What Do We Really Know About Crew Resource Management in Healthcare?: An Umbrella Review on Crew Resource Management and Its Effectiveness

OBJECTIVE

The aim of this article was to present an overview of the crew resource management (CRM) literature in healthcare. The first aim was to conduct an umbrella review on CRM literature reviews. The second aim was to conduct a new literature review that aims to address the gaps that were identified through the umbrella review.

METHODS

First, we conducted an umbrella review to identify all reviews that have focused on CRM within the healthcare context. This step resulted in 16 literature reviews. Second, we conducted a comprehensive literature review that resulted in 106 articles.

RESULTS

The 16 literature reviews showed a high level of heterogeneity, which resulted in discussing 3 ambiguities: definition, outcome, and information ambiguity. As a result of these ambiguities, a new comprehensive review of the CRM literature was conducted. This review showed that CRM seems to have a positive effect on outcomes at Kirkpatrick's level 1, 2, and 3. In contrast, whether CRM has a positive effect on level 4 outcomes and how level 4 should be measured remains undetermined. Recommendations on how to implement and embed CRM training into an organization to achieve the desired effects have not been adequately considered.

CONCLUSIONS

The extensive nature of this review demonstrates the popularity of CRM in healthcare, but at the same time, it highlights that research tends to be situated within certain settings, focuses on particular outcomes, and has failed to address the full scope of CRM as a team intervention and a management concept.

A quality improvement initiative to reduce venous thromboembolism on a gynecologic oncology service

OBJECTIVE

To describe and evaluate the effects of implementation of a venous thromboembolism (VTE) prophylaxis quality improvement (QI) initiative on a gynecologic oncology service at a single institution.

METHODS

Prior to 2018, no consensus gynecologic oncology VTE prophylaxis protocol existed at the authors' academic institution. Published, evidence-based guidelines were reviewed to create a standardized VTE risk stratification algorithm. Interventions to improve perioperative heparin administration and sequential compression device (SCD) compliance as well as provider/patient education efforts were introduced in January 2018. Initial efforts included nursing and patient SCD education, internal dissemination of VTE prophylaxis guidelines, and creation of a VTE 'dashboard' to track performance. During a second phase, VTE prophylaxis guidelines were reviewed and further refined, non-compliant operative cases reviewed weekly, and guidelines incorporated into the electronic medical record. Performance was measured using Tableau data software (www.tableau.com) and by separately evaluating adherence to the developed guidelines in three retrospective cancer-enriched surgical cohorts (2016-2017, 2018, 2019).

RESULTS

Compared to the baseline period, we observed a reduction in VTE rate during the 2018-2019 VTE QI implementation period from 2.1% (19/905) to 1.0% (20/2015, p = 0.02) among gynecologic oncology inpatients. In the retrospective cancer-enriched cohorts, adherence to evidence based guidelines improved: 31.0% in 2016-2017, 69.1% in 2018, and 82.4% in 2019 (p < 0.001). There were no significant differences in rates of peri-operative blood transfusion, surgical site infections, hematomas, or vaginal cuff dehiscences.

CONCLUSIONS

Implementation of a robust VTE prophylaxis QI initiative has resulted in improved VTE prophylaxis guideline adherence and higher rates of pre-operative heparin administration.

Improving Team Performance and Patient Safety on the Job Through Team Training and Performance Support Tools: A Systematic Review

Introduction

Efforts to improve teamwork in health care have received considerable attention. The current systematic review was conducted to identify recent studies that implemented practices to improve teamwork and were associated with positive improvements on the job.

Methods

Electronic searches of 2 databases (i.e., CINAHL and MEDLINE) were conducted to identify relevant articles published between 2008 and 2018.

Results

Twenty articles were selected for inclusion in this review. The studies most often used quasiexperimental designs and interventions were applied in a variety of hospital settings including labor and delivery, operating rooms, and emergency departments. Across studies, measures assessing teamwork skills on the job were most often collected and showed sustained improvements up to 12 months. Moreover, evidence of improved clinical processes (e.g., compliance with guidelines and efficiency) and increased patient safety (e.g., reduction in adverse events) was found in both studies of team training interventions, as well as in those that introduced performance support tools (e.g., checklist).

Conclusions

The results of the current review are consistent with previous research and add to the evidence base on the practices to improve teamwork within hospital settings. Although efforts to improve teamwork have spread to other health care settings such as office-based care, published studies are lagging behind.

Teamwork and Surgical Team-Based Training

Effective teamwork, both in and out of the operating room, is an essential component of safe and efficient surgical performance. There are multiple available assessment tools for evaluating teamwork and important contributors to teamwork such as safety culture and nontechnical skills. Multiple types of interventions exist to improve and train providers on teamwork, and many have been demonstrated to improve not only teamwork but also patient outcomes. Teamwork strategies can be adapted to different contexts, based on provider needs and resources.

Implementation of Crew Resource Management: A Qualitative Study in 3 Intensive Care Units

Objectives

Classroom-based crew resource management (CRM) training has been increasingly applied in health care to improve safe patient care. Crew resource management aims to increase participants' understanding of how certain threats can develop as well as provides tools and skills to respond to such threats. Existing literature shows promising but inconclusive results that might be explained by the quality of the implementation. The present research systematically describes the implementation from the perspective of 3 trained intensive care units (ICUs).

Methods

The design of the study was built around 3 stages of implementation: (1) the preparation, (2) the actions after the CRM training, and (3) the plans for the future. To assess all stages in 3 Dutch ICUs, 12 semistructured interviews with implementation leaders were conducted, the End-of-Course Critique questionnaire was administered, and objective measurements consisting of the number and types of plans of action were reported.

Results

The results categorize initiatives that all 3 ICUs successfully launched, including the development of checklists, each using a different implementation strategy. All ICUs have taken several steps to sustain their approach for the foreseeable future. Three similarities between the units were seen at the start of the implementation: (1) acknowledgment of a performance gap in communication, (2) structural time allocated for CRM, and (3) a clear vision on how to implement CRM.

Conclusions

This study shows that CRM requires preparation and implementation, both of which require time and dedication. It is promising to note that all 3 ICUs have developed multiple quality improvement initiatives and aim to continue doing so.

Eliminating Critical Incident Tracking Network Patient Safety Events at a Veterans Affairs Institution Through Crew Resource Management Training

The objective of this study was to determine whether rates of Critical Incident Tracking Network (CITN) patient safety adverse events change after implementation of crew resource management (CRM) training at a Veterans Affairs (VA) hospital. CRM training was conducted for all surgical staff at a VA hospital. Compliance with briefing and debriefing checklists was assessed for all operating room procedures. Tracking of adverse patient safety events utilizing the VA CITN events was performed. There was 100% adherence to performance of briefings and debriefings after initiation of CRM training. There were 3 CITN events in the year prior to implementation of CRM training; following CRM training, there have been zero CITN events. Following CRM training, CITN events were eliminated, and this has been sustained for 2.5 years. This is the first study to demonstrate the impact of CRM training on CITN events, specifically, in a VA medical center.

Cultural Transformation After Implementation of Crew Resource Management: Is It Really Possible?

Crew resource management (CRM) has the potential to improve safety culture and reduce patient safety errors across different hospitals and inherent cultures, but hospital-wide implementations have not been studied. The authors examined the impact of a systematic CRM implementation across 8 departments spanning 3 hospitals and 2 campuses. The Hospital Survey on Patient Safety Culture (HSOPS) was administered electronically to all employees before CRM implementation and about 2 years after; changes in percent positive composite scores were compared in pre-post analyses. Across all respondents, there was a statistically significant increase in composite score for 10 of the 12 HSOPS dimensions ( P < .05). These significant results persisted across the 8 departments studied and among both practitioners and staff. Consideration of score changes across dimensions reveals that the teamwork and communication dimensions of patient safety culture may be more highly influenced by CRM training than supervisor and management dimensions.

Lessons in flying: crew resource management as a quality improvement method for acute coronary syndromes care

Providing timely, high-quality, guideline-based care to patients with acute coronary syndromes (ACS) who present to the emergency department is critically dependent on cooperation, coordination, and communication between emergency medicine physicians and cardiologists. However, to achieve sustained improvement at the individual institution level, consistent implementation of quality improvement (QI) activities is needed. We describe a QI initiative for ACS care in the emergency setting that combined clinical education with a curriculum based on crew resource management (CRM) principles-a set of tools and techniques for communication, teamwork, and error avoidance used in the aviation industry and with proven applicability in the healthcare setting. Educational training sessions were open to multidisciplinary healthcare teams at 3 hospital sites, and participants were provided practical tools and resources to enhance communication, teamwork, and patient-centered care. Through patient chart reviews, participant surveys, and clinician interviews, baseline assessments of clinical performance measures and team communication-, logistics-, and skills-based efficiencies were performed and reported before the educational training was delivered at each QI site. Reviews of pre- and postinitiative participant surveys demonstrated improvement in knowledge and confidence in the delivery of appropriate and effective ACS care; however, reviews of pre- and postinitiative patient charts revealed limited process improvements. Altogether, this multicenter study of a continuing medical education program based on CRM principles was associated with improvements in provider knowledge and confidence regarding the delivery of appropriate ACS care, but had limited impact on clinical performance measures.

Team-training in healthcare: a narrative synthesis of the literature

BACKGROUND

Patients are safer and receive higher quality care when providers work as a highly effective team. Investment in optimising healthcare teamwork has swelled in the last 10 years. Consequently, evidence regarding the effectiveness for these interventions has also grown rapidly. We provide an updated review concerning the current state of team-training science and practice in acute care settings.

METHODS

A PubMed search for review articles examining team-training interventions in acute care settings published between 2000 and 2012 was conducted. Following identification of relevant reviews with searches terminating in 2008 and 2010, PubMed and PSNet were searched for additional primary studies published in 2011 and 2012. Primary outcomes included patient outcomes and quality indices. Secondary outcomes included teamwork behaviours, knowledge and attitudes.

RESULTS

Both simulation and classroom-based team-training interventions can improve teamwork processes (eg, communication, coordination and cooperation), and implementation has been associated with improvements in patient safety outcomes. Thirteen studies published between 2011 and 2012 reported statistically significant changes in teamwork behaviours, processes or emergent states and 10 reported significant improvement in clinical care processes or patient outcomes, including mortality and morbidity. Effects were reported across a range of clinical contexts. Larger effect sizes were reported for bundled team-training interventions that included tools and organisational changes to support sustainment and transfer of teamwork competencies into daily practice.

CONCLUSIONS

Overall, moderate-to-high-quality evidence suggests team-training can positively impact healthcare team processes and patient outcomes. Additionally, toolkits are available to support intervention development and implementation. Evidence suggests bundled team-training interventions and implementation strategies that embed effective teamwork as a foundation for other improvement efforts may offer greatest impact on patient outcomes.