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• W2469905238 abstract "FigureCrew resource management (CRM)—the aviation safety program that promotes team training—was initially adopted by hospitals to improve patient safety and overcome the nontechnical obstacles of ineffective communication after the Institute of Medicine's seminal report To Err is Human recommended team training as an effective method to develop safe care delivery practices.1 In subsequent years, there was a progressive increase in publications that studied the impact of team training; the number of articles increased fivefold from 2000 to 2013.2 Although studies varied by clinical location and implementation process timeline, all provided education and training for healthcare providers. The length of training, outcome measurements, and timing of posttraining follow-up varied. Posttraining interventions varied from 5 months to 1 year. Long-term behavioral changes beyond 1 year weren't measured. Multiple authors speculated that reviewing didactic content from CRM training and providing guidance to team members helped maintain a culture of safety in the workplace.3-5 However, despite the increase in publications, there was a notable lack of information related to sustaining practices beyond 1 year. In 2008, CRM team training was initiated at Rush University Medical Center, an urban, 600-bed university hospital. Over 4,000 employees and physicians attended CRM sessions from 2008 to 2012. Hardwired safety tools (HSTs), including clinical checklists and standardized communication processes for handoffs, timeouts, and pager notification, were developed and implemented. Although there were initial improvements in Agency for Healthcare Research and Quality (AHRQ) safety culture survey scores, 5 years postimplementation the scores associated with willingness to communicate fell below the 50th percentile benchmark. HSTs were inconsistently used and a plan for ongoing support wasn't developed. Managers and staff reported difficulties in reinforcing CRM skills and tools without structured follow-up support. In 2015, the crew follow-up support program was created in response to the request for a CRM refresher. The program's focus was to provide support for all healthcare team members to engage in respectful communication, use HSTs, and consistently address safety concerns. The short-term goal was to create unit-based support for CRM skills and tools; the long-term goal is to enhance clinical care quality and decrease the frequency of clinical errors. The mother-baby (MBU) and labor and delivery (L&D) units volunteered as pilot units. The obstetrical service has over 2,100 deliveries per year. The two units were the first to attend the CRM training sessions in 2008. Implementation activities Unit safety champions. A CRM facilitator collaborates with unit leadership to select a crew champion (CC). The primary responsibilities of the CC are to build peer support by providing feedback and encouragement to team members. The CC is also a member of the unit's quality improvement committee. The selection of the unit CCs was a smooth process. Several staff members were already engaged in process improvement projects and interested in honing their CRM skills to support staff. CRM refresher sessions. This session is a brief review of CRM core communication and team-building skills. Each session is 30 minutes long. The format is 15 minutes of content, followed by a 15-minute question-and-answer session. The rationale for minimizing the didactic portion is to energize attendees by providing the time for active discussions that help clarify how to apply concepts to everyday practice.6 The goal is to have 75% or more of the team members attend a session over a 1-month period. The CRM refresher sessions had an 83% participation rate. It became apparent early on that the physicians were experiencing difficulties in attending one of the scheduled sessions. Collaborating with the director of the residency program and the obstetrics chairperson, we agreed to present the session during a regularly scheduled medical education meeting. The meetings were mandatory for the medical residents; several attending physicians also participated and nursing staff members were invited. Evaluations were positive, with 85% agreement that the sessions provided a better understanding of CRM skills and tools. The same percent also agreed that the group discussion was helpful in identifying barriers to communication and solutions to overcome them. Participants responded as to how they would use the information from the sessions to improve patient safety. There were 74 comments that fell into two main categories: 1) use tools, such as debriefs, huddles, and standardized communication formats; and 2) improve communication by listening more and speaking up. Safety culture discussions. The culture checkup tool provides a structure for productive conversations about current safety culture.7 The tool is a template to discuss an AHRQ survey item and develop an action plan to improve the score for that item.8 The AHRQ safety culture survey item “staff feel as if their mistakes are held against them” was selected for the pilot units because only 15.8% strongly disagreed or disagreed with this statement on the October 2014 survey. One of the tenets of CRM training is the inevitability of human error and the need to develop counter measures to trap and mitigate error.9 To improve the system, it's important for healthcare providers to feel comfortable reviewing errors as process improvement rather than assigning blame to an individual. Attendees are asked to talk about what the survey item means to them and what changes need to occur for the score to improve. Staff participation is encouraged by respecting differing opinions and reinforcing that there are no wrong answers. These sessions occur after completion of the CRM refresher. They're 30 minutes long, with five to seven team members per session. The goal is to elicit a minimum of one suggestion for improvement that can positively impact the item being discussed. The results of these structured group discussions are shared with leadership. An action plan is developed based on staff suggestions. The plan is shared with staff members to close the communication loop. The safety culture discussion groups yielded a more in-depth discussion regarding staff members' vulnerability to criticism of their work performance. In response to the question, “what does this statement mean to you,” comments included: “incident reports sometime read like ‘blaming’ a specific person,” “others think less of you when you're involved in an error,” and “it feels like mistakes are all my fault.” Others mentioned self-blame and guilt in addition to being worried that their job was in jeopardy. Many stated that the lack of positive feedback made the negative comments more pronounced. Participants were able to describe an environment in which staff members didn't feel that they were blamed for their mistakes. The use of debriefs, conducting open discussions about all aspects of the incident, and less gossip among team members, combined with support and concern for the individuals involved in the event, were mentioned as important aspects of a positive environment. Responses to the request for actionable ideas to improve unit results were consistent with the responses in the CRM refresher session. The need to consistently use debriefs, huddles, and a standardized paging format for notifying physicians; offering tutorials on how to write incident reports; increasing positive comments about performance; and encouraging more activities to build team spirit were suggested by participants. Responses from both the discussion group and the CRM refresher session were shared with staff members and the medical/nursing leadership team. The leadership team reviewed the action plan suggestions and created a department action plan. (See Table 1.)Table 1:: Departmental action planHSTs. Simultaneous with the CRM refresher sessions, the current unit HSTs are reviewed by the facilitators and unit leadership. Tools are audited over a 2-week period for frequency and accuracy. Staff members provide feedback on the relevancy of HSTs during refresher sessions. Some HSTs may be retired and others edited. The CCs then conduct yearly reviews to assess usage, effectiveness, and potential revisions. HST review revealed that some tools weren't being utilized or were underused. Some tools were retired, whereas others were identified as being important to unit safety. The CCs, along with the nurse educator, worked together to revitalize the obstetrics physician communication, or OBDocComm, HST, which includes standardized RN to physician page messages and agreed upon response times. Outcome measures AHRQ safety culture survey questions. These questions were used as a proxy measure for safety culture. Four questions included on the annual employee engagement survey, administered 6 months before the program, were used to assess program effectiveness: 1) staff members feel as if their mistakes are held against them, 2) staff members will freely speak up if they see something that negatively impacts patient care, 3) things “fall between the cracks” when transferring patients from one unit to another, and 4) shift change is problematic for patients in this hospital. The goal is to achieve a 5% improvement in scores. This may not seem substantial; however, because this measure reflects a change in culture, even a small increase is seen as significant.10 An additional statement “other patient care units would benefit from participating in a crew follow-up support program” was included in the survey administered 3 months after the program ended. All items exceeded a 5% improvement except “shift change is problematic for patients in this hospital.” (See Figure 1.) The lack of improvement in the shift change score may reflect the recent focus on incidental overtime and recently implemented strategies intended to ensure that shift report ended on time. During the 3 months postintervention, staff members were required to document their reason for clocking out past the end of shift. Some staff members reported feeling pressured to rush through end-of-shift report. The item “staff members feel as if their mistakes are held against them” achieved the most impressive increase. In general, the positive survey response aligned with staff feedback on action plan progress.Figure 1:: AHRQ safety culture survey questionsPatient satisfaction. CRM training emphasizes the skills and tools necessary to develop safe and effective communication. Enhanced communication skills for healthcare providers are associated with improving patient satisfaction scores.11 Items from the Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction survey were selected for their relevance to team and communication training. The questions evaluating how staff members worked together as a team, nurses/physicians listening to the patient, and nurses/physicians explaining information to the patient were used to evaluate the impact of enhanced communication on the patient's experience. Targets were developed based on current performance and in relation to the peer group mean score: 1) nurse listened carefully, maintain score of 80%; 2) nurse explained in a way you could understand, increase score to 82%; 3) physician listened carefully, increase score to 83.5%; 4) physician explained in a way you could understand, increase score to 82.3%; and 5) staff worked together to care for you, maintain score of 92%. The preintervention scores were from the 3-month period before implementing the program; the post-intervention scores were obtained 3 months after the program ended. Only the nurses listening score improved. The decrease in the physician and team scores may have been influenced by being concurrent with the start of the first-year residents and new chief residents. Also, a more direct and structured approach, such as developing scripts or providing coaching on communication, may be needed to positively impact these scores. The leadership team expressed concern about the decline for the physician scores. Follow-up data were provided to the obstetrics quality improvement committee to track patient satisfaction trends; the 5-month cumulative scores improved. (See Figure 2.) The scores for the 2 months after the original survey increased dramatically in several items: nurse listened carefully, 100%; nurse explained in a way you could understand, 91%; physician listened carefully, 82%; physician explained in a way you could understand, 100%; staff worked together to care for you, 100%. Although the scores improved, the committee agreed to add patient satisfaction scores to the quality improvement meeting and continues to follow the scores monthly.Figure 2:: Patient satisfactionHand-washing adherence. Favorable safety culture scores are associated with higher adherence to hand hygiene practices.12 In addition to education and individual adherence with hand-washing practices, all team members are responsible for speaking up if they observe someone not following the hand-washing policy. The hospital's goal is 96% adherence to the hand-washing policy; hand-washing practices are audited monthly. Similar to the patient satisfaction results, the hand-washing data were obtained 3 months before the intervention and 3 months postintervention. L&D experienced a 14% increase in adherence; the MBU maintained performance above the hospital goal. (See Figure 3.)Figure 3:: Hand hygiene adherenceProviding needed support The increase in three of the four safety culture survey items is an indicator of the program's effectiveness. A more positive safety culture is associated with increased patient safety.13 The results are consistent with the level of staff participation and enthusiasm during and after the program sessions. The improvement of L&D hand hygiene scores suggests an increased willingness to speak up and encourage colleagues to adhere to hand-washing protocol. It's important to identify aspects of the environment that may impact outcomes, such as context factors, including staffing, department-based activities, and organizational support.14 Staffing shortages, changes in personnel, or lack of management support can adversely affect the impact of team training. For example, the infusion of new medical residents may influence teamwork measurements or the patient's experience with the physician. These aren't insurmountable issues; however, in addition to CRM training, they may require strategies to be resolved. In addition to outcome measures, the follow-up program has additional benefits. The discussions focus on safety culture improvements and steer staff away from blaming and judging colleagues. The structure of the discussions stimulates interest in process improvements, such as patient transfers and HST enhancements. The experience also provides leadership with valuable staff feedback on safety culture issues and fosters interdisciplinary collaboration. The 30-minute CRM refresher and discussion groups encourage participants to be direct and quickly raise their questions and concerns. The action plan is part of the existing quality structure and addresses barriers identified by care providers. The inclusive participation aids in obtaining buy-in from team members, allowing process improvements to move forward smoothly. Staying fresh CRM may influence staff actions and help develop more effective communication skills. However, the effects may take years to become embedded in the organization's culture.5 To achieve a change in culture, it's important that the goals of CRM are integrated into the organization's strategic goals. Our organization's strategic plan specifically states the intention to be a national leader in team-based care. In addition to supporting ongoing CRM training, Rush leaders encouraged the use of HSTs, such as checklists, and established interdisciplinary teams to develop best practice protocols. Embedded in a supportive environment, the crew follow-up support program, together with a strong strategic goal, can generate synergy that successfully creates and maintains a dynamic safety culture." @default.
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