NSPSS WORKGROUP 2: HUMAN FACTORS
WG - 2 human factors/behaviors/culture/high reliability
Batch: Identify principles, behaviors, and systems needed to improve surgical communication and leadership supporting a highly reliable and sustainable culture of safety.
• Andrew Grose, M.D.; Michael marks, MD, MBA; Frank Opelka, MD, Fred Shapiro, Thu;
Charlotte Guglielmi, MA, BSN, RN, CNOR
Workgroup two began with a discussion regarding Teams definition as a shared mental model.
In addition there is a Gap between reality in our working environment as opposed to recommendations being made by outside agencies.
The experience in Aviation showed that while you can put pilots in the simulator to train them away from their mistakes when you put them in the field, they make the same mistakes.
The bottom line is that We are prone to slips, mistakes, and lapses.
Error is a symptom- it is the starting point when we begin to understand how the event occurred.
"Error is actually a part of work".
To succeed We must adapt our tasks every day every minute of our lives.
Normal operations audits- Instead of distribution of rigid processes we should be asking "show me how you do this". Where does videotaping fall into this? We need to embrace non-punitive video feedback that can provide positive feedback and positive changes in our practice.
Professionals- a. we are all professionals and not providers b. Collegiality - we need a buddy system watching our colleagues. We all are at risk of mental distraction whether personal medical issues or personal issues (divorce, litigation) and we need to watch on another. C. We should move out past telling organizations this needs to be espoused in ACGME and medical school d. Disruptive behavior is not the same as dangerous behavior. I can disrupt a process when I see a danger but that is not the same as the dangerous surgeon.
We should be cautious about endorsing specific training MOC because they may change and no longer be desirable.
Is it required to have the Whole team present during trying when the team is actually in flux- the
Trauma video recording. Candice Greenberg - Observation coaching and feedback is extremely proactive and helpful if used as a non-punitive training methodology. Self assessment and learning. You cannot use this as a policing activity but as a coaching tool. Rhode Island 2009 video auditing w staff not being aware. Wisconsin state legislature is pushing for mandated videotaping if asked by the patients.
Crew vs teams- CRM is consistent whereby team training may not be. Teams imply a consistency to the membership.
Empowering staff- staff must be empowered to create a hard stop and not be afraid to slow the OR schedule. No one is NOt paying attention- everyone is paying attention. Surgeons must empower the staff. Errors in diagnosis can be reduced by second eyes by engaging professionals in the room to speak up. Educate professional students how to respond to that situation.
The task cannot be checking the box on the checklist but the actual task you are validating.
unprofessionalism may be secondary due to frustration when the staff is not providing the support needed to optimally care for the patient and this can be dangerous. Staff and the surgeon needs to be prepared. If someone is new you need to ask if they are prepared.
We need to ask if stress and fatigue is really bad or if we need to train people in stress and fatigue recognition (asking for help) and management and response. We need to understand that chronic stress and fatigue is debilitating. Avoiding stress altogether may not be possible.
The purpose of simulation is to allow one to crash a plane and not kill anyone but mitigate risk in real situations. We cannot undervalue that training.
Team stepps was originally to instill team trust which is ultimately needed to manage conflict. Pilot monitoring is only via audio and not video, because they did not trust the administrative agencies.
IQ may not be modifiable but EQ - emotional intelligence is trainable.