First, I want to say how pleased I am that we have completed our triennial Joint Commission survey with full accreditation. While we do have many things to learn, this is great news. Many thanks to the countless Medical Staff members and SHC staffers in all areas who worked so hard to make this good news possible.

In past centuries, including the one ending a few years ago, medicine often didn’t have comprehensive tools or empirical evidence to guide clinical judgments — or for that matter to know if staying up all night really did impair judgment. Increasingly we’re finding we have the evidence and the tools, including good metric models, to make hard decisions about what works and what doesn’t.

Sometimes this new knowledge can be an ego blow for us as physicians, since in the past the best substitute for facts was good judgment, comprehensive education and an impressive track record — whether or not that record was based on much beyond luck. But with our patients’ safety at stake we must turn increasingly to a burgeoning array of tools that, to put it crudely, allow us to second guess ourselves more accurately. And at the same time, along with more knowledge comes the increasing reality that we as physicians don’t have a monopoly on the incredible amount of content we need to successfully deliver treatment; we share and sometimes divide the necessary knowledge and skills with nursing and numerous other partners on our team.

The airline industry has been ahead of the curve on applying evidence and teamwork to safety management. Computerized cockpits would be foreign to flyboys who could rely on their quick reflexes, bravado and, yes, intelligence, to keep a plane aloft. I’ve used parallels with the airline industry in the past, and I wish to do this now as the Quality and Risk Management Department at SHC will be initiating some projects over the coming months that have roots in the airline industry, where examiners can dial unexpected situations into a flight simulator to assess how pilots respond.

Similarly, at Stanford we now have simulation, thanks to anesthesiologist David Gaba and the tools he and colleagues have developed and are now deploying in our new Center of Immersive and Simulation-Based Learning. David has long had an interest in the use of simulation, down to the level of a manikin used as a patient, to assess how people, often anesthesiologists and nurses, respond in various scenarios, including codes.

Our current project was inspired by a retrospective review of select sentinel events that identified some poor outcomes with certain patients. Notably, an analysis found that patient conditions such as sepsis, hemorrhage, and respiratory failure can go on to cardiac arrest. Not surprisingly, the promptness of a response to the situations can influence the outcome.

David’s team will be charged with “challenging the environment and its personnel” in multiple locations — operating room, emergency department, intensive care units, and various adult wards. The response of our medical staff, nurses and other ancillary personnel to a clinical situation using critical events simulation drills will be recorded and analyzed so that we can better learn how our processes work.

David and his team will then develop metrics to measure performance in these multiple work units of the hospital. The task is not to train physicians and nurses in the physiology or clinical management of critical illness, but instead is designed to find out how they handle these challenging events, so that we can better understand how to improve our processes and thus outcomes. The analysis is complicated, but the team will be looking for “turning points,” where a change in behavior could lead to either a positive or negative outcome.

These simulation events will take place throughout the hospital and will be “unannounced” so that we can truly assess things the way they would really happen.

We are very hopeful that this process will be illuminating. Lessons learned will be widely distributed.

The second project involves the training of all of our operating room personnel in crew resource management (CRM). This process was developed by NASA in 1979 to improve air safety. Research had shown that the majority of aviation accidents resulted from human error and that the main problems identified were failures of interpersonal communication, leadership and decision making in the cockpit.

CRM is not so much concerned with the technical knowledge and skills required to fly or operate aircraft, but rather with the cognitive and interpersonal skills required to manage the flight consistently. With this in mind, cognitive skills are defined as the mental processes used to gain and maintain situational awareness, to solve problems and to make decisions. Interpersonal skills involve communications and a range of behavioral activities associated with teamwork.

Many people have compared the atmosphere in the cockpit of an airliner with that of the operating room. Historically, both have been hierarchal. The attending surgeon and the captain had a lot in common, since their words were held in high esteem and often not questioned. CRM changed the cockpit culture to encourage crewmembers to question the decisions and actions of pilots in a structured manner.

More recently, studies have looked at attitudes toward teamwork in the operating room. Attending surgeons and anesthesiologists, as well as surgical and anesthesia residents and nurses were given questionnaires in several hospitals in the U.S. and abroad. Interestingly, the level of teamwork perceived by attending surgeons compared with other operating room staff differs markedly. A majority of surgical residents and attending surgeons perceived high levels of teamwork, a view shared by only a minority of the anesthesiology attendings, residents and nurses.

Also, most of the attending surgeons as well as the surgical and anesthesia residents agree with the statement, “Even when fatigued I perform effectively at critical times.” It’s revealing that only a minority of pilots agree with this.

CRM changes many attitudes towards personal performance and safety. As with aviation, human factors in the operating room are perceived to contribute to mishaps. In anesthesiology 65 to 70 percent of safety problems have been attributed at least in part to human error. We realize from analysis of some of our sentinel events in the operating room environment this can be generalized to the entire operating room environment.

For CRM to work in the OR, several underlying principles have to become part of the culture and implemented. These include:

A belief that the team bears responsibility for patients
A belief that clinicians are fallible
Peer monitoring and team member awareness of patient status, team member status and institutional resources

Peer monitoring is central to CRM. Each team member must be on board to monitor peers or “check” actions at appropriate moments. The team member must monitor his or her own situational awareness while cross-monitoring the actions of other teammates. If during the monitoring a team member observes a suspected error in progress, that individual must intervene with a direct question or offer of information. The teammate alleged to be erring may then acknowledge the lapse, correct it and continue working. If this does not occur, the intervening colleague is expected to provide feedback, questioning the peer’s “situational awareness.” Then if there is disagreement about how to proceed, advocacy, assertion and perhaps third-party involvement may be deployed to resolve the situation. Thus process is embedded in a situation that otherwise might be characterized as finger pointing or insubordination.

Over time, the checks become habit and are internalized. The culture of teamwork and open communication facilitates a structured questioning of authority, and that creates a climate where those in positions of authority are consistently and reasonably open to question.

I believe that we will see the philosophy of CRM rolled out over the entire institution at some point. The principles of safety and improved communication are almost surely widely applicable toward helping us make our care of patients as safe and error free as possible. We can retain common sense and leadership without voodoo.

For questions regarding this and other patient safety matters you may contact me at lshuer@stanford.edu; Kevin Tabb, MD, chief quality/medical information officer, at ktabb@stanfordmed.org; Kim Pardini-Kiely RN MS, director of quality improvement and patient safety, at kpardinikiely@stanfordmed.org; or Mary Ott, RN MS, senior director, Risk Management at mott@stanfordmed.org.