Overcoming Barriers and Objections of a CRM- based Project, Part II

This month we will continue to focus on objections raised during implementation of an aviation-based project. In the first article of our two-part series, we examined various kinds of typical objections raised throughout the course of a CRM-based project by “slow adopters”, and an effective response for each one. Here are a few more objections to watch out for during CRM implementation, and some helpful responses on how to handle them when they come your way:

CRM’s OK, but not in an emergency.

Physicians tend to accept many of the CRM-based changes in normal circumstances, but believe there’s no time for CRM in emergencies. Experience with aviation and other high-risk environments shows clearly that errors are most likely to occur in emergencies when departing from standardized, well- trained procedures. CRM is more important in unusual situations where adrenalin is flowing and error rates are always increased. This is best addressed by having well-trained physicians and staff use CRM in such settings and achieving higher adherence to accepted protocols (e.g. ACLS, ATLS guidelines, etc.).

I just don’t buy CRM, and I’m not going to do it.

This is not a common response, but it is inevitable. It’s happening right now with implementation of The Joint Commission required “time out” (a classic CRM intervention) and the read back of verbal orders, etc. Discussion of specific objections to CRM is sometimes helpful. Frequently, CRM is “rolled out” pod by pod, unit by unit. People who refuse to participate in CRM can buy some time by ignoring the requirements or hoping no one is watching. But the institution has to decide, in advance, whether it’s willing to accept refusal to participate. The “non- adopter” may be a major admitting physician, a senior charge nurse, etc. Is the institution ultimately ready to say the following? “Patient safety and CRM are not optional. We’ve listened to your concerns and have addressed as many as possible. At this point, we acknowledge your concerns and issues, but CRM is important to patient safety and the operation of this unit, and it is required.” Hand washing, wearing a surgical mask that covers both nose and mouth, and doing the Joint Commission time out were all debated and opposed initially, and all have become the standard of care.

I’ve been doing the “Debrief” and nothing happens. It’s a waste of time!

It’s better not to debrief at all than to fail to address the issues identified in a debrief. If a drug is missing from the “crash cart” and is so identified, the code participants can reasonably expect that the drug will be there the next time. It should be likewise for a missing surgical instrument, a person missing from the preshift briefing, etc. A debrief that leads to improvement is enormously powerful. One that does not have a huge negative impact. Be prepared to respond and act on suggestions before soliciting them.

OK, so I’ve been doing this CRM and I can’t tell any difference.

Careful attention to outcomes measurements and feedback to the staff are crucial. CRM is about teamwork. The institution must provide the team members feedback about compliance and outcomes where compliance has been achieved. All members of the team, but especially leaders, must know the data well enough to quote them verbally when challenged. Instances or near misses and other “saves” related to CRM implementation should be widely disseminated whenever they occur. Preventing a wrong surgery or fixing a potentially serious medical problem before it occurs can be a powerful motivator for continuing a CRM program.

Reduction in Wrong Surgeries: Achieving an Error Rate 10 Times Better than the National Average

In a hospital in the Mid-south, LifeWings worked with the Chief Medical Officer, the Chair of the Department of Surgery, and the Dean of Clinical Affairs. Their goal was to eliminate wrong surgeries by improving communication in the operating room. Both physicians and physician leadership were evaluated by the hospital based on the number of cases. There was tremendous pressure to increase throughput. The increased pace led to increased errors and a rise in claims, caused by a series of serious wrong surgery incidents (approximately one every 60 days).

The leadership wanted a way to retain their hard-won efficiencies, but reduce their medical error rates that were directly draining dollars off the bottom line. LifeWings created specific tools to allow for team building, a defined communication protocol between physicians and staff based on the aviation model, and Hardwired Safety Tools that incorporated the Joint Commission Time-out briefing.

The training and Hardwired Safety Tools were successful. To date, the hospital, with our help, achieved an error rate of 0.15 per 10,000 procedures; a rate over 10 times better than the national average. We believe this reflects the results of an improved level of coordination and communication among the staff. The improved communication in the operating room and increased efficiencies reduced the amount of profit needed to pay claims and created a better place to practice medicine for the physicians.

10 Critical Steps to Maximize Quality of Care and Teamwork Training

Demonstrate total commitment to the program. Be clear it’s not a “box-filler,” but something that will make a difference. Commitment to the training must come from the “top down.” This training will make a difference.

Explain the program before startup. Eliminate misconceptions, define the scope, and be clear about what the project does and doesn’t do. Clarify what teamwork training will do for you and what it won’t do.

Determine training needs before startup. What skills are needed? Where should you focus your efforts? Develop a baseline with which to compare results. You can develop the baseline from a pre- survey and mishap reports.

Customize the training to fit the unit. Be sure the training fits the operations and missions in the unit. It’s crucial that the training fit the mission of the unit so everyone can understand the relevance of the project.

Provide training which engages participants and provides feedback. Avoid “I talk- you listen;” Offer training which provides participants the opportunity to “do.” Your role should be that of a facilitator rather than a lecturer. Your staff wants the opportunity to “interact and do” rather than be talked to.

Make sure to check out the next issue of The Pulse that will be coming out this May to read the last 5 things to maximize quality of care and teamwork training in your facility.

Communication Practices of Physicians With High Patient-Satisfaction Ratings

By Karen Tallman, PhD; Tom Janisse, MD; Richard M Frankel, PhD; Sue Hee Sung, MPH; Edward Krupat, PhD; John T Hsu, MD, MBA, MSCE

Introduction

How do primary care physicians with outstanding patient-satisfaction ratings communicate with their patients? Which specific practices distinguish them from less effective communicators on the basis of measured performance? To answer this question, we videotaped 92 adult primary care visits in Southern California and Hawaii and interviewed both physicians and patients separately. Each participating physician and patient viewed the tapes of the visit and shared their perceptions of the communication aspects of the visit. We also audiotaped these debriefing sessions. To identify successful physician communication practices, exam room visit behaviors and comments from the postvisit debriefs were coded and compared with each physician's panel-level patient satisfaction. In the final section, we describe communication strategies reported by physicians with high patient- satisfaction ratings.

Below are a few resources that may provide some helpful pointers on how to develop a safer organization and promote cultural change throughout your facility:

Mount Carmel Health System (MCHS), Columbus, OH

MCHS has recently contracted with LifeWings to work in the Operating Rooms of their system. The scheduling process will begin soon.

The University of California Health System (UCHS)

LifeWings was recently selected by UCHS to implement our patient safety system in five of their hospitals. The comprehensive project will kick off May 1st with a Leadership Development Institute. LifeWings will be working in Surgical Services of the following UCHS hospitals:

• The University of California Medical Center—San Diego, CA
• The University of California, Irvine—Orange, CA
• The University of California, Davis—Sacramento, CA
• The University of California, San Francisco—San Francisco, CA
• The University of California, Los Angeles—Los Angeles, CA

Vanderbilt University Medical Center (VUMC), Nashville, TN

VUMC continues to spread Crew Resource Management throughout the departments of their hospital. They have developed the internal capacity to conduct LifeWings’ patient safety system on their own, and will continue to conduct training until all staff have completed the program.

Nebraska Medical Center (NMC), Omaha, NE

NMC continues to conduct LifeWings program in- house throughout their facility. They are currently working on completing training in the Orthopedic and Cardiac Surgery areas.

University of Texas Medical Branch (UTMB), Galveston, TX

UTMB has successfully completed a perioperative initiative that was created over a year ago. To date, they are working on completing a project in Women and Infant Services. A Hardwired Safety Tools workshop took place at the end of February and both infant and adult tools have been developed with the help of LifeWings.

BayCare Health System, Inc (BCHS), Clearwater, FL

LifeWings is currently conducting BCHS team skills training. The 4-hour course will be taught for Labor & Delivery departments for Morton Plant Mease Hospital and Mease Countryside Hospital.

Community Health Partners (CHP), Lorain, OH

A Hardwired Safety Tools Implementation Day for their OB department took place at the end of February. Their Observation, Coaching, and Feedback visit took place at the beginning of March in the OB as well.

Holy Cross Hospital (HCH), Taos, NM

Holy Cross has a 3-day Observation, Coaching, and Feedback visit scheduled for the end of March (for Surgery, ICU and ED areas).

Middle Tennessee Medical Center (MTMC), Murfreesboro, TN

LifeWings conducted part of the first phase of MTMC’s project, the Leadership Development Institute, which took place mid-March. They will be finished the LDI at the beginning of April.

Provena United Samaritans Medical Center (PUSMC), Danville, IL

PUSMC recently had LifeWings visit for a one day assessment for Labor & Delivery. They've also completed 4-hour skills – based training at the beginning of March. Their 3-day safety tools visit is scheduled to take place at the end of March.

Provena St. Mary’s Hospital, (PSMH), Kankakee, IL

Members of the LifeWings team have recently visited PSMH for a MD-to-MD presentation for their Labor & Delivery department.

University of Missouri Health Care (UMHC) Columbia, MO

UMHC completed a 3-day series of 8-hour course training and consulting at the end of February and beginning of March. Their next set of training is scheduled to take place in June.

Vassar Brothers Medical Center (VBMC), Poughkeepsie, NY

The next phase of VBMC’s project is the Observation, Coaching, and Feedback visit for their Labor & Delivery department and ED. That visit is scheduled for April.

Physicians Reciprocal Insurers (PRI)

PRI is completed a Train-the-Trainer program for eight PRI facilitators. They will also present a joint LifeWings / PRI program for all their insured.

If you would like a reference for any of our clients listed above, please contact K.C. DeBra at kdebra@SaferPatients.com or (901) 844-9226.

I’m a believer: A LifeWings Story

LifeWings was initiated at our Medical Center in September of 2005, starting first with training for Surgical Services medical staff and employees. In 2006 training extended to the Emergency Department and Labor and Delivery. The culture of safety resulting from LifeWings training is spreading and in ways not totally expected.

Not too long ago, one of the members of our medical staff was scheduled to have a very minor procedure in our “local room”. This member of the medical staff was the Chief of his department, not a surgeon, and known for his acerbic wit and skeptical approach to anything that he did not believe or felt was more fluff than substance. He was of this pinion regarding the LifeWings program. Upon entering the procedure room he was greeted by his surgeon and the staff, many of whom he had known for some time. The mood in the room was light and as you may expect, when all are familiar with each other, good natured banter and joking was going on as the staff prepared the room for the procedure. As the time to begin approached, the circulating nurse demanded everyone’s attention by announcing the beginning of the Pre-procedure Brief. The physician patient, having the procedure done, attempted to make a joke about the process making analogies to aviation faux pas such as delayed flights and missing luggage. Not one person reacted to his chiding and continued the brief. The RN introduced, the surgeon identified, all was confirmed and the safety statement read, all without interruption. At that moment the physician patient had an epiphany. He remembers thinking, “These people really mean this and they are serious about it!” He tells how he felt totally assured that all in the room where committed to his care and safety, even for a minor local procedure.

He became a believer! His “on the road to Damascus” experience has created an internal apostle for the LifeWings' process. He has seen it and believes in it. He has implemented the concepts of the Pre-procedure Brief on the units he manages, and advocates the training for the entire institution. His words, “Why anyone would not want to do this has to be crazy! It makes sense and it’s the right thing to do.”

Cultural change can only occur when those in the culture believe in it and live it every day. Such is the case with LifeWings at our institution and as this story shows, the message is spreading!

“Creating a culture of safety requires attention not only to the design of our task and process, but to conditions under which we work – hours, schedules and workloads; how we interact with one another; and, perhaps most importantly, how we train every member of the healthcare team to participate in the quest for safer patient care.”

~Lucian L. Leape BMJ, 2000

March Madness!

A special offer from LifeWings:

Find out the top four reasons why patient safety and quality issues should be a concern of every healthcare provider and manger, plus steps you can follow to help your organization improve the safety and quality of care it provides.

To receive this free report contact K.C. DeBra at (901) 844-9226 or email her at kdebra@SaferPatients.com, and she will be glad to send you a copy.