From Cockpit to Operating Room
After a particularly exhausting week during his training to be a transplant surgeon, Byers Shaw Jr., MD, could think of only one way to relax. An aviation enthusiast since his teens and a pilot for many years, Dr. Shaw knew that getting off the ground would be the best way to lift his spirits.
That evening, however, rather than use a checklist to guide his preflight inspection of the aircraft, he took a cursory look at the outside of the plane, climbed into the cockpit and took off.
“Minutes into the flight,” he recalls, “I realized that something was horribly wrong. I had forgotten to remove the external lock on the rudder.”
Calling upon his cumulative experiences in the air, Dr. Shaw carefully turned the plane around and brought it safely back to the airport. So much for his relaxing evening in the air.
“All through pilot training, we’re constantly reminded of the critical value of checklists,” he says. “One of the items on the checklist reminds you to make sure all the control surfaces have free movement – both during the pre-flight walk around and again just before takeoff. How could I forget something as obvious as a big wooden clamp attached to the tail of the airplane?”
It’s a lesson from the cockpit that is now being applied to the operating room.
Dr. Shaw, chairman of the Department of Surgery in the College of Medicine at the University of Nebraska Medical Center and member of The Nebraska Medical Center Board of Directors, has helped introduce an aviation safety program known as Crew Resource Management at the hospital.
Crew Resource Management (CRM) is a set of proven communication tools and safety processes adopted by the aviation industry over the last 25 years. These safety tools have been credited with reducing flight accidents and transforming the aviation industry into one of the safest in the world.
Dr. Shaw says the link between flying and surgery isn’t far-fetched if people consider the parallels. Like pilots and flight crews, physicians and other healthcare staff are highly trained professionals who work in complex, technically demanding situations where split-second decisions have life and death consequences. In a cockpit and in an operating room, these professionals have been trained in a variety of disciplines. In both places, there is a lead person who supervises the work of the team members, many of whom may have not known each other until they met that day. And, in both settings, fatigue and routine can be the enemy of precision.
CRM’s use of checklists and emphasis on communication are easily adaptable to the operating room, Dr. Shaw says. “Before the introduction of CRM, we used a few processes that resembled checklists, such as counting instruments and sponges before closing the wound to make sure we didn’t leave anything behind.
“With CRM, we look for critical processes, especially those that we take for granted, and develop checklists to ensure we don’t omit critical steps. We also put things on the checklists that facilitate critical communication among team members, such as a reminder to the surgeon to announce that he or she wants anyone in the room to speak up if they see something that bothers them.”
He says developing good teamwork skills among all operating room personnel is the heart of CRM training. “Checklists are not the main focus, but they represent a vital tool for promoting better team work.”
The Nebraska Medical Center is one of the first hospitals in the Midwest to adopt the program. CRM is one of the most ambitious, proactive projects ever taken on by the medical center, says Chief Medical Officer Stephen B. Smith, MD.
“We believe we are at the forefront of a huge cultural shift in healthcare – one that focuses on improved communication and teamwork to enhance safety and reliability for our patients,” Dr. Smith says. “Quality care and patient safety are top initiatives for our institution. We think CRM will take us another huge step closer to becoming one of the safest medical centers in the country.”
The time has come for all hospitals to embrace safety with the same regard as quality, says Glenn Fosdick, FACHE, president and CEO of The Nebraska Medical Center.
“Safety is a concept that seems so simple, yet in a highly technically advanced environment, minor flaws in a complex system of processes can result in major deficiencies,” Fosdick says. “Over the past few years, The Nebraska Medical Center has reprioritized its commitment to safety and has invested additional resources and manpower to implement many new safety initiatives that have elevated safety to a new level.”
When CRM was developed for the airline industry, as much as 70 percent of all airline accidents could be traced to a failure in communication among crew members. CRM has standardized communication and resulted in significant improvements in aviation safety.
“The success of the CRM approach in the airline industry has made it one of the most effective safety programs ever launched,” says Fosdick. “We think the application of those principles to patient care will do the same for healthcare. It’s part of our commitment to making The Nebraska Medical Center the safest and highest quality hospital in the country.”
Dr. Shaw says that in the aviation industry, “CRM has demonstrated that simple rules are most effective at managing complex environments. The complexities of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardized communication tools, create an environment in which individuals can speak up and express concerns, and share common critical language to alert team members to unsafe situations.”
To train its staff and incorporate CRM into the total culture of the hospital, The Nebraska Medical Center hired LifeWings Partners, LLC.
Stephen Harden, a former Navy pilot and president of LifeWings Partners, is the principal architect of LifeWing’s adaptation of aviation-based safety practices to healthcare. While most hospitals have focused on high-pressure areas such as critical care units, operating rooms and emergency departments, Harden says CRM can be applied to any area of a hospital where care is provided by a team.
The Nebraska Medical Center has implemented CRM in its operating rooms and continues to train additional staff with a goal of adapting the program to all procedure-based areas in the hospital.
CRM brings a set of skills and processes to medicine that in some cases didn’t exist or needed to be formalized and standardized. These include the introduction of safety tools such as standardized pre-surgical routines, protocols, debriefings and other checklists.
For The Nebraska Medical Center, the impact of these safety tools was seen during the first week of implementation. While conducting a pre-surgical briefing, Dr. Smith says, issues were identified in three different cases that may have helped prevent a potential error or problem during the surgeries. And, two months into the program, the medical center was reporting improved antibiotic delivery times.
“The operating room can be a tense place,” says Kathy Wonder, RN, BSN, lead coordinator for Orthopedics, Oral and Dental Services. “Not everyone feels comfortable speaking up if they have a concern. The CRM process forces the group to verbalize the goals and objectives of the procedure, and provides an opportunity for each member of the team to speak up, so that everyone is in agreement.”
Dr. Shaw says the process is successful because “everyone feels responsible.”
“There is a lot of teamwork involved in surgery and when teamwork breaks down, bad things can happen,” he says. “Our staff is recognizing that these tools can be used to solve other issues in the operating room, leading to even greater efficiencies.”
The Nebraska Medical Center also plans to incorporate CRM processes into the training of all medical, pharmacy and nursing students and residents. “Eventually,” says Dr. Shaw, “we will see a new generation of physicians and clinicians who will consider this the norm, not the exception.”
Dr. Shaw has been around airplanes much of his life.
As a teenager, Dr. Shaw worked at a small airport in Washington Court House, Ohio, where he nurtured an enthusiasm for aviation. Later, when he went to college, his father wouldn’t let him have a car – so he went out and bought a 1939 Piper Cub airplane.
During the summer after his first year in medical school, he and an Air Force friend who had just completed training in jet fighters, set off from Ohio in that Piper Cub on a trip that would take them all the way to San Diego.
Driven to distraction by his friend’s exciting stories of being a fighter pilot, Dr. Shaw briefly considered quitting medical school to join the Air Force. He says the reality of the impending start of his second year of medical school – along with the fact he was about to be married – firmly grounded that notion. Instead of a career, flying has remained a hobby.
Little did Dr. Shaw realize back then that soaring through the clouds would yield lessons that would one day carry over to the operating room.
Taking Safety to New Levels
Hospitals nationwide are placing a renewed emphasis on safety and The Nebraska Medical Center is at the forefront of this movement. Over the past few years, The Nebraska Medical Center has participated in a number of safety initiatives. These include:
- Institutes of Medicine 100,000 Lives Campaign – The campaign focuses on implementing changes in six key areas to prevent avoidable death.
- Joint Commission on Accreditation of Health Care Organizations’ Patient Safety Goals – These goals promote specific improvements in patient safety and highlight problematic areas in healthcare with expert-based solutions.
- The Centers for Medicare and Medicaid Services Hospital Quality Initiative – Its goal is to improve the care provided by the nation’s hospitals and to provide quality information to consumers and others.
- National Quality Forum’s 30 best practices – With support from the Agency for Healthcare Research and Quality, National Quality Forum has identified 30 safe practices that can reduce or prevent adverse events and medical errors.
- Leapfrog Group Hospital Quality and Safety Survey – A program that rates participating hospitals with a “quality index” based on the implementation of 27 procedures shown to reduce preventable medical mistakes.
- Six Sigma – The Nebraska Medical Center’s own ongoing quality improvement program that focuses on hospital efficiency, quality, safety and customer service.