%% [[Leading]] tags:: #moc/publish | #on/crm | #centerformedicalsimulation | #on/research | #on/learning dates:: 2022-03-27 people:: #people/rebeccaminehart | #people/jennyrudolph %% # Name Claim Aim - Leading with Good Judgment Lon Setnik, MD FACEP MHPE 2024-01-27 *A [[Good Judgment]] framework for leading an ad hoc team. Name Claim Aim combines inclusive and strong leadership, creating a shared mental model, role clarity and task distribution in a brief, scripted and structured concept for success during teamwork moments.* # A story _It's your second shift in a new hospital which is rural and small, and you are called by the pediatrician that they are sending down "a kid that doesn't look good." It's a 12 year old with Down Syndrome who has been sick for a week with a cough and now has a fever, they got a chest x-ray and it shows a pneumonia with tension pleural effusion. It's 9 am so you are single-coverage, you have never met the three nurses that are on and look at the call list, see general surgery, anesthesia, and pediatrics available. You look at the x-ray while on the phone, take a deep breath and ask the unit clerk to "Get Everyone." The patient is carried in by mom, is dusky and cyanotic but fighting with mom, "I don't like the hospital. No shots." You look up and see the child, mom, nurses, anesthesia, surgeon, pediatrician, 7 faces that seem brand new. **So the big question is: How do I get and keep this team organized? How do I organize our work, figure out our resources, and safely stabilize then ship this child. What does leadership with Good Judgment look like in this moment?"**_ So I'd like to start by saying some words to help get us going, this will be an example of Name-Claim-Aim, applied to this situation, then we can break it down to understand it. "Name: Right now we know we have a child with a tension pleural effusion and pneumonia, maybe sepsis, we've never worked together before and we are going to need to stabilize this child for transfer. I'm hoping to get us organized, and I'm going to need your help. I'm thinking we need weight, vitals, access, O2, and a plan for drainage. I'm thinking nursing - Mary can you get a weight and start vitals, Lori can you get more history from mom, meds and allergies, Markus - are you RT? Can you start setting up age appropriate airway equipment. Dr. Ali can you set up for thoracentesis, Joanne as a CRNA can you help work with Markus for airway prep and medications for sedation. Now, what am I missing? What else do we need?" You hear, "We should call Kris, she was a PICU nurse and is great with access." Perfect, thanks, what else? %% #### NCA Examples Let's do some more examples: 1) You are handed an EKG showing a STEMI, you go to see the patient in the triage room after activating the cath lab, the code alarm goes off while you are walking to the room. The patient is unresponsive and a tech is trying to feel for a pulse, "there is no pulse" she says. Name: The patient just went unresponsive while having an MI, he has no pulse. He is probably in VF or VTach Claim: I'm going to get us organized, and I'll need your help, ok? OK? Aim: We need to start compressions and get him defibed right away if it's a shockable rhythm, Jamie, start compressions, Mark - grab the code cart. Jaqui get pads on. We want to get to see a rhythm as soon as possible. Now what am I missing? 2) A patient comes in with burns and trauma after an explosion at a propane filling tank. He has an IV but no vital signs because he is too agitated. You push ask the nurse to push ketamine, which she does, and the patient goes apneic and flaccid. Name: _"I don't understand what happened, I thought we pushed ketamine, but the patient is apneic and not moving. I'm thinking maybe they arrested, but they're not on the monitor."_ Claim: _"I'm going to get us organized, I need everyone's help, ok?"_ Aim: _"I'm thinking we need to check a pulse, rhythm, blood sugar, what am I missing?"_ Speaking up RN: _"I think the ketamine got flushed by Rocuronium instead of saline."_ %% ## What's the big idea? In dynamic and uncertain situations teaming takes on more importance than just the sum of task ability, meaning how people coordinate and work together is _at least as_ important as what skills team members have for doing tasks.(Tannenbaum & Salas, 2020) Data suggests that the first few minutes require more forceful organizing leadership (Cooper & Wakelam, 1999) in an emergency, but too forceful a leadership style can unintentionally suppress speaking up behaviors. We have been taught for 30 years to use the 11 Crisis Resource Management Principles, the challenge is remembering and implementing them in novel situations requires an incredible amount of cognitive energy. To date, there hasn't been a simple framework for _doing_ the key CRM principles in a crisis. We need an "ABC's" of teaming, a structured system that we is simple enough to learn and implement to make the most of our team situations. We also need learning systems that take us from novice to adaptive expert, despite the limited time we have for simulation in our clinical practice. Name - Claim - Aim can be a helpful "skin" covering the "ABC's" of leading and organizing a team. The simple system includes 10 of the 11 elements of crisis resource management ("excluding knowing your environment"). It can be rehearsed in simple situations, then moved up in difficulty both through learning experiences like simulation, as well as through every day activities, like running meetings. %% Medical teams coming together in a crisis are often made of people who don't work together regularly enough to be considered an intact team. Even if you know your teammates (which is increasingly rare in today's climate of locums, traveling, and working across systems) it is unlikely that teams responding to traumas, code blues, rapid responses, code strokes, etc. have enough familiarity with one another to be able to operate at maximum effectiveness without clear organization and leadership. Highly knowledgeable and experienced clinicians who assert strong unilateral leadership may unintentionally weaken mutual support and speaking up from their colleagues. Leadership that is too forceful runs the risk of not effectively harnessing the minds of the teammates, and speaking up can be unintentionally reduced. Ambiguous or weak leadership presence, not asserting enough clear guidance may unintentionally leave the team adrift and unsure of roles and action plan. The sweet spot of enough clarity and assertiveness by the leader that does not suppress collective action and participation is often obscure. So, a delicate balance is required between clear organization and explicit requests for input. Different people are more easily recognized as the leader depending on age, gender, ethnicity, height, or other factors that might play into the implicit bias. (Minehart et al., 2020) A key need is bridging the gap between theory and practice, (Salas et al., 2018) how do teams take the ideas of teaming and put them into action. %% Ad hoc teams facing a crisis need to:  1. Recognize that this is an ad hoc teaming situation 2. Define the task (Name) 3. Organize the team into tasks and roles (Claim-> Aim) 4. Do the work (take action) Team members and struggle on three dimensions of getting the team organized to manage the patient: - Privately versus shared mental model of the crisis/problem and plan - Leader inclusiveness and follower empowerment - Role clarity and placing the right person in the right job for their skill In other cultures or languages, other phrases can be developed that meet the same need - help people remember, learn, and teach the basics of these key 4 steps. The medical literature tells us we need to train our teams in Crisis Resource Management (CRM), (Gaba, 2010) a set of team behaviors that are associated with great team functioning, such as creating a shared mental model, cross monitoring, roll allocation, and maintaining situational awareness. But, we don't have a clear schema that we can call upon to "Do" CRM, or to teach to our learners. Thus, we need a framework that is flexible enough for the variety of situations at medical team might face, balances forceful organizing speech with explicit requests for speaking up and check-backs, and helps the team co-create a shared mental model of the emergency so they can respond appropriate to the idiosyncrasies of the skills of their team members as well as the unique situation in front of them. _CRM Principles_ ![[Pasted image 20240201111210.png]] ## Name - Claim - Aim NAME-CLAIM-AIM INFO GRAPHIC ![[Pasted image 20240201111239.png]] “the mnemonic “Name-Claim-Aim” was developed at CMS to incorporate 10 of the 11 CRM principles in an easy-to-remember, and easily applied, framework” (Salvetti et al., 2019, p. 73) Name-Claim-Aim (NCA) provides a schema, a structure, a framework that can be taught and learned, then put into action upon by the team leader. NCA contains explicit balance between leading and requesting help, between suggesting and asking for input, and helps us learn how to "Do" the essential steps of Crisis Resource Management from the position of the room organizer in uncertain and dynamic situations. NCA helps externalize the mental models, establish coordination in the first few minutes of an emergency, while increasing the likelihood that teams identify teaming as an important skill, identify with the team, and co-create knowledge and task alignment through balancing leading and speaking up. ### Reducing Stress By providing clarity on a [[shared mental model]], and the [[Relating]] involved with coordinating our work and our expectations for each other, we reduce [[cognitive load]], stress, anxiety, and make it easier for people to think and contribute. ## What is Name-Claim-Aim Example: A patient has gone unresponsive, you see VF on the monitor: Name: "That looks like VF!" Claim: "I'm going to get us organized. I'm going to need your help, ok?" Aim: "I'm thinking we need to start compressions and Defib as soon as possible. Jenny can you start compressions, Mark pads on, Leandra, run the defib, charge to 200 and clear and shock when ready. Now what am I missing?" _Breaking it down_ **Name** - What is the situation we are facing? - Let's co-create a [[shared mental model]] **Claim** - Identifying a leader, or the organizational structure the team needs (based on the situation) - What is my roll, your roll, and can I get your agreement to help? - use [[inclusive leadership]] - starts to get people aligned. Aligning is a process of empowering, joining, not just organizing. - By including the "I'm going to need your help, OK?" You demand a closed loop. You need the explicit acknowledgement that they will help you. You are modeling requiring being explicit with orders and closing the loop on this team. **Aim** - what are the next steps? Who will do what? - Depending on the situation this step can be more role oriented or more action oriented. - What should we look for that would change our mind? - **What am I missing?** - explicit request for speaking up - modeling humility - distributing situational awareness - Trying to distribute the workload - The leader needs to include some of the goals, some of the actions, possibly some roles. There is room here to explore the best AIM in different circumstances. ## Ad hoc teams in crises ### What is a team? A team is a group of individuals working together towards goals. A shift from “I” to “we.” Consider using "we" as often as possible. "We are getting two patients from this explosion. We will need to organize into two teams, and be flexible with our resources." We are in this together, for the patient. ### What is an ad hoc team? A team that does not routinely all work together on the shared tasks in the same roles. Even one new member changes the dynamic of a team, even a changed context changes the team. (Lingard, 2016) ### What is a crisis? A crisis is defined differently by different people. Crises can have different shapes (the slow crisis of climate change, the immediate crisis of a V-Fib arrest). ### Creating a [[shared mental model]] Best practices on naming include [[epistemic humility]], meaning be humble about how you know what you know. Use slight modifiers such as "This looks like ..." and "I'm thinking it's ..." these keep the door open to other points of view. The goals are avoiding diagnostic fixation, promoting the shared and accurate team mental model for treating the situation and remaining flexible and changeable as the situation evolves. Exposing the uncertainty can get everyone thinking. ### What is leadership and management? So many possible definitions, in this case we argue that the leader has the role of setting the direction of the team, and the manager has the role of organizing and getting the very best out of the team in a complex situation. (Kotter, 2001) The process of direction-setting involves gathering diverse information, analyzing the data, and identifying the likely best strategy. Aligning people is different than organizing, aligning requires hearts and souls to be harnessed, so people identify with the team. #### NCA Example Name: _"We've got an 8-year-old unresponsive after falling out a window. It's a Sunday and we don't have a pediatric surgeon in house, so Dr. Carla Smith is our team leader and she does mainly bariatric surgery."_ Claim: _"I'm thinking we should get organized, and I'll need everyone's help._" Aim: _"Since they're coming in BLS, they will need Airway, and we could re-organize from usual since the anesthesiologist is here. Why don't I take team lead since I'm comfortable with pediatrics, the Anesthesiologists will take Airway, and Dr. Smith can do the primary survey. How does that sound? What am I missing with that plan?" ### [[psychological ownership]] The leader needs psychological ownership of the task of teaming, and the team members need psychological ownership of contributing to the function of the team. All team members will need to: - Value organizing and coordinating a team as a highest priority within the work of the team - Value, practice, and perfect teaming skills in parallel with clinical skills - Form a personal identity as a valid leader or follower for a team - Hold frameworks, schema, and habits for implementing during crises - Rehearse these frameworks in progressively increasingly complex moments, both in life and in clinical and team training situations - create a shared organizational mental model about how teams work ## What is Good Judgment? [[Good Judgment]] is a fundamental set of values behind how we work at CMS. It includes 3 main attributes: 1) High standards for the work and high standards for the people 2) Transparent thinking 3) Use of conversational strategies designed to meet the moment ## Dilemmas and challenges - The challenge of organizing and maximizing effectiveness of a team: - cultural barriers - "The doctor is always the team leader" - if you don’t have a framework it's impossible to “do” CRM as because of too many things to pay attention to. - The tension of being the team leader while you are called on to do procedures - when the team thinks you are leading, but your attention is zoned in on a procedure - How to distribute leadership, situational awareness and decision-making through teammates and time - The tension between organizing and action - when you feel the need to act, but the team isn't organized ## An approach to teaching and learning NCA Consider a [[SimZones]] approach to learning: ### Overview: Zone 0: Start with self-directed practice. You can train generative A/I to provide you stems, or work in small groups to craft your Name-Claim-Aim messages and get peer or coach feedback Zone 1: Stand up activity - get case stems, assign roles, get clear concise feedback, try again Zone 2: put it into situations of increasing challenge Zone 3: practice with your real teams, in situ or in sim labs Zone 4: learn from your real experiences, have structured debriefs on how you organized as a team, what enabled success and what got in your way. ### Building automaticity? Considering NCA as a habit, what are the cues to start the habit cycle? What is the best [[environmental cues]] or triggers, how do you know when you even need to perform a Name-Claim-Aim moment? - We've been working on identifying when we are in an emergency - Maybe we need to identify when we are in a team. _Maybe we've been thinking about this wrong, maybe this isn't a crisis management tool but instead is a [[Teaming by Amy Edmondson]] tool._ We should start at the action level, with [[SimZones]] Zone 1: [[Rapid Cycle Deliberate Practice]] style: You can read about how we have taught this using a VR world simulator system called “e-Real” with our partners from Italy in the following source:(Salvetti et al., 2019). Just work on the Name in different situations of varying complexity, then build in the Claim and Aim. Many clinical teams struggle with the Claim, it is not typical for people to explicitly declare themselves the leader. I believe saying you will be the leader helps you take on the role of leader, and points your [[focus attention]] towards the teaming process. ### Hand gestures to increase retention #### NAME: ![[Pasted image 20240205105609.png]] #### CLAIM: ![[645534_people_512x512-2468621733.png]] #### AIM: ![[Pasted image 20240205105643.png]] ## How can you put this into practice in your organization? Conference on this idea, discuss with the interdisciplinary groups you'll work with, then practice and refine for your context. In essence, you need to create a shared mental model for what teaming looks like, then practice it, coach to it, discuss how it helped you. ### Adaptive Expertise Having a script keeps you from being in the moment. As a fixed schema, it potentially is less flexible for experts. What if you’re not perceived to be the leader? What does NCA look like then? How does your local culture respond? How does it help when we need immediate action, or at least there is the perception of need for immediate action? How do we balance action and planning? Are there situations where we just need to act immediately, and plan when we've stabilized? How much planning is right for this moment? ### Every day readiness - How do you take a framework like this and build it into your every-day work so you have it available when you need to call on it in a crisis. The brain in a crisis is a different brain, we can’t expect to do these skills to emerge during our most difficult moments if we can’t do them in every-day work, haven’t developed them as a habit, haven't built automaticity. ## Other languages: French: "Déclarer(declare)-Désigner(designate)-Déterminer(identification)" Arabic: "Enbaa (notification)-Enshaa(establishment)-Enjraa(execution)" ![[Name Claim Aim Arabic.pdf]] # Sources Cooper, S., & Wakelam, A. (1999). 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