SaferPatients

You can’t get to 100% on your core measures.

The usual mantra is to ‘try harder’. Trying harder is impossible when you’re already trying as hard as you can.

But you can always try different.

In addition to my work for LifeWings I also fly an MD-11 for FedEx. We guarantee your package will be there overnight. On time. A 99.99% success rate won’t cut it. If we deliver 7 million packages a day, that means 700 will not make it on time to the right place and right person. These 700 service failures would be honest mistakes, made by smart, dedicated people working as hard as they can.

No matter how hard we try, we wouldn’t do better than 99% on effort alone. So we rely on a system completely different from what most organizations do. Same number of people, same number of hours working, 100% accuracy.

We added teamwork to the mix. The type of teamwork and collaboration wherepeople cross-check one another,  speak up when needed, and catch the inevitable slips, trips, and lapses that humans make - to detect and correct errors before the package is late. Or, before the patient doesn’t get antibiotics on time, or doesn’t get an aspirin on check in.

If it’s not working, harder might not be the answer. Creating a culture of accountability might be.

(Note: This post comes from Steve Montague, one of our Vice Presidents at LifeWings.)

In “Turning Doctors into Leaders,” Thomas Lee correctly notes, “team building is a critical competency for physician leaders.”  While this is clearly a necessity, Atul Gawande illuminates the pathway by which physician leaders will learn to lead; by leading a multi-disciplinary team in the OR, ED, ICU, etc.  The distributed competencies present in a modern clinical context will significantly underperform their joint capability if they are lead in an autocratic style, or not lead at all.  Dr. Gawande points out that medicine is wise to borrow from other professions (such as Sullenberger, et al) and there is a ready model for medical schools to emulate if they wish to adequately prepare tomorrow’s physicians to be servant leaders; the U.S. Service Academies. 

The first step is to clearly articulate the expectation that physicians lead.  For example, if you ask an auditorium of freshmen (or plebes) at Annapolis, “Who in this room is a leader?” there will be a sea of hands up in the air in spite of their lowly status.  Conversely, I never get a similar response from medical students, nor even residents.

Once medical students sign on as future leaders, the medical school must provide a curriculum consisting of academics and low cost of failure leadership opportunities using interdisciplinary simulation.  This allows individuals to experiment and find their specific leadership style. 

Finally, leadership must be evaluated and included in any consideration of residency or fellowship.  If it’s measured, it matters.  Whether leading a multi-disciplinary team, or serving as the leader of colleagues, an admiral or a department chair must know how to lead long before assuming the title.

(Steve is a graduate of the U.S. Naval Academy.)

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.

Here’s the account of a surgeon falling asleep in the OR during two successive surgeries. The story appeared in the Boston Globe.

“When Dr. Loren J. Borud began his first case at about 8 a.m., an operating room nurse noticed he looked tired and wobbly. She was so concerned, according to one account of the Friday last June, that she suggested Borud postpone his next patient.

Borud said he had been up all night working on a book, but he kept operating, starting a second case, during which he briefly fell asleep, according to a report from state investigators. The nurse again called him aside and suggested “maybe he should take a break,” according to her interviews with investigators, but he continued the surgery.

The operating room nurse called the plastic surgery department twice to report Borud’s behavior that morning and early afternoon, the report said, and the office nurse told her to “keep an eye on him.” But no senior surgeon or administrator ordered Borud to stop operating - even though there was widespread awareness of his history of drug and alcohol abuse, according to investigators. Read more »

I just got off the phone with the Associate Dean of Clinical Effectiveness at a large hospital in the south. His institution, like everyone else it seems, has spent a lot of time and attention on the HCAHPS results that now show up on the HHS Hospital Compare web site. Read more »