This is not a new concept. In an effort to study behaviors of healthcare providers in the late 1990’s, Harvard University created a simulation center where actual doctors, nurses and technicians were put in mock patient care scenarios in operating rooms, ERs and on the wards. When the taped sessions were reviewed several issues were identified as lacking across the board:
2. Help is not asked for when needed (pride gets in the way)
3. Communication skills are poor and angry outbursts were commonWhat can we do?
In general, neither our healthcare providers or system truly understands the concept of improving care through collaboration. Competition, productivity pressures, and little time for meetings make collaboration difficult among providers. Other non medical industries (some of which are fiercely competitive) have embraced opportunities to collaborate for improvement. In the technology sector, many companies conduct joint research–they have the vision to see the win-win outcomes when smart people work together. As providers, we can learn lessons from collaborations in other industries. A great example is the heroic collaboration among pilot, first officer, ground communications and crew that safely landed US Air Flight 1549 in the Hudson river in January 2009. As most of us recall, US Air flight 1549 suffered engine shut down due to damage caused by geese right after taking off from LaGuardia Airport. The pilot and crew remained calm under pressure and quickly came up with an action plan. The plane was skillfully and safely landed in the Hudson river without a single casualty. Although many consider this a miracle, when closely examined, US Air Flight 1549 provides insight into the RIGHT way to perform as a team. Certainly, the technical skill of the pilots was essential to the safe landing but I believe it was the non-technical skills of the crew that played an enormous role in the successful outcome. Many lessons learned from aviation training and what went right on that flight can be directly applied to collaboration in medicine and may very well result in increased quality and improved outcomes. In 2009 an article in CHEST reviewed these principles and applied them to the Intensivist setting.
1. Crew Resource Management (CRM): The aviation industry regularly requires pilots and crew to participate in training that helps to develop non technical skills that are felt to be invaluable during an in-air incident. This training focuses on applying problem solving strategies, communicating with team (and taking input from junior team members when appropriate), maintaining team structure, and executing plans. In this training, pilots are asked to consider various options for action and evaluate the likelihood for success and failure before implementing a particular plan. In this situation a junior officer should be able to provide input to a senior pilot for consideration. Much of this concept is applicable to medicine. As physicians, we must be willing to accept input from nurses, junior partners, pharmacists and other providers. Although we may have the final say, we must consider the options for therapy and each options pros and cons. The senior decision maker must not be threatened by input from other providers.
2. Effective leadership and communication: The team leader of Flight 1549 was Captain Sullenberger and he was responsible for managing information, equipment and people. Captain Sully was also responsible for avoiding procedural errors and communication with the ground and flight crew. Just as in a medical emergency (code blue or trauma in the ER) the team leader must assign roles and communicate clearly, calmly and effectively. In the case of flight 1549, the Captain called to “brace for impact” and this was relayed by the first officer to the flight crew and then to the passengers in an orderly succinct fashion. In a medical emergency, effective communication is key. The person who has identified themselves as the leader must assertively instruct the team members while considering alternative input from others. A heirarchical attitude in a medical emergency in the ICU discourages communication among more junior team members and may make nurses feel undervalued–all may lead to errors. The team leader must be able to assimilate team member concerns and not dismiss them without some consideration. Group debriefing is an important follow up activity after a medical emergency . Here leaders and team members alike can learn from errors. (Just as was demonstrated in the Harvard simulator situations).
3. Simulation and Training: Captain Sully and his crew admit that much of the technical skill and reaction that occurred in the landing of the disabled aircraft was “automatic” and due to years of simulation and repetitive training. In medical training, we often use a “see one, do one, teach one” approach for hands on training. More simulation training would certainly benefit technical responses in a medical emergency. Hours of training and multi year residencies are essential to developing keen technical skills and sound judgement. In some ways, the curtailing of “working hours” for US resident physicians, may very well decrease quality of care due to lack of experience. The US Air flight crew, however, credited the CRM and team training with providing them with the most important skills for a successful landing. Medical education and medical systems must mandate leadership and team building training for their professionals. Debriefing after clinical events must occur in order for learning and improvement to occur.
We can all learn lessons from Captain Sully and US Air Flight 1549. Certainly collaboration among team members and effective communication among leaders and those in junior positions on the team is essential. By approaching a medical situation as a team we are able to consider multiple treatment options and scenarios, make educated guesses as to outcome and implement the strategy thought to be best for success. By turning focus away from the individual and toward the system and team, the chances for success improve and care is delivered more efficiently and with higher quality. As we move to improve quality and delivery of care in the US, “fasten your seatbelts”. And from the tower, “you are cleared for take-off”.