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Physicians In Absentia
About 40 years ago, a succession of airline crashes brought national attention to the problem of safety in the skies. It was quickly determined that the great majority of aviation accidents were the result of human error, not mechanical malfunctions. But if making mistakes is fundamental to human nature, how could federal authorities reasonably hope to improve safety records while the number of flights and passengers was increasing rapidly?
Since then, intense focus on aviation accidents by the Federal Aviation Administration and National Transportation Safety Board has resulted in more than an order of magnitude decrease in aviation accidents. As I write, the three-year rate for commercial fatalities (excluding September 11) is the lowest in aviation history. Human error still accounts for the majority of aviation accidents, but the use of strict protocols (checklists and regulations) and the adoption of CRM—crew resource management—have accounted for an amazing improvement in air flight safety.
CRM was initiated after it was determined that a lack of coordination among flight crew members resulted in a number of fatal and nonfatal airline accidents. Originally dubbed cockpit resource management, CRM has been broadened to include all the members responsible for the safety of an airplane whether they serve in the cockpit or not: Crew members include pilots, co-pilots, flight engineers, navigators, flight attendants, mechanics and ground crew, FAA traffic controllers, weather briefers, mechanics and so forth. In other words, anyone who plays a role in preparing, flying or monitoring the safe progress of the aircraft is part of the “crew” and CRM attempts to develop better habits of communication, coordination, teamwork and lines of authority among them all.
Since the late 1960s, airlines have employed professional CRM trainers to work with their flight crew and aviation personnel to optimize communication and co-operation, coordination and leadership skills. The good news is that these same trainers have now begun to develop courses for medical personnel oriented toward improving patient safety.
As the work of our own Center for Innovation in Quality Patient Care has documented (and my two prior columns have illustrated), unsafe patient care scenarios often arise due to the lack of communication or coordination of care and fuzzy lines of responsibility among the myriad caregivers who come in contact with a patient. Further, voices who speak up attempting to call attention to unsafe conditions are frequently ignored or, even worse, criticized.
I recently took the half-day CRM course that is being offered at the Johns Hopkins Hospital by one of the leading CRM training companies. It was outstanding. Not only did I learn a lot about CRM methodologies, the interaction I had with Hopkins caregivers was profoundly enlightening. Unfortunately, out of a group of 25 or so, only two physicians attended, myself and one other physician who is associated with the Center for Innovation—so no Hopkins doctors practicing direct patient care were there. One of the nurses raised this point in the discussion session, and when I spoke with her afterward, she told me she had worked at Hopkins for 18 years and was going to retire because she was so frustrated trying to work for the best interests of the patient. The fact that there was not a cadre of Hopkins doctors in attendance was proof positive, she said, that the system was horribly broken.
So, I write this column urging all Hopkins physicians to sign up for one of these half-day sessions. While there are other aspects of patient safety training that will have to be undertaken as well, CRM training is a great place to start. Not only will you find the session interesting and informative, your attendance along with other caregivers will begin to bridge the wide chasm of non-communication that has developed, not just at Hopkins, but across our American health care system.
