Sanja Ivanković, MSc.

Health manager
UCHC “Dr Dragiša Mišović – Dedinje”
Vice President of UINARS
 Working with critically ill patients
 stress, high risk, and
high complex activities. Stress
 24 /7: varies widely in Lack of
Complex
medical
staff
age, clinical acuity, activities

emotional state, and Medical

error

physical and medical

needs.
Patient needs
____________
 Pressure of medical staff= Lack of staff
CRM
 The emergency department environment
is similar in many ways to other high-risk
industries, such as aviation and nuclear
power
 building safety platform for all participants
in critical care, special courses and
training that focuses on communication
and human behavior are designed
management (CRM).
CRM
CRM (Crew resource management,
cockpit resource management)
is a systematic approach for training
teams in interpersonal communication,
leadership, and decision-making
practices that allow teams to function
effectively under even the most
demanding, unpredictable situations.
CRM
 Edward J. Dunn, Peter D. Mills,Julia Neily,Michael D.
Crittenden,Amy L. Carmack,James P. Bagian. Medical Team
Training: Applying Crew Resource Management in the
Veterans Health Administration. The Joint Commission
Journal on Quality and Patient Safety. 2007; 33 (6): 317-325.

COMMUNICATION FAILURE
ARE
A LEADING SOURCE OF
ADVERSE EVENTS
How does CRM relate to health care?
Can clinicians relate to airplane cabin
crew?
 How does CRM relate to health care?
Can clinicians relate to airplane cabin
crew?
Focus on:
safety, efficiency, and morale of humans working together
Implementing CRM
 Crew resource management is one of the
most popular adaptations of the shared
mental model of team training.
 Mental models are knowledge and
mechanisms that can be leveraged to
describe, explain, and predict events.
Effective teams typically use a shared
mental model to achieve a mutually agreed
upon goal in the safest possible manner.

Eswar Sunda, Sugantha Sundar, John Pawlowsk, Richard Blum,David Feinstein,

Stephen Pratt. Crew Resource Management and Team Training. Anesthesiology
Clinics. 2007; 25: 283-300.
CRM trainings of teamwork
 Effective teamwork training uses several
key techniques and methods that can be
used to actively engage all members of the
healthcare team.
 These include briefings, checklists, and
communication techniques that can foster
an environment of mutual respect.

Stephen M. Powell, Susan M. Hohenhaus. Multidisciplinary Team

Training and the Art of Communication. Clinical Pediatric Emergency
Medicine. 2006; 238-240. doi:10.1016/j.cpem.2006.08.007.
Checklists
 standardization of processes, the use of
best practices, and the use of checklists.

WHO, Patient safety.

http://www.who.int/patientsafety/implementation/checklists/childbirth/en/
 Briefings
 In healthcare, teams of clinicians should plan for
a procedure by using a briefing that reviews the
tasks of each team member and provides an
opportunity to discuss contingency plans should
an unexpected circumstance arise. Hospitals
that have adopted these pre-procedure briefings
have reduced the incidence of wrong-site
surgeries and wrong person surgeries.

Stephen M. Powell, Susan M. Hohenhaus. Multidisciplinary Team Training and

the Art of Communication. Clinical Pediatric Emergency Medicine. 2006; 238-
240. doi:10.1016/j.cpem.2006.08.007.
Universal protocol to prevent errors due to wrong site, wrong procedure, or
wrong person surgery. Central DuPage Hospital. cited: 24 May 2006. Available
from: http://www.cdh.org/AboutUs.aspx?id=9307 .
Communication: Fostering an
Environment of Mutual Respect

 When the physician, as team leader,

sets a tone of mutual respect and
psychological safety by calling each
member of the team by name and
inviting their input, staff satisfaction
improves, staff turnover decreases, and
team members report a safer
environment for patients.
Conflict resolution
 Conflict resolution is employed when the actions of
other members of the team are questioned following
the perception that safety concerns are not being
addressed. The two-challenge rule is an effective
nonconfrontational way of asserting a team
member's concern.

 The gist of this rule is that if a pilot puts the aircraft in

an unsafe condition, the subordinate must challenge
the action twice if necessary. If no answers or if
nonsensical answers are provided, the subordinate
is empowered to take over the controls. In medicine,
when there is a conflict among team members, such
conflicts must be resolved with the best interests of
the patient in mind.
Sunda, Sugantha Sundar, John Pawlowsk, Richard Blum,David Feinstein, Stephen
Pratt. Crew Resource Management and Team Training. Anesthesiology Clinics. 2007;
25: 283-300.
 Speak up!
 These technics are not easy to use.

 CRM helps to create an environment

whereby practitioners can speak up,
irrespective of culture, nationality, or
the presence of more senior or
experienced colleagues

Crisis Resource Management in emergency medical settings in Qatar

Dr Padarath Gangaram, Professor Guillaume Alinier, Aldo Mendoza
Menacho https://doi.org/10.12968/ippr.2017.7.2.18
CRM in critical care
 Literature review: about 30 publications about
CRM practice in healthcare in the past 10
years
 Most authors agree that CRM principles are
effective in building of highly-trusted
organizations and medical teams.
 Therefore, the philosophy of teamwork training
found application in the field of critical care -
operating rooms, intensive care, emergency
services, but also in obstetrics. In such
environments, crew resource management
becomes Crisis Resource Management
CRM outcomes

EFFECTS ON PATIENTS
EFFECTS ON STAFF

CULTURE
TRANSFORMATION
CRM outcomes-effects on staff
 Taiwanese authors (2015): perceptions of patient safety
in the emergency and critical care departments.
 93.4% were satisfied,
 93.1% agreed that it enhanced patient safety and care
quality,
 85.7% agreed that it increased their confidence,
 86.4% agreed that it reduced practice errors
 90.8% agreed that it would change their behaviors.
Examining the effects of an interprofessional crew resource management training intervention on
perceptions of patient safety
Wan-Ting Wu, Yung-Lung Wu, Shaw-Min Hou, Chun-Mei Kang, Chi-Hung Huang, Yu-Ju Huang, show
all, Pages 536-538 | Received 31 Mar 2015, Accepted 19 Apr 2016, Published online: 22 Jun 2016
• https://doi.org/10.1080/13561820.2016.1181612
CRM outcomes-effects on staff
 Meta-analysis (1985-2013) : effectiveness of CRM
training in acute care domain
 Trained participants responded positively to CRM (mean
score 4.25 out of a maximum of 5),
 Large effects on participants' knowledge (d=1.05),
 Small effect on attitudes (d=0.22) and
 Large effect on behaviors (d=1.25).
 There was insufficient evidence to support an effect on
clinical care outcomes or long-term impacts .

A meta-analysis of the effectiveness of crew resource management training in acute care domains
Angela O'Dea, Paul O'Connor, Ivan Keogh, http://dx.doi.org/10.1136/postgradmedj-2014-132800
 CRM outcomes-effects on patients

 A prospective 3-year cohort study (2014): examined

the impact of a CRM implementation in a 32-bed ICU,
admitting 2500–3000 patients yearly
 A significant decrease in complication incidence rate was
observed: from 67.1/1000 patients in the baseline year to
50.9/1000 patients in the post-implementation year.
 The standardized mortality ratio was 0.72 in the baseline
year and 0.60 in the post-implementation year.
 No clinically relevant effects on ICU or hospital length of
stay were observed.
Haerkens MHTM, Kox M, Lemson J, Houterman S, van der Hoeven JG,
Pickkers P. Crew Resource Management in the Intensive Care Unit: a
prospective 3‐year cohort study. Acta Anaesthesiologica Scandinavica 2015
 CRM outcomes-culture transformation

 Group of authors (2016): cultural transformation is

possible, even in large, multihospital AMCs.
 Continual leadership engagement and endorsement is
needed.
 Systematic study of the effectiveness of the intervention
to not only calculate the potential return on investment
but also to continuously feedback potential improvement
opportunities to the frontline teams who are invested in
providing the best care possible for patients in every
environment.

Cultural Transformation After Implementation of Crew Resource Management: Is It Really

Possible? Jennifer L. Hefner, PhD, MPH, Brian Hilligoss, MSIS, PhD, Amy Knupp, MSN, RN, CNS,
CPPS, Judy Bournique, BS, MT (ASCP), John Sullivan, BA, Eric Adkins, MD, and Susan D. Moffatt-
Bruce, MD, PhD American Journal of Medical Quality Vol 32, Issue 4, pp. 384 – 390 First Published July
If you can imagine a flight setting in
the critical care environment, where
would you put black box?
Black box
 Many deaths each year result from medical errors,
most of which occur in the perioperative setting.
 Estimates suggest that potentially avoidable
complications occur in up to 40% of surgical
admissions.
 The ability to record and review events in the OR,
similar to aviation's use of a black-box recorder, can be
useful for studying team behavior, the effectiveness of
various interventions, or the usability of newly acquired
equipment, all leading to insights into human
performance in this high-risk setting

Assessing Team Performance in the Operating Room:

Development and Use of a “Black-Box” Recorder and Other Tools for the
Intraoperative Environment Stephanie Guerlain, PhD, Reid B Adams, MD,
FACS, F Beth Turrentine, PhD, Thomas Shin, BS,Hui Guo, MS, Stephen R
Black box
Conclusion
 The crew resource management changed the
perspective of teamwork in healthcare. First of all,
the aspect that the tendency towards teamwork is
not an inherent individual characteristic, but that the
teamwork can be learned, practiced and
continuously improved.
 The analysis of the teamwork significance has
proven that many mistakes could be avoided if there
was no omission in communication. Teamwork skills
certainly cannot replace clinical skills but can
improve their quality and increase patient safety.
 Measurement of teamwork using applied and
described instruments could be a good path for
organizational culture improvement in dealing with
critical and emergency care in Serbia.