The next time you see footage of an airline crew working in the cockpit of an airliner, listen to how they interact with each other. They speak crisply and clearly to ensure information is conveyed well. Each crew member watches the other’s work to spot errors.
If they can do that while flying from Newark to San Diego, why can’t your staff do the same thing while caring for a post-op surgical patient? They can, according to advocates of a strategy called crew resource management, which got its start in military aviation and then became standard procedure for commercial aircrews. The idea is just catching on for health care providers, says G. Eric Knox, MD, professor of OB/GYN at the University of Minnesota Medical School in Minneapolis.
Knox implemented crew resource management in two units at a hospital where he previously was the patient safety officer and he continues to research the benefits of the technique. The basic idea, he says, is that crew resource management helps health care providers communicate better and work more cooperatively, with the end goal of improving patient care and reducing errors.
"I think you’re going to see this turning into a major risk management tool," he says. "Five years from now, I expect to see major insurers underwriting it."
Worked well to reduce airplane crashes
The technique was adopted in commercial aviation over a period of about 25 years. After showing success in the military, now commercial airline crews are required to practice crew resource management, says Grena Porto, RN, ARM, DFASHRM, a health care risk manager and principal with QRS Healthcare Consulting in Pocopson, PA, and past president of the American Society for Healthcare Risk Management. Porto is a certified instructor in crew resource management.
Crew resource management was developed as an offshoot of airplane and helicopter crash investigations in which the experts ruled out all technical or external factors that could have led to the accident. They then used cockpit voice recorders, along with instrument readings, to analyze exactly how the crew may have committed certain mistakes. That led to the methodology known as crew resource management, in which pilots are trained in highly specific ways to communicate and oversee each other’s work.
The technique has been proven to reduce accidents in aviation and the same results can be expected in a health care setting, Porto says. "Commercial pilots are required to be proficient in crew resource management," she says. "Unlike a health care professional, a pilot can lose his credentials because of poor communication and teamwork. It’s become a standard expectation in the airline industry, and it should in health care as well."
Teamwork is foundation, but difficult to get
The aviation experts found that accidents decreased when teamwork improved, but "teamwork" can be a broad concept. Most people interpret it to mean working well with others, but Porto says crew resource management defines specific ways in which people should cooperate and communicate. "These are specific behaviors you have to engineer into the system," she says. "For instance, nurses tend to work completely independent of one another. They go to work, get their patient charts, and you don’t see them again until the end of their shifts. There’s no real way of cooperating or communicating. That’s an error-prone situation."
With good crew resource management, the environment is structured so that people can communicate and work together effectively. Then you teach the individuals how to do that.
These are some of the major components of crew resource management:
• Cross-monitoring. "I watch my own work but I watch yours too, and vice versa. We’re less likely to make mistakes and any mistake we do make are less likely to go unnoticed," Porto says. "You’re working next to each other, and you say, Hey did you really mean to set that infusion pump that way?’"
• Situational awareness. Health care workers must be aware of what’s going on around them, not just their own little slice of the pie. If you hear a commotion down the hallway, you should have some idea what it might be because you’re aware of what patients are in that area even if they are not your responsibility. Knowing generally what is happening, you can respond by either offering assistance or by covering other tasks that those staff will be unable to perform.
• Good communication skills. This technique involves crisp language that is well defined in advance. In many situations, especially during a crisis or when a mistake could be deadly, the staff communicates in a predetermined way so that there is minimal chance for confusion. In particular, the crew will have a clear way of saying there is a problem. "You have to have a clear methodology and get people comfortable with using it so that people don’t get defensive when they hear it," Porto says. "When they hear those words they understand that it means Stop. Something needs attention here.’ That is something that is acutely lacking in almost all health care settings."
Hierarchies can be challenge in health care
That emphasis in on clear communication can be the most direct benefit of crew resource management, Knox says. "If you look at claims data, at least 75% of the time it can be traced to a communication issue," he says. "A lot of that has to do with professional silos or hierarchies. They can prevent people from doing the right thing because they’re afraid to speak up."
That problem crops up frequently when nurses feel their opinions are not valued and that they are punished for voicing disagreement with a superior. And if you encourage nurses to speak up, sometimes they do so too aggressively and critically, and that leads to further discord among the staff and physicians. Crew resource management solves the problem by encouraging everyone to speak up but to do so in a way that is seen as professional and unemotional.
Knox and Porto both stress that crew resource management must be implemented incrementally. It cannot be introduced the entire organization at once because the particular needs of individual units are too diverse. Doing so would require using generic strategies or watering down the focus so much that you end up with a program that is "a mile wide and an inch deep," Porto says.
The strategy has to be implemented one unit at a time and tailor-made to fit the needs of that staff. On operating room staff, for instance, will have different needs and communication methods than a pediatrics unit.
Safety attitude survey is good place to start
Knox suggests starting with the unit that is producing the most errors, or has the potential for producing a high number. Porto cautions, however, that you should not try to use crew resource management to fix a "toxic staff environment" plagued with great animosity and poor relationships. Fix those underlying problems first, then use crew resource management to make the team work better.
Though you will need help from someone specially trained in teaching crew resource management, these are two of the first steps you can expect to take:
• Determine if the environment supports teamwork. You can’t teach this methodology if the environment doesn’t’ support it. Is there leadership commitment? Are there barriers to teamwork in the physical environment or the cultural environment?
• Conduct a safety attitude survey. This survey will determine how comfortable your staff already are in discussing safety issues, speaking up at work, disagreeing with subordinates, and similar issues. Then you know how much work you have to do.
Once the program is introduced, you must keep teaching its principles over and over again. Otherwise, people will slide back into their old habits. And Knox warns that crew resource management is not a quick fix. It took two years for the units at his previous hospital to fully adopt the strategy. "This can be a major undertaking, but it’s worthwhile," he says. "This is a tool that risk managers should take advantage of."
The next time you see footage of an airline crew working in the cockpit of an airliner, listen to how they interact. They speak clearly to ensure information is conveyed well. Each crew member watches the others work to spot errors. If they can do that while flying from Newark to San Diego, why cant your staff do the same while caring for a post-op surgical patient? They can, according to advocates of a strategy called crew resource management.
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