SaferPatients

This week’s post comes from the monthly CRM Newletter produced by Memorial Healthcare System in Hollywood, FL. Memorial is ranked as the 6th best place to work in health care by Modern Healthcare magazine. The article, reproduced here in it entirety was written by Dr. William Perryman, Chief of Cardiac Surgical Services at MHS. Dr. Perryman’s article will give you a sense of why Memorial is such a great place to work.

“Performing pediatric cardiac surgery in a foreign country with a support team from a variety of centers can sometimes be challenging to get everyone on the same page. This is a similar situation to that often faced by airline crews and was the genesis for the development of Crew Resource Management (CRM).

On a recent trip to the University of the West Indies (UWI) Hospital in Jamaica, we had the opportunity to use CRM during surgery for 7 children having complex cardiac surgery. The OR team had surgeons, anesthesiologists, perfusionists, OR nurses, residents and students from Joe DiMaggio Children’s Hospital, Jackson Memorial Hospital, University of Florida Shands Hospital and host UWI Hospital.

The equipment that we used was, at times, different from case to case and different from MRH (Memorial Regional Hospital). The perfusionists were using whatever cannulae they could find and anesthesia was using drugs, sometimes, with different names than they were used to in US. I was operating with a different faculty member each day or a resident.

As you can imagine, this is a very similar scenario to airline crews who arrive for a flight on equipment that may vary, with a flight crew who have never flown together before and a cabin crew who face the same challenge.

CRM allowed all present to understand each component of the operation, what adaptation might be needed and what specific “stuff” would be required for that particular child. CRM proved to be an excellent solution to an ever-changing operating room scenario and allowed us to leave with all children safely managed through their operations and returned to delighted and grateful parents. CRM also provided a template that could be continued after our departure.”

Dr. Perryman is correct. Airline pilots frequently fly with other pilots and flight attendants whom they have never met before, and with aircraft mechanics, dispatchers, and air traffic controllers whom they have never worked with before.

The Captain of the flight has just a few moments to create an effective team that utilizes expert communication and collaboration skills to detect, catch, and correct the inevitable small mistakes and errors humans make before those mistakes become serious or fatal. The blueprint for creating this expert team from a group of aviation experts is crew resource management (CRM).

As Dr. Perryman’s experience clearly shows, CRM is the blueprint for even widely disparate, international medical experts to creat an expert medical team. If CRM can work in that environment, it can work anywhere.

In addition to my work with LifeWings, I am an international Captain on the MD-11 aircraft for FedEx Express. I’ve been flying professionally for 33 years. Every year for 33 years I have had to undergo a competency check, either in the real airplane or in a simulator. For 24 of those 33 years I have had two competency checks per year in a simulator - for a total of 48 checks.

This week I just completed my annual competency check in the MD-11 simulator, and it was one of the most challenging tests I have ever had in aviation.

What was interesting about this check is that the basic strategy for testing my competency as a captain was completely different from anything I had ever experienced before. For years the approach to testing aviation skills was much like batting practice. Get in a simulator and demonstrate to the check pilot that you could handle a long list of potential malfunctions and emergencies. The list never varied from year to year - engine failures, electrical problems, hydraulic malfunctions, wind shear recoveries, and landings in bad weather - all accomplished at the same simulated airport. 

The disconnect with the real world is that the inability to fly the maneuvers and handle the emergencies tested annually in the simulator are rarely the cause of accidents. Prior to the advent of teamwork training for airline crews, almost 80% of airline accidents were caused primarily by a breakdown in the teamwork and communication skills of the flight crew.

Thus, the check ride for this year had a totally different approach. During the briefing for the test, the company check pilot was very clear the purpose of the event was to check my ability to operate the airplane safely by using both a high level of technical competence and effective teamwork and communication skills (CRM) with my co-pilot. Could we solve complex problems in a challenging scenario by working together effectively while simulating a regular flight from Point A to Point B? No batting practice this time.

In short, could I manage the human factors?

When you think about what really causes airline accidents this evaluation emphasis makes sense.

Our test involved a simulated flight from Taipei, Taiwan to another airport in Taiwan just 30 minutes away. The scenario tested our ability to respond to a potentially deadly wind shear, thunderstorms, an unexpectedly closed airport, holding patterns, a divert to Hong Kong, gusty winds, poor visibility, difficult to understand controller language, an engine failure, another minor engine malfunction, another divert from Hong Kong to an airport in mainland China, low fuel, and an approach and landing in bad weather conditions.

After two and a half hours of intense concentration I was totally spent. Without a technically competent co-pilot, and exceptionally effective teamwork and communication, we couldn’t have carried the flight off safely. Had I not listened to the co-pilot’s inputs and suggestions I would have made a couple of serious mistakes. Had she not listened to me she would have made a few too. 

Together, we crosschecked everything, detected and corrected our small mistakes before they became serious or potentially fatal, and eliminated the human factor of fallibility as a source of undetected deadly error.

We demonstrated how two technical experts could also function as an expert team.

My experience this week makes me think of the application to health care. The data on why medical mistakes happen is almost identical to that of aviation. Seventy to 80% of preventable medical errors have some sort of communication error as the main cause. Almost 70% of sentinel events have a breakdown in teamwork and communication as a primary cause.

If the causes are the same for both professions - the cure might be similar too. A commitment to more and better designed simulation training, and effective teamwork training and checklist usage for everyone will go a long way for improving patient safety and quality outcomes.

Surgeons involved in the WHO Surgical Safety Checklist research project were asked if they would continue to use the checklist after the research project was complete. Eighty percent (80%) said it was so benefical that they would continue to use it in their practice.

Twenty percent said “No” - they didn’t need it.

The follow up question asked, “If you were the patient, would you want your surgeon to use the WHO Safety Checklist?” This time, a lot of the surgeon’s resistance melted away. Ninety-four percent (94%) said in effect, “Yes, my surgeon should use the checklist if operating on me.”

I wonder what their patients would say if they knew their surgeon was one of the ones who didn’t want to use the checklist personally, but wanted their own physician to use it when operating on them. I think the question might go something like this, “If using the checklist is good for you when you are a patient, why isn’t it good for me when I am your patient?”

Data like this demonstrates a truism that I have stumbled onto in my work helping hospitals implement effective checklists…

Human beings, even physicians, make their decisions to do something on an emotional basis and then seek data to support the decision they have made.

The survey results from the surgeons’ involved in the WHO study show all of us that logic and data don’t always carry the day in convincing others to support our change initiative. Think about it, these are surgeons involved in a hugely successful world-wide study producing peer-reviewed data showing a 35% decline in complications and deaths. The data is near conclusive. (As Al Gore would say, “The science is settled.”) Yet, 20% of the physicians involved said they wouldn’t continue to use the checklist.

These results reveal that we should never forget the power of the personal and emotional factors needed to motivate others to change.

When recruiting support for your change initiative - whatever the project may be - never forget to answer the age old question for your colleague, “What’s in it for me?” (WIIFM) Make sure that answer is something that affects them personally and on an emotional level.

This concept is one we devote quite a bit of time to in our Leadership Development training when implementing LifeWings in a hospital. The ability to communicate your project goals in a meaningful, and ultimately successful way by simultaneously combining data, logic, and emotions in your appeal is a critical leadership skill.

If you don’t have that level of communications skill, or ignore the power of the emotions in your project communications, you cripple the chances of success for your initiative.

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Since I last made a blog entry you no doubt saw the all of the coverage of Capt. “Sully” and the miraculous ditching of the crippled A-320 in the Hudson river in New York City.

Lately, I have had a lot of questions from medical audiences about the event during my public speaking. Everyone wants to know the inside story. Read more »

With the advent of the World Health Organization (WHO) surgical safety checklist, a lot of facilities in the U.S. are trying to implement a checklist as a vehicle to accomplish the Universal Protocol (Time Out). Not everyone who tries it succeeds, and they seem very surprised when they don’t.  Why? Read more »