A bold move for training

Since St Francis Hospital, Columbus, GA, made it mandatory for its physicians to complete Crew Resource Management training, it has proved to be a step worth taking. Angie King, the hospital’s administrative director of patient safety, told HRMR how it was achieved.

Back in 2009, Angie King, administrative director of patient safety at St Francis Hospital, Columbus, GA, decided serious action was needed to tackle patient safety at her facility. 

"I laid out to the physicians that if our staff are intimidated they’re not going to tell you there is a problem."

“In 2009 we had five surgical sentinel events so I went to the governing body and said, ‘we’ve got to fix this’. We went on to do a lot of research as to who we were going to partner with in order to address the problem,” she says.

After lengthy discussion they decided to engage LifeWings to roll out a Crew Resource Management (CRM) training program at the hospital.

CRM originally developed for the aviation industry in response to the United Airlines flight 173 crash, which occurred when the plane ran out of fuel while crew were trying to deal with a problem with the landing gear. 

Subsequent studies found that human error, especially poor communication, decision-making and leadership, were the main reason not just for this crash, but for most crashes occurring around that time. CRM was developed as a way to train staff to develop procedures that would eliminate human error.

Since the 1990s, the principles of CRM have been applied in healthcare—notably through the TeamSTEPPS training provided by the Agency for Healthcare Quality and Research (AHRQ), which adopts many CRM principles. King and her colleagues explored TeamSTEPPS as an option, but felt that straight CRM was the answer for St Francis Hospital.

“We looked at all the options, but we felt that for us, CRM was going to be the best rollout, because it was very, very clear cut, and we saw that we could adapt the presentation of it to our facility, and could make it real for our staff.”

Ownership of the procedures

In particular they were attracted by the way in which CRM gave the hospital’s staff ownership of the processes that were put in place to eliminate errors.

“TeamSTEPPS is very structured but we felt that if someone came in and told our surgeons an physicians and staff exactly what they had to say in certain situations, that wouldn’t go down so well. With CRM we were able to ask them what they wanted to say to staff, and what they wanted staff to say if they spotted a problem.”

This was a key part of the training, because junior staff members had been known to spot errors but stay quiet about them through fear of speaking up.

“The senior attending is like the pilot, and they have a certain degree of arrogance and intimidation that goes with the job. What I found from doing root cause analyses was that in cases where errors occurred, intimidation was a factor, and I laid out to the physicians that if our staff are intimidated they’re not going to tell you there is a problem. 

“I asked them if they would want to know if there is a problem, and they were all adamant that they would want to know. “ 

The CRM training created the perfect environment in which physicians and staff could decide on protocol that would enable staff to speak up without fear of humiliation or reprimand.

“We posed the question: if you are in the OR and there’s a new nurse there and you’re ordering the medication but she thinks there is a problem, what can you do so that she will feel able to speak up and not feel belittled? 

“Our staff decided they would say, ‘I have a concern’ and physicians would stop, turn around, make eye contact and say, ‘tell me about your concern’.”

The results speak for themselves: King and her colleagues started to roll out the project in 2010 and 2011, and since 2012 St Francis Hospital has had zero sentinel events. 

“Another important thing that our staff here did was that as part of their time out they added this statement: ‘If anybody has any concerns, please speak up’. That gave staff permission to speak up; they feel it is okay to voice concerns—and there have been so many saves because of this, from operating on the wrong hip to operating on the wrong patient to latex allergies not being identified. 

“All of that was stopped before harm came to the patient because of this process.”

A bold move

Part of the success of the initiative is down to the hospital’s assertive move of making it an essential part of their physicians’ credentialing that they complete the CRM training.

“The department of surgery and the medical executive committee decided that if you want to book a room here, you have to take the course, and you have to take an update for re-credentialing,” says King. 

“It helped that this decision came from peers, rather than being a mandate from above. It is not required on any regulatory grounds—it was our own requirement. It was a bold step in a competitive environment but it eliminated our sentinel events.”

King believes that the success of the training owes a great deal to the way in which it was embraced by the hospital’s medical staff.

“I have never been in any organisation where you saw a physician leadership so adamant that this was what they were going to do. To me, that is showing a paradigm shift: if they were not on board it was not going to happen. 

“You can have leadership pounding the desk all day long but when physicians’ peers hold them accountable to participate, that makes the crucial difference.

“Of course you’re never going to have 100 percent of the population cheering for it—I’m one of the certified trainers and I have seen head physicians who come in and roll their eyes as if to say, ‘why am I here?’ But it was their leadership that said decided they had to do this.”

To other hospitals wishing to achieve similar results, King warns that adopting CRM training is not a quick fix, and it needs sustained effort to maintain positive results. Many hospitals stop short of making this type of training mandatory for physicians, but the success at St Francis suggests that a harder line on this issue can help save lives.

“It takes a lot of leadership commitment to do this,” says King. “You’ve got to drive a culture change. You’re talking about a six to 10-year effort as opposed to a six-month program, so you’ve got to be patient.”