Principles in Crisis Resource Management in Disasters

Principles in Crisis Resource Management in Disasters

Posted on April 9, 2012 by


Principles in Crisis Resource Management

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

March 14, 18, 19, 21, 2012; April 9, 2012 (Reviewed)

1st Version

 

Pre-convention Workshop

Crisis Resource Management in Disasters

April 16, 2012

MBFI Hall

 Greetings and Salutations!

I was asked by the organizers to talk on “Principles in Crisis Resource Management” as a prelude to a workshop on crisis resource management in disasters.

The activity during the workshop, as I was told, will be a simulation of a mass casualty incident in Manila Doctors Hospital.  The simulation aims to apply the principles of crisis resource management.

Before I proceed any further, let’s take a look at the organizers’ formulated learning objectives for the workshop not only for orientation but also for mutual understanding what I should be doing and what you should be doing.

At the end of the workshop, participants should be able to:

  • Define Crisis Resource Management and know its importance and uses
  • Understand the basic principles of Crisis Resource Management
  • Apply the principles of CRM in a simulation activity
  • Identify one’s and the team’s areas of improvement and strengthening

Thus, my tasks as a facilitator for your learning will be to help you understand what crisis resource management is, its importance, its uses, its basic principles, and give you tips on how to apply the basic principles in a simulation activity (a simulated mass casualty incident in Manila Doctors Hospital).

Are we clear on our tasks, my tasks and your tasks, during this one hour allotted to us?

Here is an outline of the contents of my talk:

Crisis Resource Management

  • Concept
  • Importance
  • Uses
  • Basic principles
  • Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital)

Crisis Resource Management – Concept

As it is currently being used now, crisis resource management (CRM) can be broadly defined as a management system which makes optimum use of all available resources – people, procedures, equipment – to promote safety and enhance the efficiency of operations during a crisis situation.

In more specific terms, crisis resource management (CRM) is a simulated training of a group or groups of people in handling commonly encountered and anticipated high-risk activities, emergencies and disasters with the end goals of effective and efficient accomplishment of the needed operations and responses with emphasis on optimal teamwork (communication, coordination, collaboration), prevention of errors and safety promotion.  (ROJoson’s synthesized concept statement)

I will expound on this concept with a historical backgrounder.

Crisis Resource Management (CRM) was first developed by the aviation industry in the late 1970s.  The original term used was Crew Resource Management.  Another term used was Cockpit Resource Management.  The CRM came about after analysis of plane crashes in the US showed that human error was involved in 85% of events.  The Crew Resource Management or Cockpit Resource Management has essentially a training program that resulted in reduction of human errors and therefore, less airplane crashes.

In the 90s, David Gaba, an American anesthetist, training as a pilot, recognizing the similarities in the high stake environments of the operating theatre and cockpit, developed the Anesthesia Crisis Resource Management (Anesthesia CRM).  In 1999, the publication of “To Err is Human, Building a Safer Healthcare System” by the Institute of Medicine in the US brought CRM into focus as the healthcare community began to realize the extent of medical error.  The publication suggested that it was the faulty systems, processes and conditions that led people to make mistakes or fail to prevent them.

Crisis Resource Management (not Crew Resource Management) is currently a buzzword in avoiding human factor errors and promoting safety during emergencies and other high stake environments or critical activities.

If we don’t look at the history, if we just look superficially at the connotations and meanings of the three words in the term, namely, crisis, resource, and management, CRM will just mean management of all available resources during a crisis (an emergency or a disaster) with resources simply connoting manpower, machines, materials, methods and monuments or the 5 Ms.  CRM has deeper meanings based on its history and its usages.  CRM encompasses the concepts of crew or cockpit resource management of the aviation industry.  Its usage is not limited to emergencies and disasters.  It can be and is used in non-medical and medical industries in training people to avoid error and improving safety.  The training promotes safety by addressing the behavioural and cognitive skills needed to effectively manage all available resources, especially during a crisis situation.    This is accomplished through the development of superior non-technical skills such as leadership, situational awareness, communication, and teamwork. Although technical and non-technical skills are important, CRM puts more emphasis on the non-technical skills with the assumption that the people on the job have the technical skills to start with.

In medicine, the concept of CRM includes critical care medicine and simulation; non-technical skills in acute medicine; and teamwork and patient safety.  In medicine, CRM is not limited to anesthesia where it was first used by Dr. Gaba.  Aside from Anesthesia CRM, we now see in the medical literature and Internet, Emergency Medicine CRM, Pediatric CRM, Critical Medicine CRM, etc.

To repeat, the concept of crisis resource management (CRM) as I have synthesized it, is a simulated training of a group or groups of people in handling commonly encountered and anticipated high-risk activities, emergencies and disasters with the end goals of effective and efficient accomplishment of the needed operations and responses with emphasis on optimal teamwork (communication, coordination, collaboration), prevention of errors and safety promotion.

Crisis Resource Management – Importance

To promote effective and efficient accomplishment of the needed operations and responses by a group of people in commonly encountered and anticipated high-risk activities, emergencies and disasters with emphasis on optimal teamwork (communication, coordination, collaboration), prevention of errors and safety promotion.

Crisis Resource Management – Uses

In commonly encountered and anticipated high-risk activities, emergencies and disasters in medical and non-medical industries

In medical industries –

  • In hospital and ambulatory centers
  • In departments with high-risk activities, such as emergency medicine, critical care medicine, operating theatres, etc.

Crisis Resource Management – Basic principles

As mentioned earlier, crisis resource management (CRM) can be broadly defined as a management system which makes optimum use of all available resources – equipment, procedures and people – to promote safety and enhance the efficiency of operations during a crisis situation.

The management system includes crisis preparedness and response plans and exercises to enhance optimal responses during an actual crisis.  The exercises can be small-scale (such as drills and table-top exercises) or full-scale simulation of crisis situation.  They can be computer-aided and /or aided by simulated patients, props and manikins.

Thus, the foremost requirements of crisis resource management are that there must crisis preparedness and response plans and there must be simulated exercises.  The simulated exercises form the backbone of the crisis resource management.

The simulated exercises or training in a crisis resource management must bring out the behaviors or non-technical skills necessary for an optimal teamwork (communication, coordination, collaboration), prevention of errors and safety promotion.

Thus, when we talk of basic principles in CRM, we are referring to the behaviors or non-technical skills or key points that must be brought out in the exercises which will promote an optimal teamwork (communication, coordination, collaboration), prevention of errors and safety promotion.  In the simulated training, the participants are given an opportunity to demonstrate and develop their non-technical skills (both behaviour and cognitive skills) through various scenarios, ultimately yielding optimal teamwork, prevention of errors, and safer practices or clinical practices for those in healthcare.
CRM follows a particular educational doctrine that has been derived from the aviation industry [Crew Resource Management (CRM)] and introduced to the health sector via the doctrine of David Gaba in Anaesthesia Crisis Resource Management (ACRM). There are seven key behaviours as originated from the Crew Resource Management:

  1. Know your environment
  2. Prepare and plan
  3. Call for help early
  4. Take a leadership role
  5. Allocate attention wisely and use all available resources
  6. Prioritize and distribute the workload
  7. Communicate effectively

Gaba added more key behaviours in the anesthesia CRM (see Nos. 8 to 15).

1. Know the environment

2. Anticipate and plan

3. Call for help early

4. Exercise leadership and followership

5. Distribute the workload

6. Mobilize all available resources

7. Communicate effectively

8. Use all available information

9. Prevent and manage fixation errors

10. Cross (double) check

11. Use cognitive aids

12. Re-evaluate repeatedly

13. Use good teamwork

14. Allocate attention wisely

15. Set priorities dynamically

(From Rall M, Gaba DM: Human Performance and Patient Safety,  in Miller 6th edition 2005)

In the Emergency Medicine CRM, one institution added the following three key behaviours to the seven key behaviours derived from the aviation industry:

  1. Triage / prioritization
  2. Efficient management of multiple patients
  3. Effective coping with disruptions / distractions

Thus, one can see that there are various packages of non-technical skills, behavioural skills, cognitive skills, so called key principles, and they vary from one situation to another.  These just have to be spelled out by the facilitators for the individual situations. Although there are variations, in a Delphi study performed in 2009 to help determine key training areas for health-care teamwork competency, the following were generated, namely, communication, task management, situational awareness, decision-making and leadership.

Thus, in simple and most basic terms, the non-technical skills in health-care industry CRM can consist of the following:

Non-technical skills

Behavioural skills

Leadership

Communication

Team working (communication, coordination, and collaboration)

Cognitive skills

Situational awareness

Planning

Decision making

Task management

Note: It must be emphasized that no one key behaviour sits in isolation from each other but rather they are all interrelated and there are overlaps.  A good team working involves excellent communication skills, task management, planning, and leadership.  Likewise good situational awareness relies on communication, team working, and decision making.

To simplify things, I would suggest using the following package or framework (with the understanding that all are aimed at optimal teamworking, prevention of errors, and promotion of safety in the absence of inclusion of the specific term on team working):

  • Leadership
  • Situational awareness
  • Planning
  • Decision making
  • Communication
  • Coordination
  • Collaboration
  • Task management

Crisis Resource Management – Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital)

To expound on the foremost requirements and basic principles of CRM mentioned above, I will show you an illustration of an application using management of mass casualty incident (MCI) in Manila Doctors Hospital (MDH) as the anticipated crisis, emergency or disaster situation.

Let us say that MDH has decided to conduct a crisis resource management simulated training to enhance optimal response during a mass casualty incident in Manila Doctors Hospital.

The prerequisites for the conduct of CRM are the presence of the MDH MCI preparedness and response plans and that all the key players have read and understood their roles and responsibilities whenever there will be an MCI and an activation of Code White (MDH response code for surge of patients disaster) by the MDH Chief Safety Officer.

To plan for the conduct of the simulation CRM, the facilitators should formulate an instructional design or lesson plan.

The facilitators should decide whether it will be a full-scale or small-scale simulation exercise (small-scale means portions of the whole response plan and using drills and table-top exercises).  The facilitators also decide who are the key players to focus on for the training and what are the non-technical skills to bring out among the players. See tables below.

General Steps in Response to MCI based on MDH Response Plan:

Steps in the Response to MCI (Surge of Patients) – MDH Response Plan

Key Players

Key Non-technical Skills to Practice and Enhance

Declaration of disaster Persons authorized to declare a surge of patients disaster (Emergency Room Officer, Hospital Chief Safety Officer, Hospital Director) Situational awarenessCommunicationCoordination

Collaboration

Task management

Call for help early”

Creation of an incident command Persons authorized to create the incident command (ERO, Hospital Chief Safety Officer, Hospital Director) and members of the incident command (Medical Director, Nursing Director, Communication Officer, Security Officer, etc.) LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

 

Notification of concerned authorities Persons authorized to notify concerned authorities (ER staff and members of incident command designated to do the task) Task managementCommunicationCoordination

Collaboration

Mobilization and organization of staff and services Members of the incident command, heads of departments and services, designated heads of disaster response and control teams (triage teams, medical teams, evacuation teams, transport teams, operating room teams, communication teams, traffic control teams, security teams, etc.) LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

Allocate attention wisely and use all available resources

Prioritize and distribute the workload

Control of disaster   Heads and members of disaster response and control teams (triage teams, medical teams, evacuation teams, transport teams, operating room teams, communication teams, traffic control teams, security teams, etc.) LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

 

Deactivation of disaster (stand down) Persons authorized to deactivate (stand down) a previously declared surge of patients disaster (Emergency Room Officer, Hospital Chief Safety Officer, Hospital Director) Situational awarenessCommunicationCoordination

Collaboration

Task management

 

Post-disaster reconstruction Heads and members of disaster response and control teams (triage teams, medical teams, evacuation teams, transport teams, operating room teams, communication teams, traffic control teams, security teams, etc.) LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

 

Post-disaster evaluation and reporting All staff, particularly the key players, who participated in the disaster response and control LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

General Steps in the Control of Disaster in Response to MCI based on MDH Response Plan:

Steps in the Control of Disaster in Response to MCI (Surge of Patients) – MDH Response Plan

Key Players

Key Non-technical Skills to Practice and Enhance

Triage Staff trained and assigned to do triaging at the ER and at the holding areas (Green, Yellow, and Red Areas) LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

Treatment Staff assigned to do the medical care of the injured patients (physicians, nurses, institutional workers, recorders, etc.) LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

Referrals / Transport Staff assigned to do referrals and transport LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

Traffic control Staff assigned to do traffic control LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

Patient log  Staff assigned to do patient log LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

Relatives Information Area Staff assigned to relatives information area LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

Press conference  Staff assigned to conduct and manage press conference LeadershipSituational awarenessPlanning

Decision making

Communication

Coordination

Collaboration

Task management

After mapping out the essential steps in the response and control plans in MCI, the key players who will undergo training, and the key behaviour and cognitive skills to teach, enhance and practice, the facilitators then determine what are considered “good,” “effective and efficient”  leadership, situational awareness, planning, decision-making, communication, coordination, collaboration, and task management in general terms and in each specific step in the response and control plans. After the criteria of quality have been determined, the facilitators then formulate specific teaching-learning strategies and activities (such as drills, table-top exercises, or full-scale exercises) that will give the participants to develop and enhance the key behavioural and cognitive skills.  Checklists that can be used to teach and evaluate the different behavioral and cognitive skills will be very helpful.

Below are brief explanations on the concepts and examples of checklists.

Leadership

Leadership – Concept

In each step in the response and control plans, there is a team involved.  A team needs a leader.  Someone has to take command, determine what tasks to be done, collect all information, make decision, make plans, communicate, distribute tasks, coordinate, integrate, ensure collaboration, evaluate, etc.

There is an overall team, the whole hospital response and control team, headed by the incident commander.  There are also subsector teams, such as the triage team, medical teams, security teams, etc. These subsector teams have their respective team leaders also.

Although a leader is not exected to know everything and not to do technical tasks, he should know the nature and requirement of the tasks to be done to be an effective and efficient leader.

He must know how to asses the situation, plan for the usual response, do contingency plan, do decision-making, distribute tasks, communicate with members of the team to ensure coordination, collaboration and optimal teamwork, prevent errors and promote safety of patients and staff.

Leadership – Evaluation Checklist (Example)

Parameters and indicators – Leadership Yes / No / (±) Remarks
There was a clearly identified and recognized team leader.
The team leader knew the mission of his team.
The team leader demonstrated skills in situational awareness.
The team leader demonstrated skills in problem-solving and decision-making.
The team leader demonstrated skills in planning for the response (inclusive of contingency plans).
The team leader was calling the shots (was in command).
The team leader demonstrated skills in effective communication with his team members.
The team leader demonstrated skills in coordinating his team members.
The team leader demonstrated skills in making his team members collaborate with each other.
The team leader was able to accomplish his mission effectively and efficiently through optimal teamwork.
The team leader was able to accomplish his mission effectively and efficiently with minimal errors.
The team leader was able to accomplish his mission safely.
Other parameters and indicators of good leadership that were needed and observed. (Add here.)

Task Management

Task Management – Concept

Task management is the process of managing a task through its life cycle, which includes planning, implementation, tracking, evaluation and reporting.

In the MDH MCI response plan, there are about 8 general steps from declaration of disaster to control of disaster to deactivation to post-disaster evaluation reporting.  There are also about 9 steps in the control of disasters which start with triage, then treatment, to press conference for media.  All these steps constitute the “tasks.”  In the presence of well-prepared disaster preparedness manual, these tasks are spelled out in the job descriptions and so called “job action sheets.”

All these tasks must be managed effectively and efficiently by each individual team leader and team member and also, the whole team.   Effective and efficient task management is facilitated by the presence of effective leadership, situational awareness, problem-solving and decision-making, planning, communication, coordination, and collaboration.

 

Task Management – Evaluation Checklist (Example)

Parameters and indicators – Task Management Yes / No / (±) Remarks
All the members of the response team knew their primary tasks even before the response.
Tasks were planned guided by the situational awareness.
Tasks were communicated effectively to all concerned members of the response team.
Tasks were properly distributed to all members of the response team.
Tasks were accomplished effectively and efficiently through optimal teamwork.
There was coordination among the members in the accomplishment of the task.
There was collaboration among the members in the accomplishment of the task.
Tasks were accomplished effectively and efficiently with minimal errors.
Tasks were accomplished safely.
Other parameters and indicators of good task management that were needed and observed. (Add here.)

Situational Awareness, Planning, and Decision-making – Concept

Situational awareness is the ability of the leaders and followers to identify, process, and comprehend the critical elements of information about what is happening with regards to the team’s mission.   To put it simply, it’s knowing what is going on around you.

All leaders and followers of the team must possess skills in situational awareness to be able to act effectively and efficiently during a crisis situation.

The situational awareness should be followed by a quick and precise planning and decision-making on responses to be made.

Situational Awareness, Planning, and Decision-making – Evaluation Checklist (Example)

Parameters and indicators – Situational awareness, planning, and decision-making Yes / No / (±) Remarks
There was awareness and assessment of the situation prior to planning and decision-making.
There was collection of information to guide in the situational awareness and assessment.
The situational awareness was done in the quickest time possible and as completely as possible.
There was planning guided by situational awareness and assessment.
The planning was done in the quickest time possible and as comprehensively as possible.
Decision-making was done guided by situational awareness and assessment.
Decision-making was done in the quickest time possible.
The planning and decision-making resulted in effective and efficient response outcomes.
Other parameters and indicators of good situational awareness, planning, and decisoin-making that were needed and observed. (Add here.)

Communication, Coordination, and Collaboration – Concept

All leaders and followers should possess effective communication skills. It is important for both the sender and the receiver of a message, no matter whether they lead or follow. Effective communication ensures that everybody knows what is going on, what needs to be done and what is already done. There must be closure of the loop of communication as illustrated by the following: address people directly; acknowledge what you have heard and confirm when you completed a task.

All leaders and followers should possess skills and attitude in coordination.

All leaders and followers should possess skills and attitude in collaboration.

Communication, Coordination, and Collaboration – Evaluation Checklist (Example)

Parameters and indicators – Communication, coordination, and collaboration Yes / No / (±) Remarks
There was effective communication  in that everybody knows what is going on, what needs to be done and what is already done.
Highest degree of coordination among different members of the team and among different teams was observed.
Highest degree of collaboration among different members of the team and among different teams was observed.
The communication resulted in effective and efficient response outcomes.
The coordination and collaboration resulted in effective and efficient response outcomes.
Other parameters and indicators of good communication, coordination, and collaboration that were needed and observed. (Add here.)

For a specific task, such as the incident command, or for an overall evaluation of crisis resource management, the following evaluation checklist can be used:

Parameters and indicators – Overall Yes / No / (±) Remarks
Effective leadership was demonstrated.
Effective and efficient situational awareness was demonstrated.
Effective and efficient planning was demonstrated.
Quick decision-making was demonstrated.
Effective communication was demonstrated.
Highest degree of coordination was demonstrated.
Highest degree of collaboration was demonstrated.
Effective and efficient response was accomplished with optimal teamwork.
Effective and efficient response was accomplished with with minimal errors.
Responses were accomplished safely.

Summary and Conclusion:

I have presented the following as planned:

Crisis Resource Management

  • Concept
  • Importance
  • Uses
  • Basic principles
  • Application in a simulated activity (a simulated mass casualty incident in Manila Doctors Hospital)

To repeat, crisis resource management (CRM) is a simulated training of a group or groups of people in handling commonly encountered and anticipated high-risk activities, emergencies and disasters with the end goals of effective and efficient accomplishment of the needed operations and responses with emphasis on optimal teamwork (communication, coordination, collaboration), prevention of errors and safety promotion.  (ROJoson’s synthesized concept statement)

I hope my lecture will facilitate the accomplishment of your workshop in a short while.

Thank you for your attention.

Workshop

Description:

The activity will be a simulation of a mass casualty incident in Manila Doctors Hospital.  The simulation aims to apply the principles of Crisis Resource Management.

Scenario:

The hospital in simulation is Manila Doctors Hospital and the participants are the staff of this hospital.

At 1800H, April 15, 2012 the Philippine President Noynoy Aquino announced that there is a bomb threat to the Black Nazarene procession that will commence at 0600H, April 16, 2012. All hospitals surrounding the area were informed of such threat.

It is now 1000H April 16, 2012.  A call from the DOH-HEMS was made to the MDH-ER saying that there was an explosion during the Black Nazarene procession.

References:

Reznek M, Smith-Coggins R, Howard S, Kiran K, Harter P, Sowb Y, Gaba D, Krummel T. Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med. 2003 Apr;10(4):386-9.

Rall M, Gaba DM: Human Performance and Patient Safety, in Miller, 6th edition 2005.

Belinda Carne, Marcus Kennedy, and Tim Gray:  Review article: Crisis resource management in emergency medicine.  Emergency Medicine Australasia (2012) 2: 7–13.

David M. Gaba, Steven K. Howard, Kevin J. Fish, Brian E. Smith, Yasser A. Sowb: Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. SIMULATION & GAMING, Vol. 32 No. 2, June 2001 175-193.

Cheng, Adam; Donoghue, Aaron; Gilfoyle, Elaine; Eppich, Walter: Simulation-based crisis resource management training for pediatric critical care medicine: A review for instructors. Pediatric Critical Care Medicine: March 2012 – Volume 13 – Issue 2 – p 197–203,..

Crisis Resource Management to Improve Patient Safety, Marcus Rall, Peter Dieckmann, Euroanesthesia, 2005

http://www.euroanesthesia.org/Education/~/media/Files/Publications/RefresherCourse/rc2005vienna/17rc1.ashx05vienna/17rc1.ashx

Crisis resource management in an Emergency environment.

www.guysandstthomas.nhs.uk

 

MS Word File:

Principles in Crisis Resource Management_RJ_LEC_pics_12mar18_21_apr9

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