Air Canada Almost in Deadliest Accident in Aviation History — CRM Training Saves Countless Lives

sfo near miss aviation simulation

Yesterday in San Francisco (July 10, 2017), Mercury News reporter MATTHIAS GAFNI wrote how Air Canada pilots almost landed an Airbus 320 onto the jetway where four other planes were waiting to take off. The incident provides a strong example of why Crew Resource Management (CRM) communication protocols allowed for everyone involved to create awareness, recommendations, and change. In this case that “must hear” communication helped save almost a thousand lives.

SAN FRANCISCO — In what one aviation expert called a near-miss of what could have been the largest aviation disaster ever, an Air Canada pilot on Friday narrowly avoided a tragic mistake: landing on the San Francisco International Airport taxiway instead of the runway.

Sitting on Taxiway C shortly before midnight were four airplanes full of passengers and fuel awaiting permission to take off, according to the Federal Aviation Administration, which is investigating the “rare” incident. An air traffic controller sent the descending Air Canada Airbus 320 on a “go-around” — an unusual event where pilots must pull up and circle around to try again — before the safe landing, according to the federal agency. FAA investigators are still trying to determine how close the Air Canada aircraft came to landing and potentially crashing into the four aircraft below, but the apparent pilot error already has the aviation industry buzzing.


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“If it is true, what happened probably came close to the greatest aviation disaster in history,” said retired United Airlines Capt. Ross Aimer, CEO of Aero Consulting Experts. He said he’s been contacted by pilots from across the country about the incident. “If you could imagine an Airbus colliding with four passenger aircraft wide bodies, full of fuel and passengers, then you can imagine how horrific this could have been,” he said.

You can bet that this exact scenario conditions will be programmed into simulators around the world, especially for those pilots flying into San Francisco. As well, I am sure that the Ground Control teams at SFO will take a deep look at the lighting patterns for the runway to see what else could be  done to better indicate approaching flights.

In aviation, such near misses cause huge safety investigations from multiple agencies. When does that happen in healthcare for our near misses? — Why is TeamStepps training not mandatory for healthcare professionals like CRM is for aviation industry professionals? Possibly because the lives of the healthcare providers aren’t also on the line, only their patients. Harsh as that may sound, why else would healthcare not force adoption of the issue, like aviation did? Tell us your thoughts in the comments below.

Read the Whole Mercury News Story About the Never-Event here


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Upcoming September ‘TeamSTEPPS Trainer Essentials Plus’ Courses by Dr. Timothy Clapper at PA Global Institute for Sim Training

teamstepps

Word today is about an upcoming September 4th early-bird deadline to participate in Dr. Timothy Clapper’s Upcoming September/October TeamSTEPPS Trainer Essentials Plus courses. Dr. Clapper was the SimGHOSTS 2013 USA keynote speaker where he spoke on the ability for TeamSTEPPS to be utilized not only for healthcare to healthcare discussions, but also for healthcare to simulation staff conversations. It’s a communication tool set that enhances performance and patient safety.

Read our other simulation TeamSTEPPS articles by with Dr. Timothy Clapper:

Poor communication and teamwork can lead to under-performing clinical teams and errors that disrupt even the best patient safety initiatives. TeamSTEPPS can make a difference for organizations, but only if the organizations and clinicians understand, adopt, and apply the four competencies (Clapper & Ng, 2012).

Course Overview: This course trains teams in the essential skills needed to function as team members and leaders. This is the only master training course that includes the use of simulation and assists the learner with developing an implementation plan.

Course: “TeamSTEPPS Trainer Essentials Plus”
Course DatesSep. 21-23, 2015 or Sep. 30-Oct 2, 2015
Course Provided By: Global Institute for Simulation Training
Location: Simulation Training Center at Education Management Solutions, Exton, PA
Instructor: Timothy Clapper, PhD

Timothy Clapper, PhD

Dr. Clapper is one of four American College of Surgeons Advanced Trauma Life Support (ATLS) Educators in the world. As a TeamSTEPPS® Master Trainer, he has improved the teamwork skills and clinical practice of inter-professional teams at numerous healthcare facilities in the US and abroad. Using TeamSTEPPS® and his Saturation in Training theory (Clapper & Ng, 2012), he has improved the culture and practice of entire departments and reduced clinical errors.

Course Objectives:

  1. Use TeamSTEPPS communication tools to improve team communication and increase patient safety
  2. Use effective patient handoff techniques to enhance information exchange during transitions in care
  3. Identify barriers to teamwork and use strategies to overcome them
  4. Participants will receive an implementation guide – it is a core value to the course. They will not have to develop it. They will receive the implementation guide, and the course content will include training on how to tailor the plan for their own institute, including training cross-departmental teams.
  5. Participate in simulation to reinforce learning

Here’s what participants say:

“I had previously taken a TeamSTEPPS®workshop, but came back feeling like I had tools, but could not get “buy in” to use them. I was also unsure of how to fit it into our program. After attending this educational program, I am armed with both education, the means to carry it out, AND a plan! The plan will help us to move the process forward”

“I enjoyed the combination of information along with how to use it and implement it; the interaction among the group as led by [Dr. Clapper] and the various modes of education (lecture, video, sim) fully engaged me and kept my attention.”

Seating is limited to a maximum of 20 participants for each workshop.
Early registration rate is available until September 4.
Institutions are encouraged to send a team of three (physicians/nurses) from each department to facilitate effective implementation.

Click here for more information about the course.

Click here to register!

Virtual TeamSTEPPS Online Program Enables Collaborative Training Opportunities

At IMSH HealthySim interviewed Rachel Umoren about her team’s Virtual TeamSTEPPS Simulation training system from the Institute for Digital Intermedia Arts at Ball State University. Watch the video below to learn all about it:

Dr. Rachel Umoren is a practicing neonatologist, a clinician educator and researcher in medical education. She is an Assistant Professor of Clinical Pediatrics at the Indiana University School of Medicine, a Faculty Fellow at the Ball State University Institute for Digital Intermedia Arts, and a visiting Scientist Scholar in Health Services Research at the Regenstrief Institute, Inc. in Indianapolis, Indiana. In these various capacities, she investigates the best practices and outcomes of educating health professional students through collaborative 3D virtual environments. Her particular interests are in interprofessional teamwork in both local and global health settings. In this capacity, she has developed simulations for teamwork, public health training, and traveler safety in global health settings.

Learn more about the project through this research report which utilized the Virtual TeamSTEPPS application.


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TeamSTEPPS Online Master Trainer CE Course Now Available for FREE!

teamstepps free training

Thrilled to share that the AHRQ has enabled all of us to take their TeamSTEPPS team-based communication master trainer course for FREE!  TeamSTEPPS is the “healthcare version” of aviation’s CRM communication tool which has proven to dramatically reduce errors in the field. This is the best communication model available for practicing in your healthcare simulation programs!

Our good friend Dr. Timothy Clapper PhD has written numerous articles on how TeamSTEPPS can be utilized in simulation training, as well as presented on the topic as the SimGHOSTS 2013 Keynote Address.

Learn more & register for the next course at the AHRQ.gov website!

What is TeamSTEPPS specifically?

TeamSTEPPS is a teamwork system designed for health care professionals that is:

  • A powerful solution to improving patient safety within your organization. An evidence-based teamwork system to improve communication and teamwork skills among health care professionals.
  • A source for ready-to-use materials and a training curriculum to successfully integrate teamwork principles into all areas of your health care system.
  • Scientifically rooted in more than 20 years of research and lessons from the application of teamwork principles.
  • Developed by Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality.

TeamSTEPPS provides higher quality, safer patient care by:

  • Producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients.
  • Increasing team awareness and clarifying team roles and responsibilities.
  • Resolving conflicts and improving information sharing.
  • Eliminating barriers to quality and safety.

free master trainer communication course

More about the NEW Online Master Trainer Course

The TeamSTEPPS® 2.0 Online Master Trainer Course consists of 11 modules, 8 of which offer continuing education (CE) credits. Learners in a cohort or noncohort group completing the full course of all 11 modules and a coaching session with a TeamSTEPPS Master Trainer (also known as a teach-back session) not only receive CE credits, but can also receive certification as a Master Trainer. Learners can also choose to complete individual modules for CE credits only.

   For example:

  • Reynolds Army Community Hospital in Oklahoma decreased delays in surgery start times, and increased productivity just 6 months after implementing TeamSTEPPS.
  • Montgomery Community Hospital, a critical access hospital in North Carolina, improved efficiency and effectiveness in high-risk pediatric situations.
  • Madigan Army Medical Center in Washington State improved the time from decision to performance of an emergency Cesarean section, with no adverse outcomes for either the mother or the child.

We encourage potential master trainees to review the readiness assessment checklist to determine if this is the right time to begin implementation of the TeamSTEPPS initiative.

While multiple online classes will be made available throughout 2014-2015, the first course offerings include:

  • Self-Paced (Noncohort) 1: Class starts January 7, 2015, limited to 350 participants.
  • Group-Paced (Cohort) 2: Class starts January 12, 2015, limited to 100 participants.

The course timing and activities are:

Group-Paced (Cohort): Complete all 11 modules, view 3 Webinars, and teach a module to at least one Master Trainer in as few as 33 days but no longer than 120 days.

Self-Paced (Noncohort): Complete all 11 modules, and teach a module to at least one Master Trainer within 210 days.

While the course is offered at no cost to participants, AHRQ has committed significant resources to make the class available online. Professionals who want to be certified as Master Trainers will need to create a change team, submit a draft change plan and write a letter of commitment prior to enrolling in the course . Professionals wishing to obtain free continuing education credits but not complete the full course can still complete individual modules to develop mastery of teamwork concepts.

Modules:

1: Introduction (No CE credits) – Provides an overview and examines the science of team performance, beginning in aviation and migrating to health care. Discusses why patient safety is so important and how teamwork can make a difference

2: Team Structure (.75 CE credit) – This is the first step in implementing a teamwork system. Delineates fundamentals, such as team size, membership, leadership, identification, and distribution.

3: Communication (1.0 CE credits) – The focus is on how to communicate effectively through standardized information exchange strategies, such as SBAR, check-back, callout, handoff, and checklists.

4: Leading Teams (1.25 CE credits) – Identifies key behaviors that leaders need to make sure teams perform effectively and attain desired outcomes. Introduces brief, huddle, and debrief skills.

bCE credits) – Discusses gaining or maintaining an accurate awareness and understanding of the situation in which the team is functioning. Results in situational awareness and, ultimately, a shared mental model among team members.

6: Mutual Support (2.0 CE credits) – Reviews backup behavior that allows teams to become self-correcting, distribute workload effectively, and regularly provide feedback. Introduces specific approaches to managing conflict; each team member becomes a part of the safety net.

7: Summary (No CE credits) – Provides an opportunity for participants to review and analyze a video case study.

8: Change Management (1.75 CE credits) – Realizing change is difficult, introduces John Kotter’s eight-step model for successful change efforts. Discussion of each step includes its implications for the change effort.

9: Coaching (2.0 CE credits) – Coaching describes a specific action, such as encouraging, reinforcing, giving feedback, and demonstrating. As coaches are important change agents and assist with implementing teamwork initiatives, the session will discuss aspects of coaching as key components in an organization’s change strategy and plan.

10: Measurement (1.50 CE credits) – Measurement helps determine if TeamSTEPPS® worked. Discusses the Kirkpatrick model of training evaluation and identifies measures that can be used to assess the impact of TeamSTEPPS®.

11: Implementation Planning (2.25 CE credits) – Based on the principle of improving health care quality and safety by improving clinical processes. Focuses on developing an actionable implementation plan for your organization.

Learn more & register for the next course at the AHRQ.gov website!

Timothy Clapper PhD Articles on TeamSTEPPS Communication Training Opportunities for Medical Simulation Programs

dr timothy clapper

Just received an email from my good friend Timothy Clapper, PhD regarding yet ANOTHER great article he has produced regarding TeamSTEPPS communication practices with regards to healthcare simulation. TeamSTEPPS was developed by the Agency for Healthcare Research and Quality utilizing CRM communication models from the space and aviation industry. Timothy’s work continues to innovate within our community, helping simulation champions better recognize and utilize simulation as a medium for revolutionary change within healthcare.

TeamSTEPPS is a teamwork system designed for health care professionals that is:

  • A powerful solution to improving patient safety within your organization. An evidence-based teamwork system to improve communication and teamwork skills among health care professionals.
  • A source for ready-to-use materials and a training curriculum to successfully integrate teamwork principles into all areas of your health care system.
  • Scientifically rooted in more than 20 years of research and lessons from the application of teamwork principles.
  • Developed by Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality.

TeamSTEPPS provides higher quality, safer patient care by:

  • Producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients.
  • Increasing team awareness and clarifying team roles and responsibilities.
  • Resolving conflicts and improving information sharing.
  • Eliminating barriers to quality and safety.

Timothy’s Letter and Article Links:

Dear Lance & HealtySimulation.com Readers,

Just an update on my latest article for TeamSTEPPS. You may recall that my first article described TeamSTEPPS and the need for this tool to improve patient safety. I am happy to share that this article is still at #25 on ScienceDirect’s top 25 articles!

This was followed by a second article that outlined some reasons why TeamSTEPPS programs fail and ways to work through those issues. My latest one, just released, focuses on next steps in TeamSTEPPS, including the observation that must be done to assess additional simulation training needs.

Clapper, T. C., & Kong, M. (2012). TeamSTEPPS: The patient safety tool that needs to be implemented. Clinical Simulation in Nursing, 8(8), e367-e373. doi:10.1016/j.ecns.2011.03.002

Clapper, T. C., & Ng, G. M. (2013). Why your TeamSTEPPS program may not be working. Clinical Simulation in Nursing,9(8), e287-e292. doi:10.1016/j.ecns.2012.03.007

Clapper, T. C. (2014, in press). Next steps in TeamSTEPPS®: Creating a just culture with observation and simulation. Simulation & Gaming. doi:10.1177/1046878114543638

Enjoy!

Tim

Timothy C. Clapper, PhD

TeamSTEPPS Master Trainer and American College of Surgeons Advanced Trauma Life Support (ATLS) Educator
Editor, Healthcare Section, Simulation & Gaming (S&G): An International Journal of Theory, Practice and Research
Public Member, Accreditation Council for Graduate Medical Education (ACGME) Review Committee for Anesthesiology
Adjunct Professor & Sr. Instructor, Graduate Instructional Technology Certificate Program University of Colorado at Colorado Springs, College of Education
Dissertation Chair Grand Canyon University, College of Doctoral Studies
Simulation and Education Consultant – TC Curriculum & Instructional Design, LLC

If you are interested in learning about TeamSTEPPS and how it can be used by not only your healthcare staff, but simulation team staff as well, check out the Laerdal sponsored SimGHOSTS 2013 Opening Keynote address provided by Dr. Timothy Clapper, which is permanently available for free on SimGHOSTS.org thanks to Laerdal!

Also, connect with Timothy through his website TC Curriculum & Instructional Design


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Help Fund Movie That Connects Aviation Simulation to Healthcare Simulation

aviation team training into healthcare

IndieGoGo, a crowd-funding platform for independent projects, is hosting the opportunity to donate towards: “Beyond the Checklist: A Feature Length Documentary Film”, which explores how lessons from industries like aviation can provide solutions to the crisis of patient deaths and injuries in healthcare. I urge you to join me in pledging towards this important documentary film which will attempt to show how training in the aviation business using evolved communication practices has lead to an incredible safety record, especially in comparison to the number of deaths attributed to medical error now occurring in the United States.

The Concept Behind the Film:

“On January 9, 2009. US Airways Flight 1549 landed in the middle of the frigid Hudson River in New York. Captain Chesley “Sully” Sullenberger and his crew – as well as ferry and Coast Guard crews – had all practiced and trained in teamwork for years. Which is why not a single passenger or crew- member was seriously injured when the plane was totally disabled when struck by a flock of Canada Geese.

Our 60-minute film will demonstrate that healthcare can transform its culture and stem the epidemic of medical errors and injuries in the US and elsewhere. It can do this by learning lessons from the safety model and culture change movement that transformed commercial aviation over the last 30 years and that has been successfully adapted to make other high-risk industries much safer. The film “Beyond the Checklist” shows exactly how this safety model and culture can be implemented in the healthcare industry.

Take a trip on a $14 million dollar flight simulator, and see how pilots, fight attendants, ground crew, and air traffic controllers all learn to work together to make air travel safer. Sit in on training sessions that teach people on very different rungs of the health care hierarchy how to communicate so they can form quick teams and react instantly in crisis. Here, pilots aren’t only graded on how well they guide a plane during both routine flights and crises but on how well they communicate and work as a team with their crew. Flight attendants mechanics, and gate agents and many others learn to speak up when appropriate and challenge each other, as well as the captain and rather than experiencing “push back,” they are thanked for it.

“Crew Resource Management gave you a process and a language…so that if I said to you, captain I’m not comfortable with this, he had to hear that because it was done in a way that we were all trained,” recalls Nancy Burns, who was a flight attendant for 39 years both and experienced the change in culture when aviation introduced CRM. “It meant that if you spoke up they had to listen. It also meant that you had a responsibility to speak up.” Airline personnel are also encouraged to report mistakes – even serious violations – without being punished and all airlines share information about near misses, errors, and other problems to change practice and insure safety.

The film concludes by showing how the lessons of these pioneering practitioners and institutions can be implemented in every single hospital and health care facility so that every patient everywhere is safe. Each and every one of us will someday be a patient. Our lives and the lives of our loved ones depend on whether our caregivers are trained to work together as a team, can learn together to prevent mistakes, and are able to create a culture of safety in healthcare.”

Click here to learn more and donate to the Beyond the Checklist Documentary Film!

NPSF President Interviewed by AHRQ & Prepares for May Patient Safety Congress

patient safety foundation

The AHRQ, aka the Agency for Healthcare Research and Quality, had Web M&M editor Dr. Robert Wachter sit down with Dr. Tejal K. Gandhi to discuss the National Patient Safety Foundation and the organization’s evolving role in enhancing healthcare safety at a national level.

What is the NPSF? The National Patient Safety Foundation’s vision is to create a world where patients and those who care for them are free from harm. A central voice for patient safety since 1997, NPSF partners with patients and families, the health care community, and key stakeholders to advance patient safety and health care workforce safety and disseminate strategies to prevent harm. NPSF is an independent, not-for-profit 501(c)(3) organization.

Before we get to the interview snippet, remember that NPSF is holding its 16th annual Patient Safety Congress this May 14th-16th at the Renaissance Orlando at Seaworld. Simulation continues to increase its presence at this event, and here is a full day pre-conference workshop I found on the topic taking place May 14th:

Pre-Congress Session
Wednesday, May 14, 2014 | 8:00 AM–4:00 pm

Continuing Education for this Program
6.5 contact hours for physicians, pharmacists, nurses, health care risk managers, health care quality professionals, and health care executives

This interactive, multidisciplinary session will push the boundaries of traditional health care simulation programs. During the first part of the program, participants will look closely at the spectrum of simulation, experience live demonstrations, help write patient safety simulation scenarios, and participate in hands-on opportunities with simulation equipment. During the second part of the program, participants in the patients and families session will join the group for a joint learning opportunity. Simulation experts and patient and family representatives will work together to provide attendees opportunities to examine ways in which patients and families, who are integral parts of the health care team, can provide perspective and knowledge not always gained through the use of traditional health care simulation programs. This session will incorporate the patient and family perspective, and participants will have opportunities to identify and apply ways to improve the patient experience and improve the safety of their organization. Take-home tools will be provided.

nps congress


I have excerpted some of the interview text for you below, but you can read the full interview on the AHRQ website linked at the bottom of this post. (You can also listen to a portion of the interview here).

RW: Much of what NPSF does is education and convening. Is the new technological world that we find ourselves in—the world of MOOCs and videos—changing the nature of how you think about getting people together and working collaboratively across time and space?

TG: This is an area that we’re just starting to explore. We, and I think other organizations, have found that it’s harder to get people to travel to meetings. Even though the one-on-one networking at meetings is really valuable, given financial and time constraints, this is a challenge for many organizations. I think we are going to be much more engaged in other forms of convening technology and best practice sharing technologies. We’ve done webinars, but in the next year or two we will be exploring other ways to try to convene folks that doesn’t involve face-to-face interaction.

RW: You’ve been one of the leading experts in the role of information technology (IT) in patient safety. We’ve gone from 10% IT in American hospitals and clinics to probably 60% to 70% in a few years because of Meaningful Use incentives. How has that changed the environment for safety generally and then NPSF specifically?

TG: I’m a firm believer that health information technology can improve the safety of the care we deliver. This rapid transition is a good thing. We’re getting over that adoption hump and getting into these new systems, which have great potential to improve care. The challenge is that often the systems are not necessarily implemented to optimize safety and quality for a variety of reasons, whether it’s workflow or poor design. But there are many reasons why I don’t think we’re maximizing the benefits of health IT. Another big issue—it often feels like every implementation is standalone, where every hospital or clinic is trying to decide which way is the best way to do things. Best practices around how to implement are starting to come out but are still quite rudimentary.

Many decisions are made in implementation that have big impacts on quality and safety, but they are decided in one-off situations instead of having a standard for how we should be implementing to optimize quality and safety. A concrete example is around drug interactions. Which ones should we show or not show to optimize the benefits while minimizing over-alerting? It’s a decision that every place makes on its own. It strikes me that there should be a standard for something like that, but also there’s all this work happening at each site that could be avoided if there was a best practice around this. Another example is around medication lists: who can touch them, how should they be kept accurate, what should a specialist do versus a primary care doctor? I know places are spending days, weeks, months, and years trying to figure this out. Is there a way to get some best practice standards out there to help people optimize these things? Because having an accurate medication list is such a fundamental component to delivering safe care, yet we really struggle with it. I feel like the role of the National Patient Safety Foundation is to use our convening function to create some of these best practices around health IT implementation, for example.


Learn more about the AHRQ and their TEAMSTEPPS Communication tools for healthcare educators.

Learn more about the NPSF, and their May Patient Safety Congress!


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Forbes: “Miracle on the Hudson” Pilot Capt. Sully Works on Patient Safety

Robert J. Szczerba, contributor to Forbes and founder of Simulation-based “X Tech Ventures” has written a great piece on the recent work of Captain Sully – the pilot who successfully landed a engineless plane in the hudson river saving all 155 passengers back in 2009. Captain “Sully” Sullenberger is working with John Hopkins to explore patient safety issues.

sully-patient-safety

Szczerba writes “What lessons on patient safety can be taught by thought leaders from such diverse domains as aerospace, consumer research, defense, nuclear power, education, and hospitality? These were some of the intriguing questions explored last week at the inaugural Forum on Emerging Topics in Patient Safety, jointly sponsored by the Johns Hopkins Armstrong Institute for Patient Safety and Quality and the World Health Organization.

[At the event] Dr. Peter Pronovost, Johns Hopkins Medicine Senior Vice President for Patient Safety and Quality, is one of the nation’s leading advocates for patient safety. During his keynote address, Pronovost explained that “… medical errors and preventable patient harm is the third leading cause of death in the United States and contributes to an estimated $800 billion—one third of all health care costs—spent each year on unneeded or inefficiently delivered care.” Click here to read how patient deaths due to medical error have increased to 220,000-440,000 every year.”

Szczerba continues “Captain Sully & each of the speakers described safety-related challenges in their own fields, and encouraged discussions as to how they might be applied to the clinical environment, with a focus on:

  • Designing safe and highly reliable systems of care delivery
  • Ways to quickly disseminate and incorporate best practices in the areas of safety and quality
  • Developing performance measures that are meaningful to patients, providers, payers, and regulators

The most interesting revelation was that the technologies and processes needed to reduce patient harm already exist and have been proven in other industries time and time again.  The obvious imperative for healthcare is to leverage these best practices to change the underlying culture.”

Read all of Robert’s Article on “Captain ‘Sully’ Sullenberger and Johns Hopkins Tackle Patient Safety” here.

Captain Sully also wrote an introduction to Beyond the Checklist: What Else Healthcare Can Learn from Aviation – and you can read my full book review of this amazing work here!

Beyond the Checklist: What Else Healthcare Can Learn From Aviation Book Review

suzanne gordon book review

I met Suzanne Gordon, lead author of “Beyond the Checklist: What else Healthcare Can Learn From Healthcare”, at the speaker’s reception of CAE Healthcare’s 2013 HPSN event in San Francisco. At that time, we had a lengthy conversation about the need to reform healthcare communication using proven methods and the opportunity inherent with medical simulation to help to do so.

beyond the checklist book review

Suzanne graciously provided me a copy of her book to review, which I can tell you now is a definite MUST-READ for anyone engaging within any avenue of healthcare, education, and/or simulation. This book goes beyond highlighting key examples of the poor communication practices causing systemic failures within healthcare by also providing a direct roadmap to solve these archaic human-made challenges. The authors poignantly remind us that the status quo of healthcare communication can no longer remain “just the way it is”.

In Beyond the Checklist, Suzanne Gordon:

  1. Diligently lays out the crisis of communication failures occurring within healthcare.
  2. Reminds us of the history of similar communication failures within commercial aviation.
  3. Demonstrates the 30+ year process of research, program development, and training systems implemented within aviation with regards to communication and team-management.
  4. Powerfully explicates “Crew Resource Management” (CRM) as an evolved system for team interactions and operational success.
  5. Highlights successful uses of the initial healthcare version of CRM called TEAMSTEPPS.
  6. Directs our attention to the unavoidable future of healthcare including regulatory bodies and advanced data-capturing systems.

Most incredibly, Suzanne and her co-authors break down the individual components that make up successful team communication, demonstrates how those pieces are failing within healthcare structures, and provides direct examples of how those issues have already been successfully addressed within aviation.

Read some of the excerpts below to better understand the benefits of this work:

“In medicine it seems now to be universally acknowledged that failures of teamwork and communication-not simply failures in technical proficiency-cause the majority of medical errors and injuries in hospitals and other health care facilities. Studies too numerous to cite have documented that it is not the incompetent surgeon or a small group of bad apples in other disciplines that cause harm to patients. It is human factors – the failure of human beings to relate effectively and productively with one another highly technological settings, to recognize human limitations in performance ability owning to “Life factors” such as extreme fatigue and emotional distress, and to actively resist the culture of blame- that are the major cause of patient harm.” p. 8.

“Even when early pilots flew with a navigator, contact was difficult and minimal. From aviation’s inception as a mode of transport, teamwork was rarely a consideration. A large part of pilot training, whether conducted in military, commercial, or general aviation arenas, is often accomplished one-on-one as flight instructors demonstrate and students unquestioningly mimic technical maneuvers-and especially behaviors. The first major milestone in any pilot’s advancement is to fly solo. Until the introduction of CRM in commercial aviation, a pilot’s primary demonstration of competency was based almost entirely on technical aptitude: the ability to perform a standard set of maneuvers and handle emergences (with little or no regard for interaction with the rest of the crew). Although commercial transport pilots flew as crews, competence had little to do with teamwork or error management in the cockpit.” p. 24.

“The aviation safety moment started out precisely because pilots did not accept their human fallibility. Mistaking the end of a very long journey for its beginning, many in medicine do not seem to understand the similarities between attitudes of pilots pre-CRM and those of physicians today. CRM did no succeed because in the 1980s pilots at United and other airlines threw their hands and said, “We give up.” A great many pilots, in fact, dismissed CRM as “Charm school”… to erode their authority. Flight attendants were also initially skeptical. The fact that human fallibility is now universally accepted in aviation is the result of a very long journey that began with a challenge to an ethos that led pilots to believe they had the power of Zeus when, in fact, many only had the hubris of Icarus. The aviation safety movement has worked not only because of the concrete lessons it teaches but also because of the reconceptualization’s ands strategic approaches it has utilized. These have been derived from, and refined through, thirty years of hands-on, human-factors research-in other words, evidence-based changes and developments”. p. 157.

Again, this 261 page book is a MUST READ for anyone engaging in medical simulation today!

Get the softcover version of Beyond the Checklist or the kindle edition through Amazon.com.

Continue reading more great examples of the content available in Suzanne’s book by “Reading More” below.

Read the rest of this entry »

Watch the SimGHOSTS 2013 Keynote Address, Sponsored by Laerdal

timothy-clapper

At SimGHOSTS 2013, Laerdal sponsored a keynote address designed to empower the voices of Simulation Technology Specialists through the AHRQ designed communication tool called “TEAMSTEPPS”. The event was recorded in full HD.

To view the Laerdal Sponsored SimGHOSTS 2013 Keynote Address, visit the SimGHOSTS.Org website article. 

The session began with an update from newly appointed non-profit SimGHOSTS Organization Event Team Chair Ryan Eling with some key survey data from our emerging technical and professional community. Next, Keynote Speaker Dr. Timothy Clapper PhD in Education, shared how to empower simulation technicians in their healthcare-based programs by using TEAMSTEPPS communication methods.This presentation has been seen by technicians within our community and remarked as “ground breaking” and “powerful!”. Learn more about Dr. Timothy Clapper and his presentation at the SG13 Laerdal Sponsored Keynote Address website.

Afterwords, SimGHOSTS heard from three individuals who wish to be considered for The Gathering of Healthcare Simulation Technology Specialist Presidential race. Read about the election results here. Those who have previously attended a SimGHOSTS event will be also be allowed to vote for this first community-elected position. Finally, SimGHOSTS Founder and ongoing Executive Director Lance Baily demonstrated a new project that has been called “Industry Game Changing” by those at the event!