Crew Resource Management
Jeff Beeson DO, EMT-P Medical Director Fort Worth
Republic of Texas
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CRM – What is the Goal?
To achieve Optimal
Performance from a team
executing multiple,
complex tasks.
Error Management is the “What”
CRM is the “How”
GOAL: OPTIMAL PERFORMANCE
To Err is Human
You Can Not Engage In Human Activity Without Introducing
Human Error
So, Can We Reach The Goal of CRM Without Eliminating Error?
When Things Go Wrong . . .
How It Is Now You are highly trained
and If you did as trained, you would not make mistakes
so
You weren’t careful enough so
You should be PUNISHED!
When Things Go Wrong . . .
How It Should Be
Humans make mistakes
Let’s also explore why the system allowed, or failed to accommodate your
mistake
Let’s IMPROVE THE SYSTEM!
and
so
and
You are Human
IAFC “Crew Resource Management” 3rd Ed. Oct 2002
Error Management
Overview: What it is… and, isn’t What Error Management Seeks to Achieve Where Error Lives Where it Fits in Our Skillset
Human Factor Error Causes Gordon Dupont’s “Dirty Dozen”
Lack of Communication Complacency Lack of Knowledge Distraction Lack of Teamwork Fatigue
Lack of Resources Pressure Lack of Assertiveness Stress Lack of Awareness Norms
Error Management Systematic Approach to Determining
Common Errors & Contributing Factors
Drives Cultural Change to Accept: Error is Universal. Error is Inevitable.
Shifts Focus from Who to What
Teach crews to TRAP, MITIGATE & AVOID Error.
Error Management Helmreich’s Error Management Model
AVOID
TRAP
MITIGATE
Helmreich, Robert L., Culture at Work in Aviation and Medicine. Ashgate Press. Aldershot. 1998.
Where Error Lives
LATENT – present but not visible…hidden in the things we do routinely
ACTIVE – present, in use…individual error
The Swiss Cheese Model (REASONS) Latent Errors in System
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2 3
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Latent Errors at Mgt Level
Individual Error (Active Error) Result/error
Organizational Filters: Training/Stan/CRM/ORM
Trajectory of Accident/Error Unchecked
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Layers of Defense to Trap Errors
Use All Resources Maintain Situational
Awareness
Follow SOPs
High Level of Proficiency
Mitigating the Consequence of Error
Employ Error Trapping in Every Aspect of:
Training
Standardization CRM
Error Trapping = Prevention & Intervention
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Avoid error Trap errors committed Mitigate the consequences of error
Crew Resource Management
An error management approach defining behavioral strategies taught as error countermeasures that are
employed to:
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“In the ten years it will take CRM to be introduced nationally, we will attend 1000
firefighter funerals…
I can’t get that out of my mind.”
Gary Briese,
Executive Director
IAFC
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Multiple Perspectives Origin from Military Aviation 30 years ago. Integrated to Commercial Aviation 20 years
ago. Discussed as a tool in medicine 10 years
ago, Fire Service text from 2004.
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Basic Premises
Technology minimizes “Tool Error”. Human Factors primary cause for errors. Rigid, hierarchal organizations prone to failure.
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An Error Mitigation Tool
Training on how to avoid errors. Potential errors are "trapped" before they are
committed. Planning for mitigation of error consequences.
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The Original CRM
Naval Air
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Although the following was designed for Military Aviation, multiple terms are easily transferred to our environment.
“Mission” or “Flight” = “Run” or “Call”
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Reference your own experience
How do these descriptions compare to your well functioning teams?
• “Mission” vs “Call”
Are we accomplishing something or
Just running a call
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Crew Resource Management Naval Air
https://wwwnt.cnet.navy.mil/crm/crm/stand_mat/seven_skills/sev_skills.asp
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Basic Elements Adaptability / Flexibility Assertiveness Communication Decision Making Leadership Mission Analysis Situational Awareness
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ADAPTABILITY/FLEXIBILITY
The ability to alter a course of action when new information becomes available
Un-briefed Situations Routine becomes Emergency Transitions Crew Member Down Interactions are strained
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QUICK ADAPTATION
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MAINTAINING ADAPTABILITY / FLEXIBILITY Anticipate Problems Recognize and Acknowledge any change Determine if an SOP or Habitual Response is Appropriate Offer alternative solutions Provide and Ask for Assistance Interact Constructively with Others
Establish an open, professional atmosphere
Ensure the crew understands the mission
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SETTING THE TONE FOR
ADAPTABILITY / FLEXIBILITY
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Example EMT: "Hey, Bob. The patient doesn't look well. His skin is turning blue. Are you sure that tube is in the trachea?" Paramedic: "I saw it pass through the cords." EMT: "Well, we've carried him down the stairs since then. What do you say we re-assess breath sounds and apply an ETCO2 detector?" Paramedic: "Good idea, Jill. Let's do that."
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Assertiveness
“The willingness/readiness to actively participate, state and maintain a position, until convinced by the facts that other options are better”
Requires the initiative and the courage to act.
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COMFORT LEVEL (Risk Homeostasis)
Comfort level is the degree to which you feel comfortable with what is happening, while taking
into account that flying a mission can be dangerous and demanding.
Whenever comfort level is exceeded, "Speak Up".
BEHAVIOR CONTINUUM
Passive Assertive Over Aggressive
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BEHAVIOR CONTINUUM Passive
Overly courteous "Beats around the bush" Avoids Conflicts "Along for the ride."
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BEHAVIOR CONTINUUM
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ASSERTIVE
• Active Involvement • Readiness to take action • Provide useful information • Makes suggestions
BEHAVIOR CONTINUUM
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OVER AGGRESSIVE
• Domination • Intimidation • Abusive / Hostile
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BARRIERS TO ASSERTIVENESS
Position of Authority Experience Rank Lack of Confidence Fear of Reprisal
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Communication
Communication is the clear and accurate sending and receiving of information,
instructions, or commands, and providing useful feedback.
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PROCESS OF COMMUNICATION
Sender conveys ideas or information to others Receiver hears or takes in information and provides feedback
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SENDER’S RESPONSIBILITIES
Communicate in Appropriate Mode Verbal versus Non-verbal Convey Information Accurately and Concisely Provide Information at Appropriate Time Request Verification or Feedback
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RECEIVERS RESPONSIBILITY
Actively Listen Active Vs. Passive Role Take action as a result of Communication Answer, or Respond, to Communications Ask for Clarification of Unclear Communication
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BARRIERS TO COMMUNICATION
Noise Rank/Experience Task Overload Gender Attitudes Culture
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Example
“Lt. Jones gives commands in an overly subdued manner.”
“During training evolutions, after direction is given, Matt often looks away from the Instructor and does not respond.”
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Decision Making
Effective decision making refers to the ability to use
logical and sound judgment to make decisions based on available
information.
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This includes: Assessing the problem Verifying information Identifying solutions Anticipating consequences of decisions Informing others of decision and rationale Evaluating decisions
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A Decision Making Strategy for Troubleshooting:
Identify all the symptoms Make a hypothesis as to the possible cause Test your hypothesis Apply appropriate remedies
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Another variation is John Boyd’s OODA Loop
Observe Orientate Decide Act
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Factors Which Promote Good Decision Making
Teamwork Time to make a decision Alert crew members Decision strategies and experience
Barriers to Good Decision Making
Time Inaccurate / Ambiguous information Pressure to perform Rank Difference
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Overcome the Barriers
Time Use SOP’s Use the available information Select the best decision
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Overcome the Barriers Inaccurate/Ambiguous Information
Ensure effective communications Cross – check information
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Overcome the Barriers
Pressure to Perform Evaluate the rationale for making a decision
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Remember:
• Good decisions optimize risk management and minimize errors, while poor decisions
can increase them
• Poor judgment or decision making is a leading cause of mishaps
• Each decision affects your future options
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You are on the scene
FF/EMT Webb continues to open the spreader on the front hinge in spite of obvious indications that he is endangering the patient.
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Leadership
WHAT IS LEADERSHIP?
The ability to direct and coordinate the activities
of other crew members and to encourage the crew to work together as a
team.
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DESIGNATED LEADERSHIP
TYPES OF LEADERSHIP
FUNCTIONAL LEADERSHIP
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DESIGNATED LEADERSHIP
Responsible Makes Final Decisions Normal Mode of Leadership
TYPES OF LEADERSHIP
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• Leadership by Knowledge or Expertise
• Occurs when the Need Arises
TYPES OF LEADERSHIP
FUNCTIONAL LEADERSHIP
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RESPONSIBILITIES OF LEADERSHIP
Crew Performance Direct Actions Ask for Assistance
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TRAITS OF AN EFFECTIVE LEADER Respected
Decisive Delegates Tasks Provides Feedback Leads by Example
Keeps Crew Informed
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TRAITS OF AN EFFECTIVE LEADER • Open to Suggestions
• Builds Team Spirit
• Directs and Coordinates Activities
• Maintains a Professional Atmosphere
• Knowledgeable of how to do the Mission
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MISSION ANALYSIS
Mission Analysis refers to the ability to develop
short term, long-term and contingency plans, as well as to coordinate, allocate
and monitor crew and resources.
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PHASES OF MISSION ANALYSIS include:
Preflight In-flight Post flight
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PRE-MISSION ANALYSIS involves:
Planning Preparation Briefing
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CHARCTERISTICS OF AN EFFECTIVE BRIEF Professional Stays Focused Assigns Responsibilities Interactive Complete
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IN-FLIGHT MISSION ANALYSIS involves: Short-term Planning Monitoring Mission Progress Identifying and Reporting Challenges or Changes
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POST-MISSION ANALYSIS is:
Selective Review Interactive Timely
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Example
“As the assigned Primary Medic, EMT-P Brown was unable to prioritize compressions vs. IV access within the context of Cardiac Arrest.”
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SITUATIONAL AWARENESS
Situational Awareness refers to the degree of accuracy
by which one's perception of his / her current environment
mirrors reality
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PERCEPTION VERSUS REALITY
View of Situation Incoming information Expectations & Biases Incoming Information versus Expectations
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FACTORS THAT REDUCE SITUATIONAL AWARENESS:
Insufficient Communication Fatigue / Stress Task Overload Task Under load Group Mindset "Press on Regardless" Philosophy Degraded Operating Conditions
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How does this relate to us?
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Give Examples:
Insufficient Communication Fatigue / Stress Task Overload Task Under load Group Mindset "Press on Regardless" Philosophy Degraded Operating Conditions
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CRM Evolved Crew Resource Management
For Fire / EMS
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Safety Culture
“Not another program!” Individual Responsibility Non-Punitive Culture and Policy to Error
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Mission Analysis & Planning
Micro – Training Opportunities Accountability Risk Versus Gain Analysis Risk Acceptance
ROADBLOCKS
The common obstructions to good CRM A combination of
Negative human factors Ingrained habits Personal attitudes and those of the crew-
members we are working with.
ROADBLOCKS NORMS: unwritten rules become pressures
that act upon a group ODD MAN OUT: Ignore input from a
particular member of the crew. Results in a loss of total crew effectiveness.
HIDDEN AGENDA: Intentionally withholding information about intentions or plans from the rest of the crew.
ROADBLOCKS (cont):
CHAIN OF ERRORS: Often the key is to recognize the chain developing-then a crewmember can act to change the situation.
BREAK THE CHAIN
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Situational Awareness
Killer Equation- Reality times perception still equals
reality.
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Situational Awareness
A Enhancement Strategy: Maintain Control Timely Assessment Multiple Sources Monitor Results
Situational Awareness
Point where perception and reality collide Reality always wins Beware of loss factors
Ambiguity Distraction Fixation Overload Complacency Unresolved discrepancy
What are the “Red Flags”?
Not Communicating No one Leading Deviating from Standards Ambiguity Confusion
What do you do when you suspect you have lost S.A.?
React Regain Reconstruct
Good Situational Awareness
Good crew coordination Proper task completion Understanding Appropriate communication Use of checklists
Checklists (example) First Responder Cardiac Arrest Checklist: Pt moved to adequate working area Communications advised CPR in progress Pit crew positions identified Continuous compressions being performed BVM is attached to oxygen and flowing AED / Defibrillator applied Sufficient personnel or additional requested
Checklists (example) ALS Cardiac Arrest Checklist: Pit crew positions identified Continuous compressions being performed BVM is attached to oxygen and flowing Monitor visible and in paddles mode Code Commander is identified and positioned at the monitor ETCO2 waveform is present and being monitored IV/IO access has been obtained Gastric distention has been considered/addressed Family is receiving care and is at the patient’s side
Preventing Loss of SA
Crew mental joggers “What do we have ?” “What’s going on ?” “How are we doing?” “Does this look right?”
Preventing loss of SA
Personal mental joggers “What do I know that they need to know?” “What do they know that I need to know?” “What do we all need to know?”
CRM Principle: Communication
Elements of Communication Skills
The most obvious of the CRM principles.
And, the easiest to affect through training.
“Say what you mean, mean what you say.”
Dyar Technique
Use name or rank when addressing them Use an emotional phrase when identifying a problem;
for instance, use the phrase "I feel uncomfortable…" Offer an alternative solution Request feedback from your teammate, which will give
them a sense of ownership of the solution
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Jeff Dyar. Far View Group Consulting. 2011
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Effective Communication
Utilizes more than one form. Both sender and receiver recognize perceptions,
influences and situations that affect the message. Must have active listeners. Communication loop
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CRM Leadership Three Steps:
Introduction Integration Trust
Recognize formal and informal (situational) leaders.
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CRM “Followership” Interaction Listening Skills Receiving, interpreting and following
instructions Making decisions together. Watching out for one another.
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Hazardous Attitudes
Anti-authority Impulsivity Invulnerability Macho Resignation Pressing
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Decision Making
Define Problem Generate a course of action Evaluate a course of action Carry out a course of action
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Keys to Good Decision Making
Maintain good situational awareness. Maintain technical proficiency Know your resources Evaluate, Evaluate, Evaluate
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We have seen this stuff before!
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HazMat & WMD G – Gathering Information E – Estimating Course and Harm D – Determining Strategic Goals A – Assessing Tactical Options & Resources. P – Planning & Implementing Actions E – Evaluating R - Reviewing
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Two Key Weaknesses
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Debriefings & Critiques Similar to CISD
“The Blue Line” Template:
1. Just the facts 2. What did you do? 3. What went wrong? 4. What went right? 5. What can be done?
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“Mandatory refresher training wastes the instructor's time, the firefighter’s time and the citizen’s dollars. Saving “a problem” for refresher training is a disservice to our firefighters and the public we protect.”
Page 254
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Strategies for Implementation
Step 1 – Train to technical proficiency Step 2 – Train to CRM proficiency Train risk vs. gain Include CRM in organization’s culture
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Strategies for Implementation
Step 1 – Train to technical proficiency
Traditional perception of “Training”
We do this well!
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Strategies for Implementation
Step 2 – Train to CRM proficiency
“Error Tolerant” Culture, especially in Probationary Training
Assertiveness
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Strategies for Implementation
Train risk vs. gain
“Fuzzy Logic”
Values are assigned to situational elements
Train “Experience”
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Strategies for Implementation Include CRM in organization’s culture What is the current culture? Do we need CRM? Take a brief inventory
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Rate: Concern with Failure We regard close calls and near misses as
a kind of failure that reveals potential danger rather than as evidence of our success and ability to avoid danger
We treat near misses and errors as
information about the health of our system and try to learn from them
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Rate: Reluctance to Simplify
Personnel take nothing for granted
Personnel are encouraged to express different points of view
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Rate: Sensitivity to Operations
During an average day, personnel come into enough contact with each other to build a clear picture of the situation.
Personnel are familiar with operations beyond one’s own job.
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Rate : Commitment to Excellence
There is an effort to build competence and abilities
Personnel have a number of informal contacts that they sometimes use to solve problems
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Rate: Deference to Expertise
If something out of the ordinary happens, personnel know who has the expertise to respond
People in this organization value expertise and experience over hierarchical rank