Crew Resource Management

Jeff Beeson DO, EMT-P Medical Director Fort Worth

Republic of Texas

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CRM – What is the Goal?

To achieve Optimal

Performance from a team

executing multiple,

complex tasks.

Error Management is the “What”

CRM is the “How”

GOAL: OPTIMAL PERFORMANCE

To Err is Human

You Can Not Engage In Human Activity Without Introducing

Human Error

So, Can We Reach The Goal of CRM Without Eliminating Error?

When Things Go Wrong . . .

How It Is Now You are highly trained

and If you did as trained, you would not make mistakes

so

You weren’t careful enough so

You should be PUNISHED!

When Things Go Wrong . . .

How It Should Be

Humans make mistakes

Let’s also explore why the system allowed, or failed to accommodate your

mistake

Let’s IMPROVE THE SYSTEM!

and

so

and

You are Human

IAFC “Crew Resource Management” 3rd Ed. Oct 2002

Error Management

Overview:  What it is… and, isn’t  What Error Management Seeks to Achieve  Where Error Lives  Where it Fits in Our Skillset

Human Factor Error Causes Gordon Dupont’s “Dirty Dozen”

  Lack of Communication   Complacency   Lack of Knowledge   Distraction   Lack of Teamwork   Fatigue

  Lack of Resources   Pressure   Lack of Assertiveness   Stress   Lack of Awareness   Norms

Error Management Systematic Approach to Determining

Common Errors & Contributing Factors

Drives Cultural Change to Accept: Error is Universal. Error is Inevitable.

Shifts Focus from Who to What

Teach crews to TRAP, MITIGATE & AVOID Error.

Error Management Helmreich’s Error Management Model

AVOID

TRAP

MITIGATE

Helmreich, Robert L., Culture at Work in Aviation and Medicine. Ashgate Press. Aldershot. 1998.

Where Error Lives

  LATENT – present but not visible…hidden in the things we do routinely

  ACTIVE – present, in use…individual error

The Swiss Cheese Model (REASONS) Latent Errors in System

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Latent Errors at Mgt Level

Individual Error (Active Error) Result/error

Organizational Filters: Training/Stan/CRM/ORM

Trajectory of Accident/Error Unchecked

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Layers of Defense to Trap Errors

Use All Resources Maintain Situational

Awareness

Follow SOPs

High Level of Proficiency

Mitigating the Consequence of Error

Employ Error Trapping in Every Aspect of:

Training

Standardization CRM

Error Trapping = Prevention & Intervention

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  Avoid error   Trap errors committed   Mitigate the consequences of error

Crew Resource Management

An error management approach defining behavioral strategies taught as error countermeasures that are

employed to:

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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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Multiple Perspectives   Origin from Military Aviation 30 years ago.   Integrated to Commercial Aviation 20 years

ago.   Discussed as a tool in medicine 10 years

ago,   Fire Service text from 2004.

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Basic Premises

  Technology minimizes “Tool Error”.   Human Factors primary cause for errors.   Rigid, hierarchal organizations prone to failure.

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An Error Mitigation Tool

  Training on how to avoid errors.   Potential errors are "trapped" before they are

committed.   Planning for mitigation of error consequences.

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The Original CRM

Naval Air

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  Although the following was designed for Military Aviation, multiple terms are easily transferred to our environment.

  “Mission” or “Flight” = “Run” or “Call”

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Reference your own experience

How do these descriptions compare to your well functioning teams?

• “Mission” vs “Call”

Are we accomplishing something or

Just running a call

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Crew Resource Management Naval Air

https://wwwnt.cnet.navy.mil/crm/crm/stand_mat/seven_skills/sev_skills.asp

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Basic Elements   Adaptability / Flexibility   Assertiveness   Communication   Decision Making   Leadership   Mission Analysis   Situational Awareness

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ADAPTABILITY/FLEXIBILITY

The ability to alter a course of action when new information becomes available

  Un-briefed Situations   Routine becomes Emergency   Transitions   Crew Member Down   Interactions are strained

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QUICK ADAPTATION

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MAINTAINING ADAPTABILITY / FLEXIBILITY Anticipate Problems Recognize and Acknowledge any change Determine if an SOP or Habitual Response is Appropriate Offer alternative solutions Provide and Ask for Assistance Interact Constructively with Others

  Establish an open, professional atmosphere

  Ensure the crew understands the mission

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SETTING THE TONE FOR

ADAPTABILITY / FLEXIBILITY

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Example EMT: "Hey, Bob. The patient 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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Assertiveness

“The willingness/readiness to actively participate, state and maintain a position, until convinced by the facts that other options are better”

Requires the initiative and the courage to act.

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COMFORT LEVEL (Risk Homeostasis)

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".

BEHAVIOR CONTINUUM

 Passive  Assertive  Over Aggressive

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BEHAVIOR CONTINUUM Passive

 Overly courteous  "Beats around the bush"  Avoids Conflicts  "Along for the ride."

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BEHAVIOR CONTINUUM

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ASSERTIVE

•  Active Involvement •  Readiness to take action •  Provide useful information •  Makes suggestions

BEHAVIOR CONTINUUM

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OVER AGGRESSIVE

•  Domination •  Intimidation •  Abusive / Hostile

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BARRIERS TO ASSERTIVENESS

Position of Authority Experience Rank Lack of Confidence Fear of Reprisal

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Communication

Communication is the clear and accurate sending and receiving of information,

instructions, or commands, and providing useful feedback.

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PROCESS OF COMMUNICATION

Sender conveys ideas or information to others Receiver hears or takes in information and provides feedback

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SENDER’S RESPONSIBILITIES

Communicate in Appropriate Mode Verbal versus Non-verbal Convey Information Accurately and Concisely Provide Information at Appropriate Time Request Verification or Feedback

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RECEIVERS RESPONSIBILITY

Actively Listen Active Vs. Passive Role Take action as a result of Communication Answer, or Respond, to Communications Ask for Clarification of Unclear Communication

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BARRIERS TO COMMUNICATION

Noise Rank/Experience Task Overload Gender Attitudes Culture

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Example

  “Lt. Jones gives commands in an overly subdued manner.”

  “During training evolutions, after direction is given, Matt often looks away from the Instructor and does not respond.”

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Decision Making

Effective decision making refers to the ability to use

logical and sound judgment to make decisions based on available

information.

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This includes: Assessing the problem Verifying information Identifying solutions Anticipating consequences of decisions Informing others of decision and rationale Evaluating decisions

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A Decision Making Strategy for Troubleshooting:

Identify all the symptoms Make a hypothesis as to the possible cause Test your hypothesis Apply appropriate remedies

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Another variation is John Boyd’s OODA Loop

  Observe   Orientate   Decide   Act

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Factors Which Promote Good Decision Making

Teamwork Time to make a decision Alert crew members Decision strategies and experience

Barriers to Good Decision Making

 Time  Inaccurate / Ambiguous information  Pressure to perform  Rank Difference

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Overcome the Barriers

Time  Use SOP’s  Use the available information  Select the best decision

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Overcome the Barriers Inaccurate/Ambiguous Information

 Ensure effective communications  Cross – check information

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Overcome the Barriers

Pressure to Perform   Evaluate the rationale for making a decision

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Remember:

•  Good decisions optimize risk management and minimize errors, while poor decisions

can increase them

•  Poor judgment or decision making is a leading cause of mishaps

•  Each decision affects your 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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Leadership

WHAT IS LEADERSHIP?

The ability to direct and coordinate the activities

of other crew members and to encourage the crew to work together as a

team.

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DESIGNATED LEADERSHIP

TYPES OF LEADERSHIP

FUNCTIONAL LEADERSHIP

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DESIGNATED LEADERSHIP

Responsible Makes Final Decisions Normal Mode of Leadership

TYPES OF LEADERSHIP

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•  Leadership by Knowledge or Expertise

•  Occurs when the Need Arises

TYPES OF LEADERSHIP

FUNCTIONAL LEADERSHIP

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RESPONSIBILITIES OF LEADERSHIP

Crew Performance Direct Actions Ask for Assistance

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TRAITS OF AN EFFECTIVE LEADER Respected

Decisive Delegates Tasks Provides Feedback Leads by Example

Keeps Crew Informed

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TRAITS OF AN EFFECTIVE LEADER •  Open to Suggestions

•  Builds Team Spirit

•  Directs and Coordinates Activities

•  Maintains a Professional Atmosphere

•  Knowledgeable of how to do the Mission

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MISSION ANALYSIS

Mission Analysis refers to the ability to develop

short term, long-term and contingency plans, as well as to coordinate, allocate

and monitor crew and resources.

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PHASES OF MISSION ANALYSIS include:

Preflight In-flight Post flight

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PRE-MISSION ANALYSIS involves:

Planning Preparation Briefing

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CHARCTERISTICS OF AN EFFECTIVE BRIEF Professional Stays Focused Assigns Responsibilities Interactive Complete

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IN-FLIGHT MISSION ANALYSIS involves: Short-term Planning Monitoring Mission Progress Identifying and Reporting Challenges or Changes

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POST-MISSION ANALYSIS is:

Selective Review Interactive Timely

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Example

  “As the assigned Primary Medic, EMT-P Brown was unable to prioritize compressions vs. IV access within the context of Cardiac Arrest.”

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SITUATIONAL AWARENESS

Situational Awareness refers to the degree of accuracy

by which one's perception of his / her current environment

mirrors reality

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PERCEPTION VERSUS REALITY

View of Situation Incoming information Expectations & Biases Incoming Information versus Expectations

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FACTORS THAT REDUCE SITUATIONAL AWARENESS:

Insufficient Communication Fatigue / Stress Task Overload Task Under load Group Mindset "Press on Regardless" Philosophy Degraded Operating Conditions

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How does this relate to us?

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Give Examples:

Insufficient Communication Fatigue / Stress Task Overload Task Under load Group Mindset "Press on Regardless" Philosophy Degraded Operating Conditions

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CRM Evolved Crew Resource Management

For Fire / EMS

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Safety Culture

  “Not another program!”   Individual Responsibility   Non-Punitive Culture and Policy to Error

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Mission Analysis & Planning

  Micro – Training Opportunities   Accountability   Risk Versus Gain Analysis   Risk Acceptance

ROADBLOCKS

  The common obstructions to good CRM   A combination of

  Negative human factors   Ingrained habits   Personal attitudes and those of the crew-

members we are working with.

ROADBLOCKS   NORMS: unwritten rules become pressures

that act upon a group   ODD MAN OUT: Ignore input from a

particular member of the crew. Results in a loss of total crew effectiveness.

  HIDDEN AGENDA: Intentionally withholding information about intentions or plans from the rest of the crew.

ROADBLOCKS (cont):

  CHAIN OF ERRORS: Often the key is to recognize the chain developing-then a crewmember can act to change the situation.

BREAK THE CHAIN

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Situational Awareness

 Killer Equation-  Reality times perception still equals

reality.

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Situational Awareness

  A Enhancement Strategy:   Maintain Control   Timely Assessment   Multiple Sources   Monitor Results

Situational Awareness

Point where perception and reality collide  Reality always wins  Beware of loss factors

  Ambiguity   Distraction   Fixation   Overload   Complacency   Unresolved discrepancy

What are the “Red Flags”?

  Not Communicating   No one Leading   Deviating from Standards   Ambiguity   Confusion

What do you do when you suspect you have lost S.A.?

 React  Regain  Reconstruct

Good Situational Awareness

  Good crew coordination   Proper task completion   Understanding   Appropriate communication   Use of checklists

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

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

Preventing Loss of SA

Crew mental joggers   “What do we have ?”   “What’s going on ?”   “How are we doing?”   “Does this look right?”

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?”

CRM Principle: Communication

Elements of Communication Skills

The most obvious of the CRM principles.

And, the easiest to affect through training.

“Say what you mean, mean what you say.”

Dyar Technique

  Use name or rank when addressing them   Use an emotional phrase when identifying a problem;

for instance, use the phrase "I feel uncomfortable…"   Offer an alternative solution   Request feedback from your teammate, which will give

them a sense of ownership of the solution

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Jeff Dyar. Far View Group Consulting. 2011

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Effective Communication

  Utilizes more than one form.   Both sender and receiver recognize perceptions,

influences and situations that affect the message.   Must have active listeners.   Communication loop

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CRM Leadership   Three Steps:

  Introduction   Integration  Trust

  Recognize formal and informal (situational) leaders.

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CRM “Followership”   Interaction   Listening Skills   Receiving, interpreting and following

instructions   Making decisions together.   Watching out for one another.

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Hazardous Attitudes

  Anti-authority   Impulsivity   Invulnerability   Macho   Resignation   Pressing

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Decision Making

  Define Problem   Generate a course of action   Evaluate a course of action   Carry out a course of action

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Keys to Good Decision Making

  Maintain good situational awareness.   Maintain technical proficiency   Know your resources   Evaluate, Evaluate, Evaluate

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We have seen this stuff before!

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HazMat & WMD   G – Gathering Information   E – Estimating Course and Harm   D – Determining Strategic Goals   A – Assessing Tactical Options & Resources.   P – Planning & Implementing Actions   E – Evaluating   R - Reviewing

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Two Key Weaknesses

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Debriefings & Critiques   Similar to CISD

  “The Blue Line”   Template:

  1. Just the facts   2. What did you do?   3. What went wrong?   4. What went right?   5. What can be done?

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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.”

Page 254

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Strategies for Implementation

Step 1 – Train to technical proficiency Step 2 – Train to CRM proficiency  Train risk vs. gain  Include CRM in organization’s culture

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Strategies for Implementation

Step 1 – Train to technical proficiency

Traditional perception of “Training”

We do this well!

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Strategies for Implementation

Step 2 – Train to CRM proficiency

“Error Tolerant” Culture, especially in Probationary Training

Assertiveness

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Strategies for Implementation

Train risk vs. gain

“Fuzzy Logic”

Values are assigned to situational elements

Train “Experience”

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Strategies for Implementation Include CRM in organization’s culture  What is the current culture?  Do we need CRM?  Take a brief inventory

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Rate: Concern with Failure   We regard close calls and near misses as

a kind of failure that reveals potential danger rather than as evidence of our success and ability to avoid danger

  We treat near misses and errors as

information about the health of our system and try to learn from them

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Rate: Reluctance to Simplify

 Personnel take nothing for granted

 Personnel are encouraged to express different points of view

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Rate: Sensitivity to Operations

  During an average day, personnel come into enough contact with each other to build a clear picture of the situation.

  Personnel are familiar with operations beyond one’s own job.

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Rate : Commitment to Excellence

  There is an effort to build competence and abilities

  Personnel have a number of informal contacts that they sometimes use to solve problems

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Rate: Deference to Expertise

 If something out of the ordinary happens, personnel know who has the expertise to respond

 People in this organization value expertise and experience over hierarchical rank