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100.08.02

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									醫療團隊資源管理 (Team Resource
Management, TRM) 簡介

          2011/8/2
     Presented by 黃敏信
Outlines

• TRM是甚麼東西的簡稱?
• 為什麼我們現在要推動TRM活動?
• TRM的內容是甚麼?
 – Team structure/Leadership
 – Situation monitoring
 – Mutual support
 – Communication
• 我的想法
                               2
TRM= Team Resource Management

• Crew Resource Management (CRM)
  – 1977/1978年各有一次嚴重空難
  – 1979年由NASA提出CRM
• TeamSTEPPS (Strategies and Tools to
  Enhance Performance and Patient Safety)
  – 2005年由AHRQ發展出TeamSTEPPS教材免費供醫學
    界使用
• 2009年醫策會引進TeamSTEPPS教材並命
  名為Team Resource Management (TRM)

                                            3
為什麼我們現在要推動TRM活動?

• For 即將到來的評鑑
 – 如同DOPS, OSCE, Mini-CEX, Healthcare Matrix …




                                                 4
2011年版教學醫院評鑑基準




                 5
衛生署2011年病人安全年度目標

• 目標六: 提升醫療照護人員間溝通的有
  效性
 – 落實交接班資訊傳遞之完整與及時性
 – 落實轉運病人之風險管理與標準作業程序
 – 落實醫療照護人員間醫囑或訊息傳遞的正確
   性
 – 檢驗、檢查、病理報告之危急值應及時通知
   與處理
 – 加強團隊溝通技能            6
為什麼我們現在要推動TRM活動?

• 難道只是為了應付評鑑?
• 促進病人安全
  – 醫療團隊成員互相提醒減少醫療錯誤


• “To err is human, to cover up is unforgivable,
  and to fail to learn is inexcusable.”
                                Sir Liam Donaldson




                                                     7
為什麼我們現在要推動TRM活動?

• 為了評鑑
• 促進病人安全
• 改變大醫院的組織文化改善我們自己的
  工作環境 讓大家活得快樂一點!




                       8
TRM的內容是甚麼?

• Content of TRM:
  – Team/Leadership
  – Situation monitoring
  – Mutual support
  – Communication




                           9
Team structure / Leadership

• Style of leadership
     權威式/獨裁式                 民主式
        Autocratic         Democratic
        Directive         Empowering
    Suitable for time-   Suitable in other
    urgent, high-stake      situations
        situations
    Contingency(權變): which is best
    depends on the situation                 10
領導技術工具

• Brief-Huddle-Debrief

  Brief    先簡報      事前說明   報告計畫

 Huddle    叫暫停      過程中之   解決問題
                     討論
 Debrief   來檢討      事後檢視   改善流程


                              11
Huddle




This is a huddle!

                    12
Situation Monitoring

• Cross monitoring
• S-T-E-P
• I’M SAFE




                       13
Cross Monitoring

• 為了病人的安全,多一些人幫忙是好的
• 一個人的眼睛能看到的東西是有限的…
 – 請看影片




                   14
S-T-E-P

S   Status of the patient   病患狀況

T     Team members          同仁狀況
E       Environment         周圍環境
P   Progress toward goal    邁向目標




                                   15
I’M SAFE Checklist
     醫療團隊成員的自主管理
 I              Illness

 M      Medication, menstruation

 S           Stress, sleep

 A         Alcohol and drugs

 F              Fatigue

 E   Eating and elimination (吃喝拉撒)
                                     16
What do you see?




                   17
Mutual Support

• Task assistance
  – 主動求援/主動協助
• Advocacy
  – Advocating for the patient (為病人代言)
• Assertion
  – Asserting your viewpoint (堅持立場)

However, advocacy and assertion may lead to conflict…
                                                        18
Conflict Resolution Options

• Two-challenge rule
• CUS
  – I am concerned…
  – I am uncomfortable…
  – This is a safety issue…
• DESC
  – Describe/Express/Suggest/Consequence
More on Conflict Resolution

• Two kinds of conflict:
   – Information conflict
   – Personal conflict
• Focus on what is right, not who is right.
• Choose the location:
   – Not in front of the patient or other team members
   – To focus on resolving the conflict rather than on
     saving face
• Use “I” statements rather than blaming
  statements
                                                         20
Communication

• SBAR
• Call-out (主動呼救/大聲通報)
• Check-back (回覆確認)
 – 3+3=33的故事
• Handoffs (確實交班)
 – I PASS the BATON (relay baton)


                                    21
SBAR
• 又名ISBAR 是一種標準化、結構化的溝通模式
• 適用時機: 護理人員向醫師報告、值班醫師向上報
  告、請人會診、病人轉床之交班…

S      Situation    現在問題點

B    Background    重要病史、目前用藥

A    Assessment    最近一次生命徵象、
                     檢驗數據
R   Recommendation   建議的處置
                             22
23
24
我的想法
• 教材中文化/本土化的困難
  – Huddle擠在一起? Baton 警棍?
  – Dictionary online is not a good tool.
• 實施的範圍
  – 全院?整個外科?開刀房?SICU?
• 如何呈現成果
  – 錯誤減少?(如何評估?)
  – 團隊合作氣氛改善?離職率降低?
• Extra time and extra effort without producing
  SCI papers…
                                             25
奇美醫院的TRM推動小組的成果   26
改變並不容易

         1. Create sense of urgency
         2. Guild the guiding team
         3. Develop a change vision &
         strategy
         4. Understanding & buy-in
         5. Empower others
         6. Short-term wins
         7. Don’t let up—Be relentless
         8. Create a new culture




                                         27
Thank you for your attention!




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