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OBSTETRICS & GYNECOLOGY

OPERATINGTHEATRE

NURSING SERVICES

MEDICAL SERVICES

SPEAK UP

CONFLICT MANAGEMENT

TEAM WORK

TEAM BRIEFING

SITUATION AWARENESS

ASSERTIVENESS

DECISION MAKING

STADARDIZE COMMUNICATION

LEADERSHIP

TEAM DEBRIEFING

CREW RESOURCE

MANAGEMENT

HIG

H R

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ILITY

SAFE & EFFICIENT HEALTHCARE DELIVERY

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SPECIALTIES

DISCIPLINES

CULTURAL CHANGE

Issue 21

Head Office Quality & Safety Division

The Hospital Authority Periodic Publication on Quality Improvement for Healthcare Professionals

November 2015

The Crew Resource Management (CRM) is a flexible, systematic method

for optimizing human performance and increasing safety

within team settings. CRM helps professionals

f rom d i f f e ren t d i s c i p l i n e s and

specialties to be more proficient in

working together.

CRM Works!Our Training for Patient Centred Care By Cluster Services Division and Quality and Safety Division, HAHO

In This Issue:

• CRM Works!

• Cultural Change for Patient Safety

• Speak Up Before It is Too Late

• “From Patient Safety to High Reliability”

H A h a s d e v e l o p e d a

unique integrated approach

to CRM training by incorporating

interactive classroom training with

scenario-based simulation training. With

this integrated approach, a group of HA local qualified trainers would conduct CRM training by using a set of HA-wide

training materials which include case scenarios for team-based simulation training practice and training videos on key CRM

components (e.g. assertiveness, team briefing, debriefing, etc.).

The efforts of clusters in CRM training in previous years have demonstrated beneficial outcomes in clinical service.

QUALITY TIMES • Issue 21 • November 2015 The Hospital Authority Periodic Publication on Quality Improvement for Healthcare Professionals

Cultural Change for Patient Safety By Dr CHOI Yu-fai, Director of Nethersole Clinical Simulation Training Centre, PYNEH

CRM training started in HA when PYNEH was commissioned to pilot the CRM training program in 2009. In recent years, such training has evolved from classroom-based didactic teaching to clinical simulation experiential learning, from generic modalities to specialty-based and multi-disciplinary team training, from PYNEH to Hong Kong East Cluster (HKEC), and is now flourishing in all HA clusters.

The success of translating CRM into patient safety culture in our Cluster hinges on commitment from management, devotion from staff members as well as strong encouragement from the positive feedback and evaluation of our CRM training program in the course of our CRM journey and pursuit for quality and patient safety. However, to further extend CRM training beyond different clinical modalities will require profound change in team collaboration and dynamics. Hence, HA Corporate’s support in delineating the future CRM roadmap is thus of pivotal importance in steering the CRM journey to the next level.

Over 3,000 staff members have attended CRM training in HKEC. Reflecting on what we have achieved in our CRM journey, we see enhancement of team effectiveness and communication, promotion of organization learning, positive shift of behavioral change, and most importantly, the nurturing of a group of enthusiastic advocates who work cohesively and unstintingly in sowing the CRM seeds for safer healthcare services.

Skills can be mastered through practice but culture can only be nurtured over time. With the positive outcome from and reinforcement of our CRM training, we believe that our patient safety culture will grow stronger and stronger to shape the behavior of our healthcare practitioners and improve the quality of care to our patients.

QUALITY TIMES • Issue 21 • November 2015 The Hospital Authority Periodic Publication on Quality Improvement for Healthcare Professionals

Speak Up Before It Is Too Late KCC CRM Training Progress By Multidisciplinary Simulation and Skill Center, QEH

First piloted in HA hospital in 2009, CRM training has continued to be promoted and extended to KCC by 2013. Since then, 42 senior rank staff in KCC were trained as CRM trainers.

In our initial CRM training program, great emphasis was placed on commonly encountered daily scenarios and clinical emergencies. Subsequently, with the collective input of experts from various specialties, high risk areas of human related errors and CRM concepts were incorporated into the training program to facilitate technical skills learning in a clinical event. In 2014 and first half of 2015, a total of 332 and 418 KCC staff respectively had undertaken CRM scenario-based training.

Training Theme Delineation - Speak up In early 2015, “speak up” training, focusing on patient’s safety outcomes in KCC, was first introduced in QEH CRM classroom teaching. This training is important since the causes of most medical incidents are multifactorial and since as many as half of such errors can be prevented if someone has recognized the danger and reported or spoke up before it is too late.

Training Outcome In our evaluation of participants attending CRM classroom teaching, apart from their overall positive response to both scenario-based and classroom training, it was shown that there was a statistically significant attitudinal shift (p<0.05). Based on the results of our pre- and post-intervention study using a validated Human Factors Attitude Survey (HFAS), we found to our surprise that staff’s awareness and incentive to speak up for patient’s safety had greatly improved after the training (Table 1). Furthermore, over 85% of participants had rated the program to be interesting, useful and relevant to their practice.

These evaluation results serve as a powerful striving force and good direction for us to further promulgate CRM training to more KCC colleagues in our endeavour to continually improve quality and patient safety.

Table 1: Means and Standard Deviations (pre and post comparison) for Human Factor Attitude Survey (n=164)

Item (related to speaking up behavior only)Pre-training Mean (S.D.)

Post-training Mean (S.D.)

p-value

Q1. Team members should question the decisions or actions or the team leader during a procedure

3.65(0.63) 4.41(0.52) <0.001

Q14. The staff in my own department need training to” speak up” when they see something that is not right

3.71(0.75) 4.09(0.75) <0.001

Q20. If I perceive a problem with the event, I will speak up, regardless of who might be affected

3.66(0.67) 4.07(0.61) <0.001

Source: Research Final Report, document no. KCKE SOP001F9bTitle: Does Crew Resource Management Teamwork Training Have an Effect on Attitudes In Health-care Professionals?

• Over 80% find the lecture useful

• 84% think CRM is relevant to their job

• About 85% think CRM could increase patient’s safety and quality of care

QUALITY TIMES • Issue 21 • November 2015 The Hospital Authority Periodic Publication on Quality Improvement for Healthcare Professionals

Editorial Board Members:

Dr T L LEE CM(Q&St), HAHO

Dr Ian CHEUNG CM(CE&TM), HAHO

Ms Susanna LEE M(N)/CNO, HAHO

Ms Karen MAK SM(AH), HAHO

Mr William CHUI Hon Assoc Prof/CSC(PHAR), HKWC

Advisor:Dr Lawrence LAI Hon. Senior Advisor(Q&S), HAHO

Comments are welcomePlease email us at address: HO Quality & Standards Department

Dr K Y PANG Dep. SD(Q&S), HKEC

Dr K H LAU ASD(Info Mgt), HKWC

Dr Y W TSANG Con(Path), QEH

Dr N C SIN CSD(Q&S), KEC

Ms K P WONG CM(Q&S), KWC

Dr Michael CHEUNG C(CS), NDH

Ms Bonnie WONG CM(Q&S), NTWC

‘From Patient Safety to High Reliability’ What Have We Grown with the CRM Seeds? By Dr Benny Cheng, Chairman, CRM Committee, NTWC

Human errors are inevitable. Despite so, their consequences and threats can be mitigated by teamwork training using Crew Resource Management (CRM). Aiming at creating high reliability organizations, CRM has therefore been rolled out to various high risk industries of which the healthcare industry is not an exception.

Since kick-off in May 2013, out of the 45 workshops organized by NTWC, 2/3 and 1/3 were mixed specialty classes and tailor made co-organized classes with various specialties respectively. Nowadays, it is encouraging to know that not only high-risk specialties are actively supporting CRM training but also other departments such as pharmacy, psychiatry and radiology are requesting for tailor-made CRM workshops. To date, the Cluster has provided CRM training to more than 650 colleagues.

With the course evaluation based on the Kirkpatrick’s typology, analysis of the pre- and post-workshop questionnaires at 1-month and 1-year interval had revealed the following evidence:

Reaction Evidence: Not surprisingly, 99.1% participants were satisfied with the workshop.

Learning Evidence: The post-workshop evaluation at 1-month and 1-year interval showed:

- Positive attitude changes under the domains of Safety Attitudes Questionnaire (SAQ) e.g. teamwork, safety climate, perception of management and job satisfaction

- Significant improvement in knowledge about CRM after the workshop, and more importantly

- Substantial retention of knowledge about CRM even 1 year after the workshop.

Behavior Evidence: After the train-the-trainer program, CRM change agents of individual departments have conducted various training activities, e.g. Surgical Safety Checklist, Co-organized CRM training workshop, In-situ simulation drills, AED in-house CRM teaching activities and Checklist-guided Briefing and Debriefing Huddles in Operating Room. This showed that CRM concepts have been transformed into daily practice in the workplace.

Outcome Evidence: One year after the introduction of “Checklist-guided Briefing and Debriefing Huddles in Operating Room”, evaluation of its efficacy by using outcome indicators (such as “elective overrun”, “start-time delay for 1st elective case” and “same day elective cancellation”) showed good results and encouraging improvement. Since better OT utilization is a reflection of improved outcome, such evaluation results can serve as objective gauges of our team effectiveness.

All the above has positively reinforced our faith in pushing CRM training further forward to more colleagues in NTWC. After all, we value patient safety and strive for high reliability as the way to maintaining and improving our quality of service.