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Hospital adopts aviation-based strategies to improve safety
Teamwork emphasized in model created by NASA
Evanston (IL) Northwestern Healthcare (ENH) has joined a growing number of health care organizations that are drawing on strategies the airline industry has used to reduce errors. Using its Center of Maternal and Fetal Health for its pilot program, Evanston Northwestern began training staff at two of its hospitals in November 2006 in safety techniques used by cockpit crews, including crew resource management.
Crew (or Cockpit) Resource Management (CRM) training originated from a NASA workshop in 1979; the agency's research had found that the primary cause of the majority of aviation accidents was human error, and that the main problems were failures of interpersonal communication, leadership, and decision making in the cockpit. Teamwork is a major concern of CRM.
"CRM is the effective use of all available resources — including equipment and technical or procedural skills — as well as contributions of the team or crew," adds David Marshall, CEO of Denver-based Safer Healthcare, which provided Evanston Northwestern with an education program that launched the initiative. "In health care, it is the structured application of skills and knowledge by individuals to make the medical environment safe and productive for teams to operate," he says.
"It's been well established in both nonmilitary and military studies that CRM clearly reduces risk of errors, especially in communication," asserts Ian Grable, MD, MPH, director of the Center of Maternal and Fetal Health. "Our goal was not to wait for an event to occur, but to make changes proactively to reduce the risk of major complications."
Grable led the Evanston Northwestern steering committee that made the decision about CRM.
While there were no specific problems at Evanston Northwestern, "I knew the workings were typical for many labor and delivery facilities," he says. "The challenges were that everyone was working in their own little world, or silo, and was not necessarily communicating with or helping each other. Care was not visualized as all one big team; each group was seen as its own team."
The education program was launched in October 2006. After assessing staff perception of safety using the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety Survey, Safer Healthcare began a program that covered:
Since Evanston Northwestern actually has two OB/GYN facilities (Evanston and Highland Park), they customized the courses. "One facility has residents, a Level III nursery, higher-acuity patients, and labor and delivery rooms with a separate postpartum floor," Grable explains. "The other has no residents, so the whole organization of care was different."
The courses were given several times a day over a two-week period, so that everyone involved in the care process — doctors, nurses, secretaries, OR technicians — was educated.
The courses included role-playing. "We used real-life cases from each institution to help illustrate some of the problems that potentially exist, and tried to help providers brainstorm on how to improve communications," Grable explains. "These were not necessarily bad outcomes, but near-misses."
As a hypothetical example, an OB/GYN facility might look at an urgent cesarean required due to fetal heart rate decline and potential problems in communication to bring all things together to perform the surgery properly.
"So in the patient's room, for example, if the OB provider is thinking about or deciding to do a C-section, they should speak to the patient and the nurse, so the nurse knows all what the doctor is thinking; thus, she can take potential steps to prevent errors from occurring," Grable says. "She should be sure to relay information to others on the team, such as the charge nurse, so they have situational awareness of all that is going on in order to triage the proper flow of all other individuals who might come in for the potential delivery. For example, they must determine a way of communicating with the anesthesiologist. Then, you have to look at what's in the operating room; is all the equipment you might need available? Is neonatal intensive care aware of the situation, so if there is a problem at any point they can deal with a complication?"
In order to ensure appropriate and complete communications, Grable's team has created protocols for the nurses' station. "For example, to cover severe hemorrhage, we list the people who need to be notified in order that there is no duplication of activities," he explains. The protocol lists are laminated and readily available to everyone. "We currently have them for shoulder dystocia and severe hemorrhage, and we're working on others," says Grable.
The biggest difference so far has been in preparation. "In the past, for example, one potentially would not have known that there was a very large baby who might be at risk for certain complications; the physician would have been aware, but nobody else," Grable notes. "Four times a day, we have team meetings at Evanston and three times at Highland Park."
During these meetings, every patient is reviewed. Nurses present in a stylized format the background of each patient, the assessment, and the recommendation or plan for the patient. "Then, the meeting is opened to everyone, so all participants are aware of potential issues," says Grable, who notes that in addition to labor and delivery nurses and physicians, the meetings include an anesthesiologist and a representative from the neonatal ICU.
"Preparation is the big difference — and a major factor in preventing the risk of medical errors," Grable asserts.
Culture is changing
While the new program has been in place only a few months, Grable says that "preliminary results of our surveys demonstrate tremendous improvement in staff perception of safety." Adverse outcomes are being tracked, but Grable says it will probably be six months or more before there is significant data.
Based on past experience, Marshall is confident the eventual results will be positive.
What are the keys to a successful culture change? "The hardest thing in any change is this: Everyone can get excited initially, but you have to carry on," says Grable. "We have seen our staff equally excited as it was in November; there has been no slacking off on the protocols. People have felt those changes, that improvement in communication, and they like the idea of working together; it has brought all of us closer. They not only feel there has been improvement in safety for the patient, but the overall level of safety is felt to have improved as well; that's been a major carrier."
"Physician buy-in and leadership commitment are huge," adds Marshall. "Another other key piece is organizational and facilitywide support; executive management from the top down has to be there. The other piece is the training — anybody can try to conduct sessions around these topics, but an important differential we have found is the learner-centric nature — in and out of the classroom. Working side by side with teams in the OR or wherever, you should use an observation and coaching model."
The level of organizational commitment, he stresses, is critical. "I can't overstress the importance of the physician leadership piece, and in the case of Evanston, it was critical that the medical staff and physicians buy in to this concept."
Evanston currently is considering expanding the program to other departments. "We chose ours first because we have definite data that shows CRM reduces the risk of medical errors, and this of course is a place where errors can have drastic consequences," says Grable.
Currently, he says, the team is working on creating more protocols for more complicated problems. "Then, my hope is to be able to develop the training program for doctors, nurses, residents, to involve more role playing — to practice urgent care, or preventing infections."