Patient Safety, Quality Care and Cultural Transformation-There’s More to it than Just a Few Training Programs

At least two major university hospitals in the United States have invested in a form of crew resource management (CRM) training in the hopes of improving patient safety only to be frustrated by modest results of uncertain permanence. Why?

Why is it so hard to change culture in the first instance and even more difficult to sustain any positive change for long? Psychologists and industrial engineers will know far more about the reasons than I, a cancer surgeon and pilot, do, but I've got a suspicion that those of us interested in safety are seeing only a small part of the safety challenge and, as a result, our attempts are too narrowly focused and our effort is exerted over too short a period of time.

If one polls students immediately after CRM training in surgical settings, most nurses, residents, technicians, surgeons and anesthesia providers get the essence of the message. Their awareness of human factors, red flags signifying times of increased risk, methods of communication and cultural and hierarchal effects is relatively good. A year later, with some exceptions, most places have returned to business as usual. If the institution is unlucky, an administrative or fiscal officer will conclude the CRM training is of no value and any further efforts at improving patient safety will be shelved until the next patient gets the wrong side of the brain opened. Then there will be a great deal of effort expended on managing the public relations horror show that ensues.

Much like a good anti cancer drug that is abandoned for lack of efficacy after a phase one trial in a small number of moribund patients, CRM might never get the chance to make a contribution in healthcare, as opposed to other industries where it has. Very likely, little introspection or interest in looking to other high reliability industries for helpful guidance will be expended.

If one were to look to commercial aviation, for instance, a wide variety of tools and techniques are routinely employed to create, promote, manage and sustain a culture of safety. Airlines start by looking at emotional intelligence as well as sick and rudder skills in their pilot applicants. Pilot training is constantly reinforcing the need and expectation for safety. Recurrent training every six months back at headquarters provides another opportunity for practicing and emphasizing CRM skills. Checklists, minimum equipment lists, dispatch calculations, and lots of other tools, both obvious and subtle, continue to ring home a message of safety.

The recent world wide medical excitement over a positive study demonstrating that the use of checklists in operating rooms can improve communication between nursing, surgery, and anesthesia and save lives bears great promise. But it is also possible that the excitement will die down, that the use of checklists will enjoy a momentary popularity only to slide back down the slope of chaos that surrounds most surgical operations, leaving us right back we started.

The fact is it isn't just a checklist and it isn't just CRM; it is all that and more, including routine line assessments as to how these skills and tools are being used day in day out by the people who have sharp objects in their hands. It is only by doing it all will we become safer and finally honor the responsibility that each of us, whether we be an administrator, an accountant, a nurse, or a surgeon, bears towards the patients who have entrusted us with their lives.

Bio: Along with his academic pursuits, Dr. Karl is an active pilot and a contributing editor to FLYING Magazine, where his monthly column "Gear Up," appears. He has combined his two life-long loves, surgery and flying, by founding the Surgical Safety Institute, Inc. in 2005. The institute assists institutions in their quest for improved patient safety and quality care. His first book, Across the Redline, Stories from the Surgical Life, was published in 2002. It has recently been translated into Chinese. He is type rated in Cessna 500 jets and the Boeing 737.