Crew Resource Management   What can we prove and do we   have to prove it? Experiences    from Swedish Patient safety     ...
Who am I..• M.D Resident in pediatrics at  Astrid Lindgrens childrens Hospital  Karolinska University Hospital  Stockholm•...
Quality and safety improvement                          Identify            Follow up                                     ...
Articles in my thesis
Working in the dark• Many hospital boards and most clinical teams have little or no  ongoing safety information• They ther...
Quality and safety strategies –exemples of on going activities    Department leaders, Division leaders             Quality...
Platform for research in patient safety                                          Participatory research design            ...
Research topics• Assessment of safety                                            • Patient safety information  culture    ...
Temporal trends in rates of patient harm: |     North Carolina United States                         Landrigan et al, NEJM...
Communication in healthcare • “A lack of an organised process of handing over   information or recording information. Peop...
Reliability of ward care• (1) How well do you understand the goals of care  for this patient today?• (2) How well do you u...
Implementing evidence based work practice with support of a checklist
Decreasing catheter related bloodstream infections• Hand washing                      • Median rate of infection per• Full...
Making it happen in practice• Specific strategies   – Education about infection control strategies   – Central line cart w...
Effects of structured patient handover                                Monitor                   Ventilator                ...
Crew Resource Management – CRMAims at creating a safetyculture  through:    Training staff in communication     and teamw...
What is Crew Resource Management Designed to                  Produce?• Crew members who consistently   – Form cohesive te...
CRM saves lives          “Association Between Implementation of a Medical Team Training Program and Surgical Mortality."Ju...
One Hospital     Several Sites     Full Range of Care Solna               Huddinge21
Teamtraining at the emergency room                                         Pediatric simulation center                    ...
   Doctors involved   Teamworkcompetency is considered part of being a professional   CRM supported by other teamtraini...
Complex interventions at many levels in the system-                            Safer Patients Initiative             Goal:...
Results take time...    The observations in this case suggest apossible generalisation: that there is an initial phase in ...
Thank You!
What can we prove and do we have to prove it, KikuPukk Härenstam
What can we prove and do we have to prove it, KikuPukk Härenstam
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What can we prove and do we have to prove it, KikuPukk Härenstam

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What can we prove and do we have to prove it? Experiences from Swedish Patient safety research and practice
KikuPukk Härenstam M.D. PhDM.PhD

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What can we prove and do we have to prove it, KikuPukk Härenstam

  1. 1. Crew Resource Management What can we prove and do we have to prove it? Experiences from Swedish Patient safety research and practice• Utbildning i Kiku Pukk Härenstam M.D. PhD Säkert teamarbete• Utveckla och implementera säkerhetsverktyg i det dagliga patientarbetet
  2. 2. Who am I..• M.D Resident in pediatrics at Astrid Lindgrens childrens Hospital Karolinska University Hospital Stockholm• Researcher at Medical Management Centrum, LIME-PhD in april 2007 in patient safety• Patient safety and quality officer at Astrid Lindgrens Childrens Hospital Stockholm
  3. 3. Quality and safety improvement Identify Follow up Analyse CategoriseLearn and improve Feedback
  4. 4. Articles in my thesis
  5. 5. Working in the dark• Many hospital boards and most clinical teams have little or no ongoing safety information• They therefore cannot review performance• They therefore cannot target change• If they make changes they cannot know whether they have been effective• Repeat for all other levels of the organisation Charles Vincent
  6. 6. Quality and safety strategies –exemples of on going activities Department leaders, Division leaders Quality controllersSteering committee and improvement groups Adherence to practice guidelines Quality walks Quality council Identify Risk assessments Safety information Research GTT-chartreview database Patientsafety dialogues DRG Adverse events Follow up Simulations Safety culture measurements Observations Point prevalence measurements Quality registers Staff surveys Patient surveys Process and production data Analyse categorise Learn and Implementation of new workpractice RCA teams Unit for quality and safety improve Patientflow CRM Quality council Decision support for medication order entry CRM group Hospital acquired infections Medication group Hygiene PedCAMST Clinical and nursing guidelines KP Simstraining SVU Development of IT support Improvement boards Quality and safety yearly summaries Monthly and weekly reports Feedback Results from improvement projects
  7. 7. Platform for research in patient safety Participatory research design The project is a collaboration Aim: between researchers at Medical To use sources of safety information Management Centre, Karolinska in healthcare to create and evaluate Institutet and researchers and interventions aiming at practitioners at Danderyds hospital improving patient safety and Astrid Lindgrens Childrens hospital, Karolinska University To create possibilities for Hospitallearning across projects and to develop competencies in research methods Kiku Pukk Härenstam Italo Masiello Johan Thor Drew Gaffney Magna Andreen Sachs Maria Unbeck Eva Wesslén Eriksson Mats Hedsköld Karolina Peltomaa
  8. 8. Research topics• Assessment of safety • Patient safety information culture Mats Hedsköld systems• Study of adverse events in • Evaluation of the Orthopeadic care Maria Unbeck implementation of CRM at• Effects of teamtraining on the Astrid Lindgrens neonatal resuscitacion childrens hospital• Eva Wesslén Eriksson• Study of situational awareness and teamwork in anestesia teams Karoliina Peltomaa
  9. 9. Temporal trends in rates of patient harm: | North Carolina United States Landrigan et al, NEJM 2011
  10. 10. Communication in healthcare • “A lack of an organised process of handing over information or recording information. People record information in different places, theres nursing notes, theres surgical notes and actually everybody’s got their own, their own piece of territory but it’s not all tied together. ” • “What we’ve got is an organic system which has grown and developed over the years which includes multiple parallel hierarchies and people working independently” Nagpal, 2009
  11. 11. Reliability of ward care• (1) How well do you understand the goals of care for this patient today?• (2) How well do you understand what work needs to be accomplished to get this patient to the next level of care?• Less than 10% of nurses or doctors could answer these questions Pronovost et al, 2003
  12. 12. Implementing evidence based work practice with support of a checklist
  13. 13. Decreasing catheter related bloodstream infections• Hand washing • Median rate of infection per• Full barrier precautions during 1000 catheter days decreased the insertion of central venous from 2.7 at baseline to 0 at 3 catheters months• Cleaning the skin with • Mean rate at baseline chlorhexidine decreased from 7.7 to 1.4 at• Avoiding the femoral site if 16-18 months follow up possible• Removing unnecessary catheters
  14. 14. Making it happen in practice• Specific strategies – Education about infection control strategies – Central line cart with necessary supplies – Checklist/care bundle to ensure adherence – Staff were stopped (in non-emergency situations) if practices not happening – Removal of catheters discussed at daily rounds – Regular feedback and discussion of data• Chief Executive backing• Within strategy for safety
  15. 15. Effects of structured patient handover Monitor Ventilator ODA Consultant Power Anaesthetist Anaesthetic Registrar Pump CCC Reg Drain / Nurse Pump s Nurse Nurse Urine Surgeon Multiple specialists Complex tasks Complex interfaces Time pressure Need for accuracy Catchpole et al, 2007
  16. 16. Crew Resource Management – CRMAims at creating a safetyculture through:  Training staff in communication and teamwork  Hardwired tools: Implement new work practice based on CRM principles and best practice
  17. 17. What is Crew Resource Management Designed to Produce?• Crew members who consistently – Form cohesive teams – Maintain situational awareness – Communicate effectively – Speak up when necessary – Employ all resources – Make quality decisions – Constantly learn from and teach others via standardized performance feedback under stressful conditions in a time constrained environment
  18. 18. CRM saves lives “Association Between Implementation of a Medical Team Training Program and Surgical Mortality."Julia Neily; Peter D. Mills; Yinong Young-Xu; Brian T. Carney; Priscilla West; David H. Berger; Lisa M. Mazzia; Douglas E. Paull; James P. Bagian. JAMA Vol 304, No 15, pp 1693-1700, published online 20 October 2010
  19. 19. One Hospital Several Sites Full Range of Care Solna Huddinge21
  20. 20. Teamtraining at the emergency room Pediatric simulation center Established in 2006 40 instructors from different professions and parts of the hospitalSimulations- och TräningsCentrum Barn
  21. 21.  Doctors involved Teamworkcompetency is considered part of being a professional CRM supported by other teamtraining strategies Implementation is conducted according to evidence and experience in change management CRM implementation is systematic CRM part of the patient safety strategy CRM evaluated on multiple levels Patienten part of the team Teamtraining is recurrent
  22. 22. Complex interventions at many levels in the system- Safer Patients Initiative Goal: To reduce adverse events by 50% in 24 hospitals Expert support Programme model SPI programme elements 1 QI methodology  SPI programme elements 3 Iterative development of local innovations Breakthrough Series Model Incremental spread Safer Patients Initiative 10 8 Participating hospital site Change elements  SPI programme elements 2 Process measurement  SPI programme elements 4 80 metrics Annotated Run (34 standard) Charts Collaborative learning AA Process analysis AA BB Point of initial intervention Point of initial intervention BB Improvement = shifting the level of the Improvement = shifting the level of the process in the desirable direction (A) or AA BB process in the desirable direction (A) or reducing variation (B) reducing variation (B) 11 9
  23. 23. Results take time... The observations in this case suggest apossible generalisation: that there is an initial phase in which the healthcare system needs to build a quality infrastructure. After thisphase some process improvements may start to show. If these are sustained, outcomeimprovements will start to show. Jonkoping is in the situation where they do in one department but they are still ‘in the pipeline ‘ for others Ovretveit & Staines, 2007
  24. 24. Thank You!
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