crew resource management in ems operaons - · pdf filecrew resource management in ems...
TRANSCRIPT
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Crew Resource Management in EMS
Opera6ons
Jeff Beeson, DO, EMT‐P, FACEP Medical Director Ft Worth, TX
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Objec6ves: • Review CriAcal Thinking • Discuss Crew Resource Management • Introduce Culture of Safety • Discuss OperaAons ApplicaAons
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The process of determining the authenticity, accuracy and value of something; characterized by the ability to seek reasons and alternatives, perceive the total
situation and change one's view based on evidence.
Critical Thinking
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Mistakes We Make • EMS educaAon focuses on manual skills by algorithmic protocols
• We should focus on – Honing our Assessment – Clinical Reasoning – CriAcal Thinking
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“Pre‐Loss” Strategies
Things we can do before a loss occurs.
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Heuris6cs • Rules that explain how people make decisions, come to judgments, and solve problem
• Can predispose a specific response to certain situaAons.
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The goal is to unmask cogniAve errors in the paAent assessment process for the development of
debiasing techniques.
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Confirma6on Bias • “Cherry Picking” • Look for evidence that confirms the assessment we’ve made
• We fail to consider persuasive evidence that changes that assessment.
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Decision Momentum
The aRached a label tends to sAck—
Even if it’s erroneous.
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Anchoring
The tendency to lock onto the iniAal impression
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Overconfidence Bias:
The tendency to believe we know more than we
actually do.
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Search Sa6sfying
The tendency to call off a search once something is found
(comes from not being methodical)
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Reducing Errors
• Recognize our biases • Work with the insight gained. • Always consider alternaAves. • Ask what else might be going on. • Learn to step back.
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Reducing Errors
• Scenario‐based training • SimulaAons • Focus less on algorithmic protocols
• Focus more on criAcal thinking and reasoning skills
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Crew Resource Management
Training system for industries where human error can have devastaAng errors that focuses interpersonal communicaAon, leadership, and
decision making.
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United Flight 173
16
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CRM – What is the Goal?
To achieve Op,mal
Performance from a team execu,ng mul,ple,
complex tasks.
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Error Management is the “What”
CRM is the “How”
GOAL: OPTIMAL PERFORMANCE
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You Can Not Engage In Human
Activity Without Introducing Human Error
So, Can We Reach The Goal of CRM Without Eliminating Error?
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Human Factor Error Causes Gordon Dupont’s “Dirty Dozen”
• Lack of CommunicaAon • Complacency • Lack of Knowledge • DistracAon • Lack of Teamwork • FaAgue
• Lack of Resources • Pressure • Lack of AsserAveness • Stress • Lack of Awareness • Norms
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Error Management Helmreich’s Error Management Model
AVOID
TRAP
MITIGATE
Helmreich, Robert L., Culture at Work in Avia,on and Medicine. Ashgate Press. Aldershot. 1998.
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Where Error Lives
• LATENT – present but not visible…hidden in the things we do routinely
• ACTIVE – present, in use…individual error
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“In the ten years it will take CRM to be introduced nationally, we will attend 1000
firefighter funerals…
I can’t get that out of my mind.”
Gary Briese,
Executive Director
IAFC
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Mul6ple Perspec6ves
• Origin from Military AviaAon 30 years • Integrated to Commercial AviaAon 20 years • Discussed as a tool in medicine 10 years • Fire Service text from 2004
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Basic Premises
• Technology minimizes “Tool Error”. • Human Factors primary cause for errors • Rigid, hierarchal organizaAons prone to failure
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Basic Elements • Adaptability / Flexibility • AsserAveness • CommunicaAon • Decision Making • Leadership • Mission Analysis • SituaAonal Awareness
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ADAPTABILITY
The ability to alter a course of acAon when new informaAon becomes
available
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EMT: "Hey, Bob. The paAent doesn't look well. His skin is turning blue. Are you sure that tube is in the trachea?" Paramedic: "I saw it pass through the cords." EMT: "Well, we've carried him down the stairs since then. What do you say we re‐assess breath sounds and apply an ETCO2 detector?" Paramedic: "Good idea, Jill. Let's do that."
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Asser6veness
• The willingness/readiness to acAvely parAcipate,
• state and maintain a posiAon, unAl convinced by the facts that other opAons are beRer”
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“
Requires the iniAaAve and the courage to act.
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Risk Homeostasis
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Comfort level is the degree to which you feel comfortable with what is happening, while taking into account that flying a
mission can be dangerous and demanding.
Whenever comfort level is exceeded, "Speak Up".
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BEHAVIOR CONTINUUM
• Passive • AsserAve • Over Aggressive
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Passive • Overly courteous • "Beats around the bush" • Avoids Conflicts • "Along for the ride.”
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ASSERTIVE
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• AcAve Involvement • Readiness to take acAon • Provide useful informaAon • Makes suggesAons
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OVER AGGRESSIVE
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• DominaAon • InAmidaAon • Abusive / HosAle
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CommunicaAon is the clear and accurate sending and receiving of informaAon,
instrucAons, or commands, and providing useful feedback.
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Decision Making EffecAve decision making refers to the
ability to use logical and sound judgment to make decisions based on
available informaAon
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John Boyd’s OODA Loop
• Observe • Orientate • Decide • Act
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Barriers to Good Decision Making
• Time • Inaccurate / Ambiguous informaAon • Pressure to perform • Rank Difference
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Promote Good Decision Making
• Teamwork • Time to decision • Alert crew members • Decision strategies and experience
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Key to Success
• Good decisions optimize risk management and minimize errors
• Poor decision making is a leading cause of mishaps
• Each decision affects future options
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You are on the scene • FF/EMT Webb continues to open the spreader on the
front hinge in spite of obvious indications that he is endangering the patient.
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WHAT IS LEADERSHIP?
The ability to direct and coordinate the acAviAes of other crew members and to encourage t he crew to work
together as a team.
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Types of Leadership • Designated
– Appointed Leader – Typical Design – FDM
• FuncAonal – Leadership by Knowledge or Experience – Occurs when need arises
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RESPONSIBILITIES OF LEADERSHIP
• Crew Performance • Direct AcAons • Ask for Assistance
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Traits of Effec6ve Leaders • Respected
– Builds Team Spirit • Decisive
– Open to SuggesAons • Delegates Tasks • Provides Feedback • Leads by Example • Keeps Crew Informed
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Mission Analysis refers to the ability to develop short term, long‐term and conAngency plans, as well as to
coordinate, allocate and monitor crew and resources.
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Mission Prepara6on
• Before • During • Ajer
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SituaAonal Awareness refers to the degree of accuracy
by which one's percepAon of his / her current environment
mirrors reality
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PERCEPTION vs REALITY • View of SituaAon • Incoming InformaAon • ExpectaAons and Biases • Incoming InformaAon vs ExpectaAons
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How does this relate to us?
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EMS Examples • Insufficient CommunicaAon • FaAgue/Stress • Task Overload • Task Underload • Group Mindset • “Press on Regardless” • Degraded OperaAng CondiAons
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Situational Awareness Point where perception and reality collide
• Reality always wins • Beware of loss factors
– Ambiguity – Distraction – Fixation – Overload – Complacency – Unresolved discrepancy
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Good Situational Awareness
• Good crew coordination • Proper task completion • Understanding • Appropriate communication • Use of checklists
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Checklists (example) First Responder Cardiac Arrest Checklist: • Pt moved to adequate working area • Communications advised CPR in progress • Pit crew positions identified • Continuous compressions being performed • BVM is attached to oxygen and flowing • AED / Defibrillator applied • Sufficient personnel or additional requested
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Checklists (example) ALS Cardiac Arrest Checklist: • Pit crew positions identified • Continuous compressions being performed • BVM is attached to oxygen and flowing • Monitor visible and in paddles mode • Code Commander is identified and positioned at the monitor • ETCO2 waveform is present and being monitored • IV/IO access has been obtained • Gastric distention has been considered/addressed • Family is receiving care and is at the patient’s side
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Preventing Loss of SA
Crew mental joggers • “What do we have ?” • “What’s going on ?” • “How are we doing?” • “Does this look right?”
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Preventing loss of SA
• Personal mental joggers – “What do I know that they need to know?” – “What do they know that I need to know?” – “What do we all need to know?”
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The Principle of CRM is Communica6on.
Say what you Mean and Mean
what you Say.
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CRM Evolved Crew Resource Management
For Fire / EMS
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Safety Culture
• “Not another program!” • Individual Responsibility • Non‐PuniAve Culture and Policy
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Culture of Safety • EMScultureofsafety.org • NaAonal DirecAve • Change “Culture”
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Roadblocks to CRM
• Negative human factors • Ingrained habits • Personal attitudes • 4 ft 8 ½ in
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Roadblocks to CRM • NORMS: Unwritten Rules • ODD MAN OUT: Ignore input from a
particular member • HIDDEN AGENDA: Intentionally
withholding information about intentions or plans from the rest of the crew.
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A Near Miss is simply an Incident Not Yet
Occurred.
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“Mandatory refresher training wastes the instructor‘s time, the firefighter’s time and the citizen’s dollars. Saving “a problem” for refresher training is a disservice to our firefighters and the
public we protect.”
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Repor6ng Programs • Self ReporAng • Anonymous • OperaAons Feedback • Rewarded for Ideas
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Vehicle Opera6ons
• Call PrioriAzaAon • Response Mode • Transport Mode • Quality Improvement
– Road Safety – Black Box
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Response / Scene Times • No Evidence • Load and Go
– Time SensiAve – What to do?
• Public PercepAon
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Stretcher Opera6ons • Lijing • Securing PaAent • TransporAng • Loading/Unloading
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Crew Safety • Ambulance OperaAons • Safety Designs
– KKK Specs • Restraint Devices • TransporAng Modes
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Ques6ons in Life are Guaranteed.
Answers Aren’t
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jeaeeson.com
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