Home

Cover Story

Table of Contents

E-Newsletter

Article Archive

Editorial Calendar

Datebook

Writers' Guidelines

Orgs/Links

Opinion Polls

Reprints

Forum

July 17, 2006

Help From Above — From Cockpit to Hospital: Adopting a Culture of Safety
By Kim M. Norton
Radiology Today
Vol. 7 No. 14 P. 30

In 1977, a communication mix-up led to the collision of two B747 aircraft, one of which was taxiing and the other of which was taking off. In 1978, a DC-8 aircraft crashed short of the runway because it ran out of fuel due to confusion among the crew. These two accidents and many others prompted the aviation industry to reevaluate the way crews functioned.

The result was the adoption of Crew Resource Management (CRM) training, a program designed to teach staff to work as a team and “effectively use all available resources.” Twenty years after the airline industry implemented this strategy, the Institute of Medicine released To Err is Human, which highlighted the inefficiencies within healthcare and the abundance of medical errors. It reported that between 44,000 and 98,000 patients die every year due to medical errors.

“The healthcare industry today is where the aviation industry was in the early 1980s,” says Richard Clark, an airline pilot who is vice president of LifeWings, a Memphis, Tenn.-based company that applies aviation safety tools to healthcare. Clark says just as a culture change was necessary in aviation, it has become apparent that the same measures are needed in healthcare to improve patient safety and reduce medical errors.

Inspired by the Institute of Medicine report and the success of CRM, the culture of medicine is slowly evolving from one of individuals working together to one of teamwork, which fosters open communication and a willingness to listen across authority gradients. “Teamwork in general is a momentum that is gaining within the healthcare industry,” explains James Battles, PhD, senior service fellow for patient safety at the Agency for Healthcare Research and Quality in Rockville, Md. “Unfortunately, though, the task of implementing a teamwork mentality is ultimately falling onto the healthcare organization’s shoulders rather than being taught at the residency and medical school levels.”

When people speak about a safety culture, they must recognize that humans are fallible. “But, traditionally in the healthcare industry, there has been a reluctance to speak about risk because of the litigious nature of our society,” Battles says. The healthcare profession has seen itself as having to be perfect so the shift to a culture of safety is one of openness where problems are addressed and resolved with effective communication, which has long proved less than optimal in healthcare, he says.

“By employing CRM principles to a hospital setting, the goal is to improve communication across healthcare disciplines, ingrain the concept of teamwork, and reduce medical error. All these will ultimately improve patient safety,” says Clark.

The Nebraska Medical Center
In 2005, J.D. Power and Associates recognized The Nebraska Medical Center (NMC) for service excellence under its Distinguished Hospital Program. According to J.D. Power and Associates, “The Nebraska Medical Center performed especially well compared to the national study in the speed and efficiency with which the staff delivered care to their patients, receiving high marks from patients on the nurses’ performance of their regular duties and the doctors’ coordination of care with nurses.”

The primary teaching hospital for the University of Nebraska Medical Center (UNMC), NMC is a 689-bed facility known for its organ and bone marrow transplantation services as well as its oncology, neurology, and cardiology programs. In addition to the main campus, the hospital has affiliations with the Eppley Cancer Center to do further research on cancer treatments and the Lied Transplant Center, which houses a 24-hour clinic, research labs, and suites for transplant and cancer patients and their families.

According to J.D. Power and Associates, NMC received high marks for its patient satisfaction and teamwork abilities. But, there is always room for improvement and just as several other healthcare institutions have taken on the task of reducing medical errors and improving communication among physicians, nurses, and other necessary hospital departments, so has NMC. In August 2005, NMC and LifeWings began working together to assist the medical center in improving the way it practices medicine.

“The decision to begin a patient safety program at NMC was an easy one. Anything we can do to improve communication among our staff, while improving our patient satisfaction, is vital,” explains Chief Medical Officer Stephen Smith, MD. In fact, Byers Shaw, Jr, MD, chairman of the Department of Surgery in the College of Medicine at UNMC, was already working with LifeWings to revise resident training when Smith’s office began negotiations. “We both knew this was something that we should address and began the training program last year,” says Smith.

Safety Through Education
Any training program will inevitably begin in the classroom and LifeWings’ model is no exception. However, Clark says LifeWings’ program differs in that it is designed to be incorporated into the fabric of the hospital—to become a part of the culture—and demands that the hospital and its staff take ownership of its principles for it to be considered a success.

Six years ago, LifeWings emerged from Crew Training International, Inc. to begin working with providers to change the way healthcare professionals communicate with each other through espousing CRM’s benefits and intricacies. CRM’s five guiding principles are:

• situational awareness;

• communication skills;

• teamwork;

• task allocation; and

• decision making.

According to Clark, the LifeWings management team tailored these five points to the healthcare industry and developed a training plan that can help improve a hospital’s bottom line by reducing malpractice cases, having fewer medical errors, increasing efficiencies, and improving patient satisfaction. To accomplish these feats, the company designed a specific skills-based training program designed for the hospital setting that features a standardized lexicon, not unlike aviation speak, to enable the hospital to be a truly multidisciplinary team.

Other items LifeWings has adapted to the healthcare industry include Hardwired Safety Tools that enable the surgical team to identify and eliminate errors, says Clark. “NMC and LifeWings have created checklists, briefing guidelines, transfer checklists, and most importantly, we created measurement plans so management is able to quantify the successes of CRM,” he says.

All these tools are designed to reinforce the CRM mentality and help those who may regress into old habits. The intention of any healthcare system that hopes to adopt a patient safety program is one of lasting change. “CRM is not a flavor-of-the-month approach to improving patient safety in medicine nor is it a way to practice cookie-cutter medicine,” Clark says.

Tackling a Culture Change
“In many operating rooms [ORs], there is a hierarchy among the surgical team members and a delineation between what is each member’s responsibility,” explains Smith. “Through the LifeWings program, NMC is intent on changing the way surgical teams communicate with each other, [thereby] reducing adverse events, improving efficiency, and avoiding delays.”

The training of select surgical teams began in February with the cardiovascular, oral, maxillofacial, and orthopedic teams. Following the training period came the building of essential tools to incorporate into the training and assist the teams in staying focused and on task. Such tools include going beyond the JCAHO “Time-Out” verification before the surgery begins, Smith says.

“Instead of the nurse going over the preoperative verification, the first thing our teams do before commencing the surgery is to introduce themselves,” Smith says. The surgeon then runs the pre-op brief, which is a thorough and detailed checklist that includes contingency plans if any issues arise, he adds. “Other tools that we have implemented through the LifeWings’ training are standardization procedures. Instead of the nurse saying, ‘Yes, the patient’s name is John Doe,’ she will actually look at the patient’s wrist bracelet before answering. Think of it as a ‘check’ on the checklist,” says Smith. A similar confirmation could apply to any images available for use during the procedure.

Following the surgery, as the patient is being sutured, the surgeon will debrief the team. “There is a candid look at the procedure and a discussion as to what went right, wrong, and what we can do better,” explains Smith. The team will also address what tools they may or may not need to make the surgery more efficient. “It is the information obtained in the debrief that will assist us in standardizing specific procedures. If we know what tools we need in the OR, we can be sure they are readily available and that there are no delays due to missing equipment,” says Smith.

Another important skill learned through the training program is how to communicate effectively. “We want to get away from the ‘hint-and-hope’ mentality and teach our staff how to make an assertive statement without being confrontational,” Smith says. The code words NMC staff use are, “I’m uncomfortable because this is happening,” he says.

At the utterance of these code words, the surgical team’s ears are trained to listen. The person who mentions that he or she is uncomfortable will then offer a recommendation to remedy the concern. But, Smith says this is not to say that the recommendation will be followed because the team collectively must decide the best course of action.

Smith says the most important part of this exercise is to realize that no one is limited to their specific task and everyone is to be aware at all times of what is occurring in the OR. “Under crew resource management, the surgeon is still captain of the ship,” Shaw explains in an NMC press release. The only difference is that the “captain openly invites, in fact, expects the other members of the crew to speak up whenever they notice something that appears unusual or out of place.”

Early Results
The LifeWings program at NMC is in its infancy, but it has already had an effect. “Although it is a bit early to evaluate the success of the training, we did have three cases in the first week where an issue was identified and corrected before it became a problem,” Smith says. Those working on the cases were confident that the open communication and accountability of the entire team contributed to the catches, he adds.

“Our teams are identifying tools and issues that would make the surgical process more efficient,” Smith continues. “By compiling this data into a database, we will soon be able to standardize what tools are necessary for a particular procedure to streamline the entire process, thereby reducing the patient’s wait time and increasing the efficiency of the surgical team.”

As NMC strives to change the way its surgical teams communicate, it is expected that some resistance may come from such a broad and fundamental shift in the steadfast culture. However, Smith explains, “some of the staff was hesitant at first about the training, but it did not take long for everyone to realize that what we are trying to accomplish as an institution will ultimately improve patient safety and our staff is dedicated to the safety of the patient.”

Another result the hospital is expecting to realize is decreased staff turnover due to the open communication among all disciplines. By ingraining in the staff the ability to openly communicate across all disciplines, management hopes to see a shift toward a truly interdisciplinary staff working without the bureaucracy that currently exists between such critical members as nurses and physicians, says Smith.

Long-Term Goals
“It is our intention to have critical care departments trained within the first year, and the University of Nebraska is working to incorporate the training at the residency level to make the CRM training second nature,” says Smith. The training program will be ongoing to make it both permanent and mandatory, he adds.

Clark says, “The success of the Life-Wings program will be established when it not only becomes second nature but when it survives staff retirement and is still the culture in the OR.”

— Kim M. Norton is a freelance writer/journalist.