Aspects of CRMMaking a welcoming environment, so that others feel they can speak upCRM is not about being perfect. It’s about identifying and mitigating the times of increased risk of making mistakes and identifying why a particular mistake was made.The perceived tension between performance and “soft skills” (CRM)Some people view these non-technical skills as costing time and money and not contributing to patient safety or as detracting from efficiency. The reality is that good CRM skills make teams more efficient. Additionally, we are no longer in a stage in medicine where we can say that leadership or non-technical skills don’t matter. We have plenty of evidence that failures of leadership have directly resulted in bad outcomes (morbidity and mortality).Additionally, CRM skills improve the working environment for all, which leads to the preservation of healthcare workers and mitigates burnout.The origins of CRMCRM developed in aviation because of a data-driven approach where successive accident investigations determined that the majority of aviation accidents were caused by human error (team performance) rather than mechanical failure, as had happened in the past.In medicine, we can safely assume the same trend, but as a profession that purports to follow the evidence, we should investigate and build a dataset on which to make these kinds of decisions. This could look like the aviation-style medicine incident investigation systems that exist in the UK and Norway and could use systems like audio and video recording of operating rooms, ICUs, and resuscitation bays. It would also likely require a change to legislation to protect that data from being used in litigation, as currently exists for aviation black boxes.The evolution of CRM in aviationfrom elective courses to mandatory SOPs to the point where even if a pilot completed the tasks technically correct, but exhibited poor CRM skills, they would fail their flight test.“Anticipation builds vigilance; vigilance aids recognition; recognition leads to recovery.”CRM & Error ManagementIn aviation, CRM treats errors as inevitable events to be managed, not moral failures.Error prevention: reduces the chance of making an error in the first place. Usually through human factors engineering and improving working conditions. The focus is here, which involves planning, discipline, and preparation. (e.g. aircraft design, fatigue risk management, rules around how much additional fuel must be onboard, use of checklists to avoid memory errors).Error trapping: catching the error before there is any effect. This is often about vigilance and teamwork. (e.g. crosschecking, callouts, assertiveness to encourage speaking up)Error mitigation: to limit the severity of outcomes. This is about resilience and recovery. (e.g. unstable approach leads to missed approach. Short on fuel > divert to alternate.)Error chains: a single error rarely, if ever, causes a major accident. It is untrapped, unmitigated error chains that result in accidents.In clinical medicine we see this often: errors are inevitable (ask any clinician), harm is not.Medical examples of error management:Error prevention: pre-printed order sets, standardize drug trays, avoiding look-alike drugs.Error trapping: Surgical “time-out” checklists before skin incision, closed-loop communication during resuscitation.Error mitigation: iatrogenic opioid overdose that was recognized and naloxone is given.Acceptable delays to ensure appropriate margins of safetyThere are occasions in medicine and aviation where one group of professionals needs to push back on the production pressure to perform tasks appropriately in order to ensure safety. Both professions must understand that certain delays are required, however, the degree to which this happens is not consistent around the world. Mike gave the example of arriving early to train a new pilot and occasionally needing to close the cockpit door after saying the flight crew needed ten minutes. Amir and Adam gave anesthesia examples where they had to delay the OR in order to prevent or trap errors (additional airway equipment, provide preoperative medications). CRM is alive and well in medicine, but we must meeting people where they are atIn this episode, there were many examples where medical teams are performing good CRM, particularly Threat and Error Management through the use of briefings. Mike mentioned the public health example of meeting people where they are. We should acknowledge that a lot of CRM strategies and skills exist in modern medicine, but much of it is not formalized.CRM as an inclusive tool to improve team performanceCRM by its nature of improving team performance has its foundation on clear communication from all team members. While it used to be called Cockpit Resource Management, it changed to become Crew Resource Management to emphasize the inclusion of flight attendants, ground personnel, air traffic controllers, etc. Many errors have been prevented or trapped by ancillary personnel speaking up.Escalation of Language of ConcernIn order to encourage everyone to speak up, formalized escalation of language models exist. In aviation this is the PACE model:Probing: “I’ve never seen [x] done before. Can you tell me why you’re doing it this way?”Alert: “The oxygen saturation is 90%.”Challenge: “The oxygen saturation is critically low, we need to move to BiPAP.”Emergency: “This is an emergency. Dr. [x] will perform a cricothyroidotomy.”In an emergency, you can start ‘higher up’ on the PACE ladder, as appropriate, but starting lower is less aggressive and can prevent conflict.Instrumentation to avoid fixation-induced loss of situational awareness Cockpit instrumentation is being redesign to account for the fact that hearing is one of the first things to go in a high cognitive load. Rather than just the aural announcements of “terrain, terrain”, the words are being displayed in red letter on the displays in front of the pilots.Cognitive load in training: much of what we can process related to cognitive load. As novice become experts, they can deal with greater and greater cognitive loads before becoming task saturated. This is well-recognized in pilot training.Line Oriented Safety Audits (LOSA) Trained observers in the cockpit observe and report on real-world operations. In this way, an accurate analysis of company-specific operations can occur. These observe comment on both salutary solutions and errors which can then be fed-back to trainers and risk management.Theoretically, there is no reason such a system could not exist in medicine. In such a system, trained people would observe physicians and provide information solely for the purpose of improving safety, rather than any punitive action.Use people’s first names as opposed to their title, when it is critical to get their attention.Who can do what tomorrow Policy / government / regulator: Canada could have an aviation-style investigation board for medical incidents, as the UK and Norway currently have. This would be a non-punitive investigation conducted by a knowledgeable independent board to determine the causes and contributing factors of specific medical incidents. The report would be anonymized and publicly available and would include recommendations for practitioners, training institutions, medical device manufacturers, and regulators.Hospitals / heads of department: We saw in aviation how CRM was a data-driven response in the 1970’s and onward to team performance becoming the predominant reason for aviation accidents. We don’t have the same quality of evidence in medicine, however, we need not wait for the government or regulator to mandate the technology that would lead to this data becoming available. The technology exists for audio and video recording (“black boxes”) of the OR, ICU, and resuscitation bays of emergency departments. Individual hospitals or departments could run a pilot program (ensuring that such information is prevented from being used in litigation by invoking current quality of care investigation legislation). Much like Tommy Douglas’s creation of publicly-funded healthcare in Saskatchewan, which was later expended to cover all of Canada, any hospital that begins such an endeavour may be credited with pushing the entire profession in this direction.Residency program directors: while modules on human factors are a good start, we can look to the evolution of CRM in aviation and see that formalized CRM training with high-fidelity simulation is the gold standard. For those that are already doing this, Mike’s comments about the field of aviation ideally incorporating CRM into earlier stages of pilot training can be instructive for the medical field.Other Resources: United Flight 232 - Captain Al Haynes (YouTube) Next episode: Escalating Language of Concern with Dr. Katie Lin
