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.

Creating and implementing checklists to fix flaws in work processes is the “buzz” in health care right now. Fueled by the success of the WHO Surgical Safety Checklist in reducing post surgical infections and deaths, the mistaken view of checklists as the “magic bullet” for improvements in care is becoming more pervasive. 

After 10 years of experience helping hospitals create and implement effective checklists, one thing we know at LifeWings is that checklists, if done right, have their place and can significantly contribute to improving performance and care, but they are definitely not a magic fixall.

One common myth that reduces the magic of checklists is the idea that it is easy to take a successful checklist produced in another facility and by other people and just “drop it in” to your situation in your hospital. That rarely, if ever, works. There is no buy in, no investment, and no customization to your unit’s particular needs and work flow. Even the WHO checklist says on the very bottom of the sheet that individual customization of the checklist is encouraged.

Every checklist or safety tool must be created by the people who actually do the work - and not by administrators or managers, or worst of all, by people at another institution who have no idea what goes on in yours.

Research by the Robert Wood Johnson foundation and Plexus Institute on the concept of Positive Deviance supports this point. These entities funded a study on the work process improvement methodology called Positive Deviance (PD). PD is a concept of process improvement that solicits ideas for solving a problem from those who deal with that problem every day. It encourages the workers who actually do the work to think of a solution that might be considered “out of the box,” but nevertheless one that just might work.

This approach is the essence of Kaizen from the Toyota Manufacturing Process (Lean). It overcomes the natural human resistance to change by allowing frontline workers and their peers to solve their own work process problems. Thus, there is investment in their solution.

The concepts of Kaizen and PD are the key components of the methods LifeWings uses to help hospitals create and implement their own safety tools like checklists, communication scripts, handoff forms, and teamwork algorithms. We know from years of tough, hard-won experience that this approach works best of all.

So it’s not surprising the study from the R W Johnson Foundation reveals that using Positive Deviance to lower MRSA rates has succeeded. Their success with this approach was announced at the annual scientific meeting of the Society for Healthcare Epidemiology of America . The study began in 2006 and introduced the idea of Positive Deviance into three hospitals from different parts of the country. 

A team from the Centers for Disease Control and Prevention analyzed the data from these facilities to show a reduction in MRSA rates between 26 and 62%.

Proof that the best way to improve work processes is to make sure the people who actually do the work create the tools that improve their work.