symptoms. Documentation of receipt of instructions and hardcopy is in the medical record.

Problem: The CDAC process of retaining a chart for one project request to another project did not allow the provider an opportunity to include the booklet as part of the medical record. The provider may fail elements that affect their validation score.

Solution: A Discharge Instruction Checklist. A booklet is an effective teaching tool for the patient, but adding a Discharge Instruction Checklist is a quick and efficient way to provide documentation of your teaching and the details of instruction. In addition:

• It will reduce costs by eliminating the need to include a booklet copy with each validation chart request.
• It will prevent failing the element by providing documentation of discharge instructions details.
• It will provide an opportunity to document the patient receipt of the discharge instructions.

Review your processes. Are you prepared to showcase your patient care? Is all the documentation included in your medical record at all times? Remember, if it is not documented, it did not happen.

 

 

Order Free Materials

Ohio KePRO offers a variety of free CD-ROMs, brochures, booklets, and posters to help you with your quality improvement and patient education activities. View Shopping Bag>>

 

 

Acute Care Services Team

David A. Bitonte, DO, MBA, FAOCA

Rita Bowling, RN, MSN, MBA, CPHQ

Jennifer Bitterman, RHIA, MBA

Ann Fitzsimons, RN, MBA

Karen Gallagher, RN

Dawn Knopp, RN, BSN, CPHQ

Donna Moore, RN, MBA, CPHQ

Patricia Nelson, RN

Karl E. Peters

Liz Simpson

Barbara G. Stiebeling, RN, MSN

Mona D. Wendell, RN, BA, MBA

 

Medical Editor: David A. Bitonte, DO, MBA, FAOCA

Editor: Robert A. Feigenbaum, MS

Associate Editor: Barbara G. Stiebeling, RN, MSN

 

 

 

To Contact Us
E-Mail: hospital@ohqio.sdps.org
Provider QIC Line: 1.800.385.5080

 

Rock Run Center, Suite 100 · 5700 Lombardo Center Drive · Seven Hills, OH 44131 · www.ohiokepro.com

 

Ohio KePRO, the Medicare Quality Improvement Organization (QIO) for Ohio, is working with committed hospitals, nursing homes, home health agencies, and physicians throughout the state who are dedicated to the common goal of Continuous Quality Improvement for Medicare beneficiaries.

 

Publication No. 8031-OH-017-8/2006. This material was prepared by Ohio KePRO, the Medicare Quality Improvement Organization for Ohio, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.