In this series, Steve Kreiser describes a model for applying aviation’s crew resource management to healthcare. This model incorporates different elements inherent in most CRM programs but has an additional benefit of including simple error prevention tools and techniques that help reduce human error. These seven tools, essentially a “people bundle” to make humans more reliable, can help individuals experience fewer errors while encouraging teams to catch and trap those errors that do still occur in complex systems. The series concludes with this article.
Element #7 — Decision Making
People make decisions, or choices, based on their knowledge of the current operating environment and their past education or experience. This past education or experience is stored in the human brain in the form of rules. The human brain perceives a situation, scans for a rule from its long-term memory, recalls and then acts to apply the rule. James Reason calls this rule-based performance.1 Most of the common choices people make in everyday life are rule-based in nature. This usage does not imply policy or law — it means operating principle. In common speech it would be referred to as knowledge. For a clinician, knowledge is stored as rules, and when a situation presents itself for which care providers are well prepared and trained, they recall and apply that rule. Experienced staff and physicians have a vast system of well-established rules they can recall in milliseconds, while novices have a more limited number of rules from which they can draw to make informed decisions.
All humans make errors from time to time. Rule-based errors come in three varieties. The first one is called wrong rule. In this situation the person actually learned the wrong answer thinking it’s the right answer, and thus they have stored the wrong rule in their long-term memory and every time they recall and apply the rule, it’s a mistake.
The second type is wrong application of a rule. In this case the person has the right knowledge — they know the right rule — but they are confused or mixed up in their thinking. In healthcare this is most often referred to as a critical-thinking breakdown.
The third variety of rule-based error is non-compliance with a rule. In this case they knew the rule, thought about it at the time, but then made a conscious choice not to comply, usually thinking they can get the same or better result with lesser effort.
To optimize good decision making as it applies to CRM, teams should strive to use all available sources — information, equipment, and people — to avoid these rule-based errors. Teams are most effective when they cross-monitor to inform one another if a wrong rule or wrong application of a rule error has been made. They can also hold each other accountable to comply with those rules they know they should be using as part of safe practice habits.
High Reliability Tip #7 — Use all available sources — information, equipment, and people — to make good decisions, while cross-monitoring using peer checking and coaching to catch one another’s errors.
A recent study published in the Journal of the American Medical Association measured the effects of a team-training program on patient outcomes. This research demonstrated an 18% reduction in annual patient mortality rates for teams that had gone through training in CRM concepts and theory, compared with a 7% decrease for the control group who did not receive training.2 This data is compelling and supports the need for CRM training to optimize the outcomes of high-performing teams.
The benefits of CRM training have been well known in the aviation industry for years, yet despite the best efforts of many healthcare organizations they have not been widely embraced in the medical community — largely due to perceived difficulties in implementation and sustainability. A simple roadmap is needed for organizations to integrate CRM concepts within their operating rooms, emergency departments, intensive care units, OB departments, and anywhere teams of individuals work closely with others on high-risk, safety-critical tasks.
The model presented in this series — seven simple elements to help teams make better use of their resources, share information more efficiently, and make better, more informed decisions — has been designed to help teams in this effort to perform more effectively, with the ultimate goal of reducing events of patient harm.