1. ©2014 Louis P. Halamek, M.D. Defining, Achieving and Documenting Proficiency in Neonatal Resuscitation Louis P. Halamek, M.D., F.A.A.P. Professor, Stanford University Attending Neonatologist, Packard Children’s Hospital Director, Center for Advanced Pediatric and Perinatal Education halamek@stanford.edu

2. ©2014 Louis P. Halamek, M.D. Safe and Effective Patient Care accomplished via appropriate use of pharmaceuticals Center for Drug Evaluation & Research devices Center for Devices & Radiologic Health procedures institutional review boards hospital credentials committees

3. ©2014 Louis P. Halamek, M.D. Safe and Effective Patient Care Yet at the center of all patient care is not a drug, device or procedure but a human being who must possess a skill set commensurate with the demands of working in his or her particular specialty or subspecialty. Human performance is therefore the key to safe and effective patient care.

4. ©2014 Louis P. Halamek, M.D. I. Defining Proficiency in Human Performance

5. ©2014 Louis P. Halamek, M.D. Proficiency the ability to do something successfully AKA expertise in healthcare effective efficient safe the ability to do something successfully AKA expertise in healthcare effective efficient safe

6. ©2014 Louis P. Halamek, M.D. Proficiency depends on… intrinsic human capacities cognitive: knowledge, decision-making, critical thinking physical: vision, hearing, strength, coordination, dexterity behavioral: leadership, teamwork, management of stress

7. ©2014 Louis P. Halamek, M.D. Proficiency depends on… extrinsic environmental factors aka ergonomics three branches cognitive physical organizational

8. ©2014 Louis P. Halamek, M.D. cognitive ergonomics how human mental processes influence human-human/human- system interactions simultaneous arrival of distinct data streams, each of which requires processing by the same cognitive resource, producing data overload

9. ©2014 Louis P. Halamek, M.D. physical ergonomics interplay of human somatic, physiologic and biomechanical characteristics (size, shape, strength, etc.) with the environment patient bed that cannot be raised/lowered to adjust to the height of healthcare professionals

10. ©2014 Louis P. Halamek, M.D. organizational ergonomics effect of overt/subtle structures, policies and processes on human- human/human-environment interactions deficiencies in institutional culture resulting on ineffective communication and poor teamwork

11. ©2014 Louis P. Halamek, M.D. Proficiency: The Big Issues What intrinsic human abilities are necessary to carry out this task and how can each be evaluated? What environmental factors affect the ability of the human beings to perform this task? What distinguishes individual vs team performance? How can performance over time be rated?

12. ©2014 Louis P. Halamek, M.D. What is proficient performance in neonatal-perinatal resuscitation? For example, a single task such as intubation…

13. ©2014 Louis P. Halamek, M.D. Proficiency in Intubation cognitive elements indications for intubation recognition of these indications type and size of equipment indicators of a successful intubation recognition of these indicators

14. ©2014 Louis P. Halamek, M.D. Proficiency in Intubation technical elements assembling the laryngoscope holding the laryngoscope inserting the laryngoscope to expose the airway to view position in 3-D space in relation to airway structures force exerted per unit area of tissue

15. ©2014 Louis P. Halamek, M.D. Proficiency in Intubation technical elements holding the endotracheal tube inserting the endotracheal tube into the airway to the proper depth assessing position of the endotracheal tube securing the endotracheal tube at the proper depth

16. ©2014 Louis P. Halamek, M.D. Proficiency in Intubation behavioral elements communicate effectively regarding the need for intubation, specific pieces of equipment, etc. distribute workload so that specific tasks are assigned to the team members most likely to carry them out successfully. maintain situational awareness

17. ©2014 Louis P. Halamek, M.D. Defining Proficiency if multiple skill sets (cognitive, technical and behavioral) are required to successfully complete a task, proficiency must be defined in terms of all of those skill sets Halamek LP. J Pediatr 2007;151(4):329-30

18. ©2014 Louis P. Halamek, M.D. II. Achieving Proficiency

19. ©2014 Louis P. Halamek, M.D. Achieving Proficiency refining human skills cognitive study technical repeated practice on task trainers behavioral simulation

20. ©2014 Louis P. Halamek, M.D. Achieving Proficiency refining intrinsic human capacities cognitive: critical thinking receive feedback physical: hand-eye coordination sports behavioral: eye of the hurricane multiple difficult sims

21. ©2014 Louis P. Halamek, M.D. Achieving Proficiency optimizing extrinsic environmental factors cognitive: unambiguous data streams clear, concise com (FAA) bedside monitor display (Boeing) physical: adjust bed height organizational: support for training create a culture of continuous evaluation and feedback

22. ©2014 Louis P. Halamek, M.D. Proficiency is achieved by practicing doing the right thing under highly realistic conditions.

23. ©2014 Louis P. Halamek, M.D. Simulation is practice.

24. ©2014 Louis P. Halamek, M.D. III. Documenting Proficiency

25. ©2014 Louis P. Halamek, M.D. Documenting Proficiency at a minimum, assess skills cognitive technical behavioral

26. ©2014 Louis P. Halamek, M.D. Cognitive Proficiency content knowledge written/online examination multiple choice fill-in-the-blank/essay oral examination

27. ©2014 Louis P. Halamek, M.D. Technical Proficiency procedures skills stations, task trainers simulations

28. ©2014 Louis P. Halamek, M.D. Behavioral Proficiency how one applies cognitive skills and implements technical skills while working with colleagues

29. ©2014 Louis P. Halamek, M.D. Specific Behavioral Skills know your environment anticipate and plan assume the leadership role communicate effectively distribute work load optimally know your environment anticipate and plan assume the leadership role communicate effectively distribute work load optimally allocate attention wisely utilize all available information utilize all available resources call for help early enough maintain professional behavior allocate attention wisely utilize all available information utilize all available resources call for help early enough maintain professional behavior Halamek LP, et al. Pediatrics 2000;106(4):e45-e50

30. ©2014 Louis P. Halamek, M.D. Documenting Proficiency probe more deeply by analyzing each skill in terms of intrinsic human capacities vision, dexterity extrinsic environmental factors physical layout of room joint MD/RN/RT training opportuities

31. ©2014 Louis P. Halamek, M.D. It should be acknowledged that: 1) neonatologists must possess and apply a wide range of cognitive, technical and behavioral skills, and 2) the skills of a neonatologist are influenced by intrinsic human and extrinsic environmental factors.

32. ©2014 Louis P. Halamek, M.D. Any assessment of performance that fails to take into account these realities is incomplete and simplistic at best and inaccurate and misleading at worst.

33. ©2014 Louis P. Halamek, M.D. The best assessments of performance objectively assess one’s intrinsic capacities while on the job working in the real environment. We need the equivalent of the commercial aviation “check ride”.

34. ©2014 Louis P. Halamek, M.D. Thank you. Lou Halamek halamek@stanford.edu