Training Top 125 Best Practice: University of New Mexico Hospitals’ LoboWings Crew Resource Management Program

LoboWings incorporates Crew Resource Management (CRM) skills and tools adapted from commercial aviation to improve and standardize communication and teamwork for safe patient care at University of New Mexico Hospitals (UNMH). This program provides a foundation for effective interdisciplinary practice and problem solving, process improvement, Lean methods, etc.

UNM teams have used LoboWings concepts to:

• Ensure clear staff roles and accountabilities
• Improve accuracy of team communication and functions
• Reduce/eliminate inefficiency, delays, and rework
• Catch, correct, and eliminate preventable errors before they can result in patient harm

Program Details

The program was initiated in 2009 to improve patient safety, quality, teamwork, and communication in UNMH’s main operating rooms. At the time, the main ORs were experiencing the effects of professional “silos,” a culture of disrespect and individualism, and an inability to recruit and retain staff, resulting in dependence on contract nurses (travelers) to sustain operations. Other approaches to process improvement and team development had been tried unsuccessfully.

Implementation included change management training for leaders, CRM skills training for all staff, and selecting and training an interdisciplinary team responsible for developing and implementing “hardwired safety tools” to standardize and streamline practices and overcome human limitations that can lead to error. Among the tools created: 

• A scripted pre-procedural “time-out” (enlisting all team members to participate in confirming details about the patient and procedure before surgery)
• Hand-off communication checklists
• A post-procedure debrief process to capture what worked well and opportunities to improve

Results

Within 18 months of LoboWings implementation, UNMH went from 50 nurse travelers on staff to two, and at three years its main ORs had not experienced a single major sentinel event (an error exposing a patient to potential loss of life or function). These and other process improvements and practice changes have resulted in a 5 percent annual growth rate in volume of surgical procedures.

UNMH’s successes in surgical services spurred the desire to expand LoboWings to other areas. CRM concepts and tools have translated well to other departments and produced good results, including:

• Emergency Medicine developed a hand-off communication tool that reduced missed medications, diagnostics, and therapeutics.
• OB-Gyn developed an emergency C-section time-out tool, improving team availability and function, and reducing C-section wound infection rates.
• Interventional Radiology developed a time-out tool recognized as a “best practice” by The Joint Commission (the regulatory agency that accredits health-care organizations for the Centers for Medicare and Medicaid Services or CMS).
• Adult and Pediatric Behavioral Health Services developed a more effective, collaborative management structure, resulting in improved communications and teamwork across Behavioral Health components, and between Behavioral Health and the Medical-Surgical system.
• Psychiatric Emergency Services instituted a shift huddle, resulting in a shared mental model for clinic operations and cohesive teamwork.
• The Trauma-Surgical-Burn Intensive Care Unit (TSICU) standardized infection prevention practices, resulting in zero urinary tract infections for five straight months and zero bloodstream infections for six months. Also, after implementing a “fall bundle,” TSICU experienced zero patient falls with harm in more than a year.
• The Neuroscience Intensive Care Unit implemented similar infection prevention measures, reporting zero central line-associated bloodstream infections (CLABSI) in six months and has seen the annual rate of catheter-associated urinary tract infections (CAUTI) fall from 25 in 2018 to 14 in 2019—a 44 percent reduction.

LoboWings expansion and system improvements are ongoing. New staff and medical/nursing/pharmacy students receive CRM training to foster and sustain a culture of patient safety. Fiscal year 2018 had 389 participants and 300 attendees at the annual inter-professional training event.