Lessons from aviation applied to the operating room

The aviation cockpit model of crew resource management (CRM) can be applied to the operating room (OR) as a tool for improving communication and preventing medical error. This system uses the resources of the participating individuals to promote excellence in patient outcomes and safety, to increase productivity, and to improve patient, staff, and surgeon satisfaction.

Implementing CRM was easier to accomplish in the airline industry than it will be in health care. Airline crews are part of very large institutions; pilots are trained in a standardized fashion and employed in an integrated system with centralized control. The healthcare field is very different, due to the decentralization of service, the number of independent groups of professionals, and the wide range of socioeconomic backgrounds of its employee base.

The advantages of having a mechanism in place to quickly build a team structure, however, are many—in both military and civilian medicine.

CRM in military medicine
Military medicine has had a somewhat easier time in transitioning to the development and implementation of CRM. The military command structure and vertically integrated system demand that personnel respond to an order, once given. Despite this clear command structure, the professional and social interactions of OR personnel must be addressed to facilitate communication and patient safety.

CRM has been part of military aviation since the early 1980s, but not until 2003 did the Department of Defense (DOD) look at applying CRM in its hospitals. In collaboration with the Agency for Healthcare Research and Quality, the TeamSTEPPS (Strategies & Tools to Enhance Performance and Patient Safety) program was developed (Fig.1). The goal of TeamSTEPPS is to produce highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients. Implementation began in 2005, and, currently, 75 DOD military treatment facilities, representing all three service branches, have TeamSTEPPS programs.

Implementation starts with a site visit to gather data and identify specific needs for each facility. A train-the-trainers team conducts a 2-day course at the hospital. Trainers are a diverse group that includes physicians, nurses, and technicians, who then conduct TeamSTEPPS sessions for their work sections, based on local goals and needs. Follow-up training is done at 3-, 6-, and 12-month intervals and is primarily based on staff questionnaires.

These data are currently under review, but the following findings are clear:

• Without surgeon “buy-in” and leadership, the program will not work.
• Training needs to include all members of the team. Training half the staff does not work well.
• Surgeons are seen as team leaders in the OR, but ALL team members have important roles in protecting patients and helping them regain health.

Veterans Administration
The Veterans Administration (VA) became interested in the possible implementation of CRM in its ORs in 2003. In 2006, the VA rolled out its version of CRM—Medical Team Training—a formal training program that targeted ORs and intensive care units. It is similar to the TeamSTEPPS program and has been implemented in 92 facilities.

Early perceptions of the program were reported in 2008. Participants expressed high satisfaction in the areas of training, safety, and efficiency as they related to patient safety, job satisfaction, and working conditions. The most recent VA study (October 2010) reported a 50 percent reduction in surgical mortality between CRM-trained surgical teams and non–CRM-trained teams.

Both the DOD and the VA are committed to CRM and have seen considerable interest in the effectiveness of CRM in maintaining high levels of team building, despite a high rate of personnel turnover. The DOD has recently started a complementary program—Microsystems—that focuses primarily on using a skills-based approach for understanding the clinical work environment and applies systems-based process improvement at the provider-patient interface.

CRM in civilian hospitals
CRM training at the public hospital level can vary from 1 to 3 days. Several commercial training programs are available, with a variety of training scenarios. Although the time necessary and the overall costs/benefits of these programs have yet to be determined, some small studies have shown a trend toward improved safety and efficiency.

Finding the balance between the desires of hospital administrators and state and federal bureaucrats and the needs of practicing surgeons is important to the success of CRM programs. Surgeons need to actively participate in the discussions at the local and system levels. One specific program will not work in all settings. Fortunately, the AAOS and The Joint Commission have played significant roles at the federal level to help shape the patient safety movement. Outside of the mandated Universal Protocols and requirements, CRM can be shaped at the local level to meet the needs of patients, surgeons, and hospitals.

Facilitating communication among members of the surgical team is key to the success of CRM. The ability to communicate and challenge actions or lack of action by other team members empowers every team member to put the patient first. CRM requires that team members are well-versed in their respective roles, the roles of others on the team, and the surgery itself, and have a desire to work in the best interests of the patient.

CRM does not reduce the need for leadership, but it does require a change in the surgeon’s leadership style. Surgeons need to use the talents and interpersonal communication skills of their surgical teams to maximize patient safety and, ultimately, their surgical successes.

The surgical profession is a culture of healing. The challenge is to synchronize scattered attempts to minimize preventable errors by systematically working to develop a culture of patient safety within that culture of healing. Then, patients and society will receive the best medicine that orthopaedic surgery can offer.

Dirk H. Alander, MD; Robert Brooks, MD, PhD, MBA; David B. Carmack, MD; and Col. Joseph Legan, MD, have served on the AAOS Patient Safety Committee and presented a symposium on “Crew Resource Management (CRM): The Orthopaedic Surgery Perspective. “Where are we and how did we get here?” during the 2008 AAOS Annual Meeting.