Keywords: Crew Resource Management, CRM, Teamwork, STEP, STAR, healthcare

Summary of the three major concepts in the book: CRM, STEP and STAR

Let’s start with definitions:

CRM (Crew Resource Management) has been defined as the ways in which humans safely and effectively interact with hardware, software, and their fellow human beings. We have narrowed this definition to focus on team interactions that enhance safety and effectiveness. Our CRM model is a teamwork model modified from TeamSTEPPS and Team Dimensional Training. It consists of four skills:

• Exchanging Information: passing the right information to the right person at the right time.
• Communicating: transferring the information using the right formats, protocols, and terminology, followed by confirming that the information is understood.
• Leading: setting the expectations, standards, and climate for CRM; and Following: inquiring when unsure, and advocating and even asserting when safety is an issue.
• Mutually Supporting: providing task and social support and feedback to a team member to prevent, avoid or mitigate errors.

NOTE: These four skills are common to all organizations, teams, and situations: all teams must exchange information, communicate, lead and follow, and mutually support. The application of these skills, however, changes with different organizations, teams, and situations. What is the right information, the right format, the right climate, or the right task support will vary.

STEP (Status, Team, Environment and Progress) was also modified from TeamSTEPPS. It is a mnemonic that reminds you of the four areas necessary to achieve “big picture” situation awareness.

• Status: the condition of whatever your team is operating on (the operand), and the tasks being performed on the operand.
• Team: your colleagues (their roles and responsibilities, strengths and weaknesses, etc.) and how you expect them to interact (i.e., using CRM).
• Environment: everything external to your team (for example, physical environment, time of day, past decisions, organizational policies and practices, etc.).
• Progress: your performance against your team and individual schedules, times-to-effect, and margins. Time-to-effect indicates the amount of time available to perform a task in order to prevent a problem. Margin is defined as the extent to which a parameter (such as temperature or pressure) can increase or decrease before a contingency plan must be activated.

STAR (Stop, Think, Act and Review) derives from NASA’s Johnson Space Center Flight Operations Directorate (Houston, TX), which had its origins in Callaway Nuclear Power Plant operations (Fulton, MO). It is a mnemonic signifying the phases necessary for the execution of sound plans made from equally sound decisions.

• Stop: cease performing any tasks not essential to STEP and focus on the situation when faced with conditions that you did not expect.
• Think: divided into two sub-phases. First, identify the problem and the critical factors that determine success, or limit or enable possible courses of action. Second, decide on a course of action that meets all of the critical factors. Note: your decision-making may be based on your organization’s policies (codified), experience (naturalistic) or analysis (deliberate).
• Act: divided into two sub-phases. First, act to develop a plan that will implement your course of action. Second, act on (or execute) the plan. A key point to note here is that the use of CRM is required if you want your team to develop a sound plan, and then prevent, avoid, or mitigate errors during the execution of that plan.
• Review: the need to check that you are getting the result that you expect as your plan is executed in a step-by-step manner. That means checking whether you got the indications you expected after each step in a procedure. If not, then Stop and perform a STAR. Review must also be performed at the end of each phase of STAR (for example, at the end of the Think phase), at the end of your shift, and at any other pause in clinical activities. Are there CRM behaviors that you can improve prior to the next phase or shift?

How do these three concepts tie together? For a team to be safe and effective, every member must have the “big picture” (referred to as Total Situation Awareness in the book) so that he or she can perform his or her tasks and accomplish the team goals. However, be aware, that no one can have the ‘big picture’ by oneself. No one can see or hear everything that he or she needs to see or hear. No one can comprehend what all those perceptions mean now or project what they might mean in the future. You will need information that another team member has, or you will have knowledge that another team member needs. That is where CRM applies. CRM helps team members build the ‘big picture’ by exchanging the right information with the right person(s) at the right time, in the right way, in a team climate where team members feel comfortable asking questions, advocating or even asserting a contrary opinion, and supporting one another in stressful, error-prone situations.

However, what constitutes the “big picture”? The “big picture” requires that every team member possess situational awareness in all areas of STEP. Let’s use healthcare as an example, although this applies to other high-risk activities such as firefighting, spacecraft operations or oil drilling. Every team member must be aware of the following:

• Status: what is the condition of the patient and what interventions are being performed on the patient (for example, intubation)?
• Team: who are the team members? What are their roles and responsibilities, strengths and weaknesses, and the stressors they are experiencing? Is a physician fatigued or a nurse new to the organization? Every team member must also be aware how well the team is applying CRM skills. Is your team exchanging crucial information? Are team members using the proper formats? If not, what needs to be changed?
• Environment: is it 2 AM during an arduous shift? Are team members using non-standard equipment or working in an unfamiliar facility? What are the organization’s practices concerning CRM? What previous medical decisions have been made? How do any of these affect the current situation?
• Progress: are you and your team on schedule? Has your team determined if there are any times-to-effect or margins that must be monitored? How long have you been trying to intubate? What is the oxygen saturation level? How close is a time-to-effect (for example, you will go to Plan B in X seconds if Plan A is unsuccessful) or margin (you will go to Plan C if oxygen levels reach Y)? Which team member is monitoring what time-to-effect or margin? If a time-to-effect or margin reaches zero, does the team know what the contingency plan is and how to transition to it?

NOTE: There is no THE “big picture”. Each team member’s “big picture” is different based on different STEPs based on different roles and responsibilities. A physician’s “big picture” is different than a nurse’s or a respiratory therapist’s. However, team members’ “big picture” must agree on intersections and interactions. For example, the physician and nurse must agree on how their roles and tasks intersect (how the physician’s tasks affect the nurse and how the nurse’s tasks affect the physician) and how they need to interact (i.e., use CRM) to accomplish their tasks safely and effectively.

Finally, once all team members have used their CRM and STEP to develop their ‘big picture’, the team can use STAR. STAR is utilized to decide on the proper course of action and execute a plan while dealing with possible threats or errors. If, as you are performing a task, you get a result that you did not expect (such as a temperature higher than expected), even one better than expected, then Stop. Make sure that you are not distracted and have the cognitive resources to Think. What are you seeing or hearing? What are you not seeing or hearing that you should? Based on what you are seeing, what is the most likely problem? Are other team members seeing something different, or comprehending or projecting it differently than you, and therefore see a different problem? Use your CRM to figure out why there are differences. Once you decide what the problem is, do your organizational policies or experience tell you what to do? If not, do you need to look at various possible courses of action and weigh them against benefits, costs, and risks? Are other team members seeing different possible courses of action or different benefits, costs, or risks? Again, use your CRM to figure out why there are differences. Now you are ready to Act or develop a plan to execute the course of action. Are team members asking questions, appearing confused or have concerns about the plan? Hopefully, you have built a team climate where colleagues are comfortable asking questions and voicing concerns. As you develop a plan, make sure to embed CRM behaviors: when to exchange what information and with whom, in what format, and when threats or errors are most likely, what they might look like, and how to prevent, avoid, or mitigate them. Then, as you execute your plan, Review the results. Is the team confused about what procedure to do or why, not communicating clearly, making small errors or behind schedule? If so, perform a STAR: Stop what you are doing, and Think about why the team is not performing well. You can then Act to develop a plan to correct those problems. As you act on the new plan, you Review to ensure that the new plan is producing the results you expect. If not, then perform another STAR.

William S. O’Keefe has spent 25 years training CRM to high-risk occupations. He has trained healthcare, NASA astronaut and flight controller, firefighter, oil drilling, maritime and military teams.

Lacey L. Schmidt, PhD, is an Industrial-Organizational Psychologist with over 20 years of experience in helping select and train teams to thrive in extreme environments. She is also a recognized expert in occupational health psychology and faculty development.

Louis P. Halamek, MD, is a Professor of Pediatrics at Stanford University and a practicing neonatologist and Director of Neonatal Resuscitation at Packard Children’s Hospital. He is an internationally recognized expert in clinical debriefing.

Danny Castro, DO, MEd, is an Associate Professor of Pediatrics at Baylor College of Medicine and an attending physician in the pediatric intensive care unit at Texas Children’s Hospital. He is a recognized leader in graduate medical education.

Sharon P. Pickering, PhD, has over 20 years of international experience in human factors, both in research and safety-critical industries. She specializes in working with aviation, military, and healthcare teams to optimize human performance under stress in their highly complex environments.

A Practical Guide to Crew Resource Management for Healthcare Teams is available now in Hardback at a 25% discount. Enter code PROMO25 at checkout to redeem.

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