Disruptive Innovators: Using aviator techniques in the hospital

Lean may be the biggest craze these days in creating efficiencies in hospitals and health systems, but some facilities are having success with a process that got its start at NASA.

Crew resource management – also known as cockpit resource management – developed out of the aviation industry, said Richard Doss, senior advisor for performance breakthroughs and strategy at LifeWings Partners, a Tennessee-based provider of teamwork training.

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It was used in aviation to institute procedures to avoid human error and the disasters that can sometimes happen because someone makes a mistake.

Over the years, CRM has been adopted in a number of other industries. The healthcare industry began showing interest in the process about 12 years ago, said Doss, who has worked with a number of hospitals to introduce and train staff on CRM.

CRM is based on interpersonal communication and decision making – qualities that, historically, are alien in many clinical settings, Doss noted, which means that instituting the process often means changing a department’s or a facility’s culture. 

At Memorial Health System’s six hospitals in South Florida, surgeons and anesthesiologists had some concerns about CRM, said Joseph Loskove, MD, the system’s chief of anesthesia.

Mainly, they were worried the debriefing tool that was being established in the operating rooms as a result of using CRM would add time in the ORs. It had the opposite effect. Using the debriefing tool has made surgeries more efficient because less time is spent having to leave the sterile environment to obtain additional needed instruments or assemble equipment, Loskove said.

Overall, Memorial has seen improved quality and safety, patient experience and satisfaction and improved employee and physician satisfaction, Loskove said.

The surgical areas at the University of New Mexico Health Sciences Center faced a tougher challenge than at Memorial.

“You have to understand that our operating room was a tough, tough environment,” said David Pitcher, MD, UNM Health Sciences Center’s chief medical officer. “There was serious skepticism on the part of a number of staff and a number of the physicians.”

Based on the University of New Mexico’s Albuquerque campus, UNM Health Sciences Center is the state’s largest academic health complex. Before the ORs began instituting CRM in 2009, the organization had a problem with harm events occurring in the OR. Various tactics had been tried to reduce harm events in the ORs, said Pitcher, to no avail.

“It had gotten to the point where we recognized that one of the reasons we couldn’t make any progress was the environment for communication and teamwork was so poor in the operating room that no one could agree on anything, and nobody could work collaboratively together,” he said.

The dysfunction in the ORs was known in the community, so the health center had a hard time hiring and retaining staff.

“There was general acknowledgement that we needed to do something differently, and there was general agreement that the root cause was poor communication and team skills,” said Pitcher.

After reviewing their options, the health center decided to try CRM and hired LifeWings to help. LifeWings staff trained leadership and met with the OR teams. Each team received training on how to identify potential harm and communicate about that potential harm and solve the problem as team. Each team developed their own tools based on what they decided as a group was needed to help them.

The initial skepticism at another “flavor of the month” solution turned into support.

The results in the ORs have been spectacula,r Pitcher said. The ORs had been having one retained surgical device or object every quarter before CRM. For the eight or nine quarters following the start of using the CRM process, there were no such retensions.

When the health center started the CRM process, about half of the OR’s nursing and technicians staff were travelers – an expensive means of staffing the ORs – but even with the travelers, the health center couldn’t keep all its ORs open.

Because of CRM, the environment in the ORs did an about-face and now it is the place to work, Pitcher said. The health center doesn’t have travelers staffing the ORs any more and because there is sufficient staff now, the ORs are open all the time, eliminating surgical bottlenecks and resulting in a sustained increase in surgical volume.

“I’m not a finance person,” Pitcher said. “It’s hard for me to fully quantify what that translates to in dollars, but I do know that the dollars saved from avoiding harm events is not insignificant in terms of risk pay out. It’s also not insignificant in terms of the dollars saved from a staffing point of view, and also it’s not insignificant in terms of the increased revenue we see through increased surgical volume ….”

The use of CRM has expanded at UNM Health Sciences Center to labor and delivery, behavioral health and psychiatry and interventional radiology. While the focus has been to bring CRM into the clinical settings, non-clinical environments are not barred from using the model. A couple of the lawyers from the center’s legal department were trained and brought what they learned back to their department, said Pitcher, and many other departments have shown interest.

“The initial organizational skepticism – after seeing what happened in our operating rooms – turned into ‘pick me, pick me next,’” Pitcher said. “Really different areas of the organization are begging to be next because they’ve seen such positive results from the operating room – and it’s not just because we’re telling them good things have happened. It’s word of mouth. … It sells itself.”

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