Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High Stakes Enviroment

229 Pages·2008·3.79 MB·English

by  Michael St. Pierre

Michael St.Pierre
Gesine Hofinger
Cornelius Buerschaper
Crisis Management in Acute Care Settings
Michael St.Pierre
Gesine Hofinger
Cornelius Buerschaper
Crisis Management
in Acute Care Settings
Human Factors and Team Psychology
in a High Stakes Environment
With 47 Figures and 12 Tables
123
C. Buerschaper
Woehlerstrasse 12
10115 Berlin
Germany
E-mail: [email protected]
G. Hofinger
Hohenheimerstrasse 104
71686 Remseck
Germany
E-mail: [email protected]
M. St.Pierre
Department of Anesthesiology
University of Erlangen
Krankenhausstrasse 12
91054 Erlangen
Germany
E-mail: [email protected]
Library of Congress Control Number: 2007931732
ISBN 978-3-540-71061-5 Springer Berlin Heidelberg New York
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Preface
All of life is problem-solving weaknesses as human decision makers, this book
(Sir K.R. Popper) attempts to provide an outline of the way the hu-
man mind operates. Humans think and act the
Providing safe patient care in an acute care setting way they do because the underlying psychological
has always been, and still is, one of the greatest mechanisms provide an efficient approach to cope
challenges of healthcare. On a regular basis health- with environmental demands. In contrast to wide-
care professionals are faced with problems that are spread belief, errors are not the product of an irra-
sudden, unexpected, and pose a threat to a patient’s tional or deficient psychological mechanism but in-
life. Worse still, these problems do not leave much stead originate from useful processes as well. Some
time for in-depth reflection but instead demand of them, such as communication patterns, can be
thoughtful action despite the need for swift deci- changed, whereas others cannot: Our perception,
sions. This, as most of us know only too well, is far attention, motivations, feelings, and thoughts are
easier said than done: Time pressure, uncertainty, not entirely subject to our will.
stress, high stakes, erratic team processes, and or- But not only individual performance obeys cer-
ganizational shortcomings all intermingle in a task tain rules; the same is true for teamwork. As acute
environment which makes good decisions and suc- medical care is never a one-man show, but rather
cessful management a critical endeavor. the result of many professionals on different lev-
The capability to master these challenges, how- els of a healthcare organization cooperating for a
ever, requires more than profound medical know- patient’s well-being, the knowledge of successful
ledge and clinical expertise: A set of skills are strategies to improve team performance can create
needed that will enable healthcare professionals to an ever safer clinical environment.
reliably translate knowledge into safe patient care Finally, errors in healthcare are not random
despite varying and often hindering circumstances. events. They are rooted in systemic causes which
These skills are the subject of this book. Thus, you are deeply embedded in the architecture of health-
will not encounter any information concerning the care organizations and are amenable to change. The
clinical management of critical situations through- totality of these individual, team-related, and orga-
out the entire book: no guidelines; no algorithms; nizational factors that influence our decisions and
and no recommendations. Many excellent text- actions are called “the human factors.” The human
books have been written on the medical aspect of factors are decisive for the outcome of complex so-
crisis management in acute medical care settings; cio-technical systems, such as healthcare.
therefore, another book of that kind is not yet war- There are basically two approaches you can take
ranted. Instead, the present book focuses on peo- to this book: You can follow the text according to
ple, on the healthcare providers from a vast array its inner logic, or you may prefer to read selected
of specialties and professions who are expected to chapters. Both approaches are valid. The book has
manage the unexpected: nurses; physicians; para- a modular character in which every chapter stands
medics; and technicians. All of them have their alone and can be read without knowledge of pre-
defined set of technical and nontechnical skills vious chapters. In order to avoid excessive redun-
which enables them to manage critical situations. dancy, basic concepts are explained only once and
All of them can also improve their performance by then are cross-referenced.
thoughtful application of basic theories on human Every chapter follows the same internal logic: A
decision-making and action. case study from an acute care specialty illustrates
At the same time, though, all healthcare pro- central aspects of the subject matter and is then
viders suffer from inescapable cognitive limita- taken as the reference point for further exposition
tions that contribute to errors and hinder success- of the topic. Every chapter provides answers to the
ful crisis management. In order to help healthcare same questions: “What is the relevance of the mat-
providers to better understand their strengths and ter? Which problems can be explained by this par-
I Preface
ticular human factor? What can we transfer into our volved in the team process. The characteristics and
clinical task environment and how can we apply the pitfalls of teamwork (Chap. 11) are followed by an
knowledge to improve patient safety?” To enhance outline of communication (Chap. 12) and leader-
practicability the chapters on individual and team ship (Chap. 13), the two main factors of successful
factors (Chaps. 5−13) offer “tips for daily practice” teamwork.
which comprise many helpful clinical suggestions. Section IV focuses on the influence that health-
Every chapter ends with a short paragraph which care organizations have on the performance of their
summarizes the essentials of the chapter. providers. Basic organizational theories as well as
The first section of the book addresses basic systemic models that enhance patient safety are
principles of errors, complexity, and human be- presented (Chap. 14). The final chapter (Chap. 15)
havior. Chapter 1 sets the stage by providing a sur- develops an outline for a comprehensive concept
vey of published data on the incidence of human of organizational development which could help
error and accidents in acute medical care. A body healthcare institutions to avoid and better manage
of research underscores the significance of the hu- clinical errors.
man factors in both, the development as well as the The clinical relevance and the practicability of
prevention and management of errors in a medi- this book has been our major concern; therefore,
cal high-stakes environment. Chapter 2 describes we tried to formulate the text in an easy-to-read
the characteristics of acute medical care as a com- and common language, devoid of psychological
plex-task domain where errors are bound to occur. jargon. As we tried to build every chapter around
Chapter 3 contrasts two current perspectives on a case study from different acute medical care en-
error and provides workable definitions on error. vironments, we hope to have brought even more
In Chap. 4 we paint a basic picture of the “psycho- sophisticated psychological theories “down to
logic” of human behavior, which will enable the earth.” In writing this book we had in mind physi-
reader to understand how humans arrive at deci- cians, nurses, technicians, and paramedics as target
sions. groups. Hopefully, they will all be able to benefit
The structure of the second section follows the from the book.
structure of human action as a problem-solving For us, creating this book was teamwork ex-
process. It focuses on the limitations that the basic perience at its best. The writing process was very
cognitive architecture and thinking patterns of the challenging yet certainly fruitful. We are grateful
human brain impose on decision-making and ac- to have learned a great deal from the different per-
tion. The individual chapters outline human percep- spectives clinicians and psychologists have on the
tion (Chap. 5), information processing (Chap. 6), same problem, and from the divergent approaches
goals and plans (Chap. 7), attention (Chap. 8), and to problem-solving. We hope that the reader will
the impact of stress (Chap. 9). The final chapter of benefit from this process as well.
the section, Chap. 10, focuses on how healthcare Finally, because all of us contributed to every
providers can arrive at good decisions, the ultimate chapter, all of us take responsibility for the inevi-
goal of the problem-solving process. table errors as well. We are grateful for any remarks
Section III broadens the perspective by shifting concerning the content of this book as well as for
the focus from the individual healthcare provider clues to misperceptions and/or errors in the text.
to the team and the relevant human factors in-
II
Acknowledgements
Our ideas have been shaped by many colleagues, tion of the German original would not have taken
among whom we must single out Dietrich Dörner, its current shape without the encouragement and
head of the Department of Psychology at the Uni- support of our valued friend Robert Simon, Center
versity of Bamberg (Germany). He has been a great for Medical Education, Boston, and the very practi-
teacher and we are grateful for the many years of cal assistance of Alina Lazar and Jonathan Bernar-
collaboration. His book “Logic of Failure” has been dini, both anesthesia residents at Harvard Medical
a great inspiration to us, exemplifying how even School, who edited all of the case studies.
the most sophisticated matters of psychology can Last but not least, our families have contributed
be made accessible and readable. In addition, we considerably to the success of our work: thank you
thank our colleagues of the Department of Psy- to Ulrike St. Pierre and Michael Brenner, and to
chology at the University of Bamberg for their seven very patient children.
friendship, support, and ideas. Prof. Schüttler, chair Finally, one of the authors would like to dedicate
of the Department of Anesthesiology, University of this book to his father, Roland St. Pierre, for whom
Erlangen (Germany), has been, and still is, one of a dream has come true.
Germany’s leading proponents of simulation-based
training in acute medical care. His personal support July 2007
has encouraged us to pursue our goal of providing Michael St.Pierre
a comprehensive handbook on human factors for Erlangen
healthcare providers. Many healthcare profession-
als, both physicians and nurses, contributed to the Gesine Hofinger
final version of this book. Their critical review of Remseck
the manuscript and their helpful corrections added
much to the clarity and understandability of our Cornelius Buerschaper
thoughts; however, the translated and revised edi- Berlin
IX
Contents
I Basic Principles: Error, Complexity,
and Human Behavior
1 The Human Factors: Errors and Skills ................................. 3
1.1 Case Study .............................................................. 4
1.2 Human Factors in Healthcare: the Problem ............................ 4
1.3 Levels of Human Factors ................................................ 5
1.4 “The Human Factors”: in a Nutshell ..................................... 13
2 The Challenge of Acute Healthcare ................................... 17
2.1 Case Study .............................................................. 18
2.2 Medical Emergencies and Critical Situations ........................... 18
2.3 Complexity and Human Behavior ...................................... 19
2.4 The Skills, Rules, Knowledge (SRK) Framework ......................... 24
2.5 “The Challenge of Acute Medical Care”: in a Nutshell .................. 26
3 The Nature of Error .................................................... 29
3.1 Case Study .............................................................. 30
3.2 What is an “Erorr”? ...................................................... 30
3.3 How Can Errors Be Classified? .......................................... 32
3.4 The Dynamics of Accident Causation ................................... 36
3.5 “The Nature of Error”: in a Nutshell ..................................... 37
4 The Psychology of Human Action ..................................... 39
4.1 Case Study .............................................................. 40
4.2 The “Psycho-logic” of Cognition, Emotions, and Motivation ............ 40
4.3 Principles of Human Behavior .......................................... 41
4.4 Motivation .............................................................. 44
4.5 Emotions ............................................................... 46
4.6 Thinking ................................................................ 49
4.7 Hazardous Attitudes .................................................... 51
4.8 “Principles of Human Behavior”: in a Nutshell .......................... 52
II Individual Factors of Behavior
5 Human Perception: the Way We See Things ........................... 57
5.1 Case Study .............................................................. 58
5.2 From Stimulus to Sensation: Sensory Physiology ...................... 58
5.3 “Gestalt” Theory and Meaningful Patterns: the Organization
of Visual Perception .................................................... 60
5.4 Recognition and Creating Meaning .................................... 63
5.5 Perception and Emotion ................................................ 64
X Contents
5.6 Tips for Clinical Practice .............................................. 64
5.7 “Perception”: in a Nutshell ............................................ 65
6 Information Processing and Mental Models: World iews .......... 67
6.1 Case Study ............................................................ 69
6.2 The Organization of Knowledge: Schemata and Mental Models ..... 70
6.3 Are We Too Lazy to Think? Economy, Competence, and Safety ....... 71
6.4 Wishful Thinking and Reality: Distortion of Information ............. 72
6.5 Illusions: Inadequate Mental Models ................................. 73
6.6 What Is likely? The Handling of Uncertain Information ............... 75
6.7 Tips for Clinical Practice .............................................. 78
6.8 “Information Processing and Mental Models”: in a Nutshell .......... 79
7 Goals and Plans: Turning Points for Success ........................ 81
7.1 Case Study ............................................................ 82
7.2 Setting and Elaboration of Goals ..................................... 83
7.3 Planning .............................................................. 87
7.4 Tips for Clinical Practice .............................................. 90
7.5 “Plans and Goals”: in a Nutshell ...................................... 90
8 Attention: in the Focus of Consciousness ........................... 93
8.1 Case Study ............................................................ 94
8.2 The Control of Action: Attention, Vigilance, and Concentration ...... 94
8.3 Open for News: Background Control and the Horizon
of Expectations ....................................................... 96
8.4 Situation Awareness .................................................. 98
8.5 Disturbances of Attention ............................................ 98
8.6 Tips for Clinical Practice .............................................. 101
8.7 “Attention”: in a nutshell .............................................. 101
9 Stress ................................................................. 103
9.1 Case Study ............................................................ 105
9.2 What is Stress? ........................................................ 105
9.3 Coping Mechanisms .................................................. 112
9.4 Overwhelmed by Stress .............................................. 113
9.5 Coping with Stress .................................................... 114
9.6 The Role of Organizations in Reducing Stress ........................ 116
9.7 “Stress”: in a Nutshell ................................................. 116
10 Strategies for Action: Ways to Achieve Good Decisions ............ 119
10.1 Case Study ............................................................ 120
10.2 Strategies for Good Actions .......................................... 120
10.3 Strategies for Coping with Error ...................................... 125
10.4 Tips for Clinical Practice .............................................. 127
10.5 “Strategies for Action”: in a Nutshell .................................. 127
III The Team
11 The Key to Success: Teamwork ...................................... 131
11.1 Case Study ............................................................ 133
1
XI
Contents
11.2 The Team ............................................................. 133
11.3 Team Performance: Input Factors .................................... 136
11.4 Team Process ......................................................... 139
11.5 The Result: Successful Team Performance ............................ 142
11.6 Strengths of Teams ................................................... 143
11.7 Why Teamwork Can Go Wrong ....................................... 143
11.8 Tips for Daily Practice ................................................. 145
11.9 “Teamwork”: in a Nutshell ............................................ 145
12 Speech is Golden: Communication .................................. 149
12.1 Case Study ............................................................ 151
12.2 Organizing the Chaos: Functions of Communication ................ 151
12.3 Understanding Communication ...................................... 153
12.4 General Disturbance of Communication ............................. 158
12.5 Poor Communication in Critical Situations ........................... 160
12.6 Good Communication in Critical Situations .......................... 163
12.7 Communication After a Critical Situation ............................ 168
12.8 Tips for Daily Practice ................................................. 169
12.9 “Communication”: in a Nutshell ...................................... 169
13 Leadership ........................................................... 173
13.1 Case Study ............................................................ 175
13.2 The Case for Leadership .............................................. 175
13.3 Leadership Theories .................................................. 177
13.4 A Conceptual Framework for Leadership ............................. 178
13.5 Leadership Tasks in a Critical Situation ............................... 180
13.6 The Process of Leading ............................................... 181
13.7 Leadership Problems in Critical Situations ........................... 182
13.8 Situational Leadership ................................................ 184
13.9 Tips for Daily Practice ................................................. 184
13.10 “Leadership”: in a Nutshell ............................................ 184
I The Organization
14 Organizations and Human Error ..................................... 189
14.1 Case Study ............................................................ 190
14.2 Organizations as Systems: Different Perspectives .................... 191
14.3 Organizations, Human Error, and Reliability .......................... 192
14.4 Organizational Sources of Error ...................................... 195
14.5 “Organizations and Human Error”: in a Nutshell ...................... 201
15 Reliable Acute Care Medicine ....................................... 203
15.1 Case Study ............................................................ 205
15.2 Business Objective: Patient Safety .................................... 206
15.3 Avoidance of Error .................................................... 208
15.4 Error Management ................................................... 215
15.5 Imagine the Future: Safe Acute Medical Care ........................ 219
15.6 “Reliable Acute Care Medicine”: in a Nutshell ........................ 224
Subject Index .................................................................. 229
I
I  Basic Principles:  
Error, Complexity,  
and Human Behavior
1 The Human Factors: Errors and Skills
2 The Challenge of Acute Healthcare
3 The Nature of Error
4 The Psychology of Human Action
> The first section of the book addresses the relevance of human error as a con-
tributory factor to incidents and accidents in acute medical care. Basic prin-
ciples of human error, complexity, and human action are outlined.
Chapter 1 focuses on “the human factors” which provide both, the potential
to trigger critical situations as well as the skills to master them. An overview
of published data on the incidence of human error and accidents in acute
medical care underscores the fact that human behavior dominates the risk
to modern socio-technical systems such as healthcare. Nevertheless, the hu-
man factors should never be equated with “risk factors,” because they also
include “nontechnical skills” which enable healthcare providers to cope with
critical situations.
Healthcare in a high-stakes environment has a number of properties that
make it considerably more challenging than decision-making in an every day
context. Chapter 2 describes these characteristics which psychologists call
the “complexity of a working environment.” The response of healthcare pro-
fessionals corresponds with the levels of familiarity with a task or an environ-
ment. These varying levels at which behavior is controlled are described.
Chapter 3 provides workable definitions on error and contrasts two current
perspectives (consequential and causal classification) which give rise to two
different approaches to deal with human fallibility (person-based and sys-
tem-based approach). Emphasis is placed on the fact that accidents occur as
a result of latent conditions which combine with other factors and local trig-
gering events to breach the defensive barriers of the system.
Chapter 4 attempts to provide understanding about how humans arrive at
decisions. The “psycho-logic” of human action regulation is presented which
conceptualizes that human behavior does not strictly follow the consistency
of logical arguments but instead is always influenced by motivation and
emotions. The combination of all three factors gives rise to decisions and,
hence, action.