On a recent visit to a hospital in Memphis, I sat next to a FedEx® pilot who was attending a training exercise. As we spoke, I realized he was not there to learn about the newest flight regulations or technology, but rather, he was instructing the attendees in crew resource management. I immediately thought about scheduling pilots and attendants and the incredible job it is to keep track of everyone and everything to make sure they are at the right place at the right time to get their respective jobs done. When my new friend told me his students were physicians, I became captivated by what he was describing.
Crew Resource Management (CRM) has been around for more than twenty-five years as an evolving quality and process discipline for the aviation industry. In short, CRM is about managing human resources as a team with particular focus on human factors and human limitations, techniques of leadership and followership, and guidelines for addressing operational concerns in the face of command hierarchies and interpersonal disagreements. Generally, CRM shifts managing a team from autocratic and individualistic styles to one that is more team based with mutual interdependence and shared responsibility.
Interdisciplinary team functioning is the backbone of all inpatient rehabilitation care models. The effectiveness of the team members’ contributions in aggregate is not only the expectation and requirement of the IRF level of care, but also the differentiation factor among rehabilitation provided in all other levels of post acute care. And yet, IRFs struggle the most in this aspect of care delivery. No discipline is specifically trained in team management as part of their basic education as providers. In fact, physicians are trained to be independent thinkers, self-sufficient and individually responsible for the care they deliver.
In 2000, the Institute of Medicine made the recommendation that CRM principles of crew training should have application to healthcare delivery teams. Since then, a merger of aviation and care delivery training principles and process control techniques has resulted in a positive impact on several areas of safety and quality concerns in healthcare:
– Wrong surgeries
– Observed-to-expected mortality ratios
– Surgical infection rates
– Surgical counts errors
– Sentinel events
– Medication errors
– Medication discrepancies
– Patient injuries
– Patient identification discrepancies
CMS has mandated that patient-team conferences must occur at least every seven days for each patient receiving IRF care. This requirement seems to place obligatory value on the management and coordination of interdisciplinary team function practiced in IRFs, but may have little or no effect on the care process or outcome of that care. For the most part, care coordination most often happens between care givers outside of the team conference.
A growing trend is seen to attempt coordination of care and communications through daily stand up meeting, walking rounds and flash reports to augment the shortcomings of weekly team conferences. These activities are effective in promoting communications, but more often, they’re held between nursing and/or other disciplines and too often without the physician.
Perhaps CRM principles have application to improving care and resource coordination in the IRF. The practice of “briefings” before, during and after each flight presents a comparison and possible value to the interdisciplinary rehab model. Starting with a flight plan, each crew member is asked to verify their understanding of the plan. This practice is essential to establishing a mental model shared among the team, focusing on the objective and establishing the expectations of each member’s contribution. The flight plan and interdisciplinary care plan can be viewed in the same context. With focus on the plan, team member responsibilities are understood and agreed upon; brief and frequent status checks occur to measures progress against the plan. Checklist verification shortens the reporting time in key areas. Variances to the plan or unanticipated problems are attended to immediately with corrective actions. At all times, it’s expected that the pilot is in command and control.
CRM includes training in the acceptable ways to challenge the actions of other team members if expectations do not materialize. These challenges are not only appropriate but also expected. This team behavior shifts the focus away from personal attacks to the understanding that challenge is expected and demanded from all team members.
With attention to plan and objectives, briefings focus on team member performance as standards of practice, communication likewise provides team feedback where expectations are not met.
I don’t know if physicians can perform as pilots in managing their crews, but I found it very interesting that the IOM suggest they should. Today, many physicians are attending CRM training conducted by pilots and evidence shows that it’s working.