Crew resource management (CRM) can be defined as a group of techniques that can be used by a crew or team to reduce human performance errors. Those techniques form the basis of a training program that we used in the York Hospital operating room (OR) to create a culture of safety.
CRM originated from a National Aeronautics and Space Administration workshop in 1979. In the 1960s and 70s, the aviation industry began to realize that the primary cause of commercial aviation accidents had shifted from equipment failure to human error. The concepts and techniques encompassed in CRM help teams perform at optimum levels, recognize and correct errors and other threats, and reduce incidents and accidents. For several years, commercial air carriers have utilized CRM techniques to reduce human performance errors on the flight deck, thereby reducing airline accidents. These techniques have proven so successful that CRM training is mandated by the Federal Aviation Administration, and CRM has been adapted in such diverse activities as nuclear power station control rooms and medical operating theaters.1
York Hospital is a 572-bed, Magnet designated, nonprofit community hospital located in York, Pennsylvania. In 2006, the hospital began discussions to enhance the culture of safety in the OR. In the ORs, despite implementing numerous nationally recognized safety initiatives, there continued to be a significant number of adverse outcomes, including retained foreign objects and wrong-site surgeries. An internal analysis revealed that some errors were related to issues of communication and coordination of care. The surgical service line (SSL) leadership felt that implementing a CRM training program for all members of the OR team might lead to a decrease in these events. CRM was chosen because it emphasizes techniques that improve communication and interdependence among the team members. These include briefings, a shared mental model, situational awareness, debriefings, and communication techniques that permit each team member to voice concerns in a timely way.
The SSL and patient safety officer evaluated several companies and individuals prior to development of the CRM program. Crew resource management has been adapted to healthcare in multiple formats. One of the earlier programs (introduced in 2000), which has now been recognized with the prestigious Eisenberg Award, was implemented by Benjamin Sachs and colleagues in the Beth Israel Deaconess Medical Center (BIDMC) labor and delivery unit in Boston, Massachusetts.2-3
The SSL leadership had discussions with Donald Moorman, MD, then at BIMDC, and developed a curriculum for the OR team members. Moorman facilitated development of the delivery of this curriculum by creating a model whereby successive teams of learners drawn from the OR staff become team trainers. The educational approach espoused by Moorman embraces a “train the trainers” philosophy because it is more effective than straightforward didactic instruction about the goals of highly effective teams in creating cultural change. The SSL elected to work with Dr. Moorman to adapt his program to our local needs.
The hospital CRM steering committee was created with leadership representation from all stakeholder disciplines in our ORs. The steering committee set its project goals and defined the behaviors it wished to inculcate; developed its own curriculum; enlisted surgeons, anesthesia providers, nurses, and surgical technologists as the trainers; and developed its own training videos and observational measurement tools to measure the impact of the program on daily work performance. (See Table.)
|Module/Length (Min)||Title||Topics Presented|
|Module 1/60||"History of Crew Resource Management and its Potential to Improve Patient Safety"||Analogy of aviation disasters to operating room misadventure, Institute of Medicine recommendations, definition of a team|
|Module 2/30||"How Team Leader Constitutes a Team"||Introductions, shared mental model, briefings, team leader's role, situational awareness|
|Module 3/30||"Effective Team Communication"||Differences in communication style between disciplines, standards of effective communication, information transfer techniques, appropriately assertive communication, conflict management|
|Module 4/30||"Postoperative Debrief"||Checklist, what went well, what could have been done better, what were additional resources needed that were not anticipated, as well as follow-up on significant events|
Developing the York Hospital OR CRM training program was a two-year project that required the commitment and attention of the 17-member CRM steering committee. The steering committee’s primary focus was developing the CRM presentation and acting as CRM trainers and champions by coaching surgical teams in the OR on conducting briefs and debriefs. In order to facilitate day-to-day operations of the project, the CRM executive committee, consisting of the SSL medical director/chair of the surgery department, clinical director of surgical services, perioperative medical director/anesthesia department chair, patient safety officer, and CRM project manager, was formed. The CRM project manager was a designated assignment that allotted 25% of the manager’s time to the project. The project manager was responsible for logistically implementing the program and developing program outcome measurement tools. The total time commitment to complete the development and implementation of this program was approximately 2,200 hours. The members of the OR and the steering committee committed to designing scenarios and presentations and producing videos, with an emphasis on creating a hospital-centric program. This commitment has been a primary factor in the positive reception of the use of CRM techniques to foster better communication, enhance teamwork, and improve patient safety.
The goal of York Hospital’s CRM training program was to encourage each OR team, as it gathers to perform a procedure, to participate in a brief, creating the same mental model of the goals to be accomplished at surgery. The brief included introductions of all team members; identification of the patient; confirmation of the procedure to be performed, as well as site, side, or level; summation of the patient’s medical history; and anticipation of potential problems and key portions of the procedure. Another goal of the CRM training was to encourage each OR team to participate in a debrief to determine what went well and what could have been done better, thus creating an environment that encourages everyone, from surgeons to housekeeping staff, to speak up if they feel that patient safety needs to be addressed.
The SSL charged the CRM steering committee to develop an overall CRM delivery strategy. CRM team training consisted of four modules: (1) the history of CRM and its potential to improve patient safety, (2) how a team leader constitutes a team in the OR, (3) effective team communication, and (4) postoperative debrief. The modules were delivered to groups of 30 to 40 members of the OR staff by various combinations of OR team members who represented surgeons, anesthesia providers, and nursing and OR staff.
To illustrate the modules, CRM steering committee members acted in a series of videos, which were filmed in the OR. An internal marketing campaign, including “Where’s the Brief?” posters, was implemented along with monthly three-hour training sessions. To encourage attendance at educational sessions, classes were approved for physician and nurse continuing education credits and patient safety credits. Hospital staff members were also compensated for their training time. To avoid closing the OR, presentations were scheduled during the evening and weekend hours. SSL leaders were present at every training session given by steering committee members. Usually, a physician member of the SSL acted as the program facilitator. The trainers for each session consisted of a surgeon or anesthesia provider and a registered nurse or surgical technologist. The educational sessions were attended by interdisciplinary teams of surgeons, anesthesia providers, registered nurses, surgical technologists, anesthesia and instrument technicians, secretaries, nursing assistants, and housekeeping staff. In addition to the hospital-developed videos, two videos from the BIDMC program were used to further emphasize the importance of using CRM tools in the OR.
In April 2008, the first CRM training classes were given; by May 2009, more than 530 (98%) surgical services staff members were trained. Anecdotal reports of staff practicing the CRM techniques were noted in June 2008.
In evaluating the results of the implementation of CRM in the OR, there has been a slight decrease in the percentage of problematic responses in the Stanford Patient Safety Consortium: Patient Safety Culture Survey from 15.9% in 2006 to 15.2% in 2008, scoring a lower percent problematic response than the mean (17.2%) for all ORs in the consortium, as well as lower than the overall hospital mean (16.1%) score. While some studies demonstrate a positive correlation between safety culture and clinical outcomes, in our case, the Stanford survey was coincidentally carried out before and after our CRM team training program and was not part of a study design. No p-value calculations or formal statistical analysis has been done nor would such analysis be appropriate. There also has been a slight improvement in National Database of Nursing Quality Indicators RN satisfaction scores in the RN:RN and RN:MD dimensions, but this again is a coincidental observation and was not part of a study design.
At the completion of team training, the brief/debrief utilization rate was estimated in an observational study to be 67% and 42%, respectively. A year after the CRM training program was initiated, a second observational study was implemented to monitor progress and found that the brief/debrief utilization rate had increased to 100% and 87%, respectively. We believe the best evidence of success of our CRM program can be measured by the use of the brief and debrief because these moments of leadership and team cohesion have not been mandated but rather are voluntarily adopted and observed. The effect of observer presence in the OR may have been a factor in the utilization rates, but the observers were medical students present each summer for educational purposes and not identified as observers collecting data.
We have demonstrated that a community teaching hospital can develop and implement a CRM program tailored to local needs. The response to our CRM program was the gradual adoption of communication techniques and was best measured by assessing the voluntary implementation of the brief and debrief. We have utilized quarterly, joint grand rounds on patient safety topics to re-emphasize the value of CRM. To measure progress, we have developed several observational strategies that will help us monitor CRM activity, including using a tracking system that indicates when a brief/debrief activity is done during a surgical procedure and, over time, looking at our data to see if there has been a decrease in incidence of retained foreign objects and wrong-site surgeries. Steady increases in the utilization of these CRM techniques confirm that there has been widespread adoption of CRM in the York Hospital OR. The SSL will continue to assess the impact of the CRM program on changing the culture of safety in the OR. We will continue to closely follow these trends and others, including Agency for Healthcare Research and Quality safety indicators, nurse satisfaction scores, and patient outcomes (e.g., postoperative complication rates).
- Fuller D. Crew resource management: reducing human performance errors in space operations. Presented at: 20th AIAA International Communication Satellite Systems Conference and Exhibit; 2002 May 12-15; Montreal, Quebec, Canada.
- Sachs BP. A 38-year-old woman with fetal loss and hysterectomy. JAMA 2005 Aug 17:294(7);833-40.
- Pratt SD, Mann S, Salisbury M, et al. John M. Eisenberg Patient Safety and Quality Awards. Impact of CRM-based team training on obstetric outcomes and clinicians’ patient safety attitudes. Jt Comm J Qual Patient Saf 2007 Dec;33(12):720-5.