(For those of you not members of the ACS General Surgery
Community-Tyler Hughes asked me to post
this. The response was, as I suspected, ALL OVER THE PLACE. I am not copying
the responses of this private community, but this was my overall message)
For those not aware, the American College of Surgeons
(ACS) and the American Academy of Orthopedic Surgeons (AAOS) hosted the
first National Surgical Patient Safety Summit (NSPSS) Program Aug
4-5 2016 in Chicago IL. The mission of the program was to "propose
solutions that effectively combine elements of safety science, principles of
high reliability and best safety practices across all phases of surgical
care." Key leaders from the ACS and AAOS have been meeting over the past
two years to establish the framework for proceeding with a safety summit. The
preliminary workgroup identified key surgical safety content (knowledge),
current knowledge gaps, and key evidence / consensus-based surgical safety
practices and behaviors. This initial group expanded to include the ASA and
AORN to draft initial safety standards, propose content for safety education
programs, and identify surgical safety data needed to improve safety for
surgical patients. (Summary located at: http://crisislead.blogspot.com/2016/08/national-surgical-patient-safety-summit_8.html
)
As expected the topic frequently turned towards our constant shift in medicine
to create aviation crew H.R.O. models to improve patient safety. The group
noted pros and cons in using that model. In typical fashion, the speakers often
related seemingly factual information about Pilot Aviation Training
requirements and as usual, I was a bit incredulous about the validity of these
statements. In this particular case several in the audience indicated that
pilots would not undergo annual testing and crew management training unless
forced to do so. I have been known to accost pilots and crews frequently in
airports and hotels to ask them to refute or validate rumors I have heard from
others (Ie post flight debriefing sessions, Sleep hazard regulations etc).
Upon leaving the NSPSS,
as luck would have it, Two United Airline pilots (one my age and a younger
pilot) accompanied me on the airport shuttle. As they were reviewing their
updated weather reports and radar screens, I interrupted them to inquire
exactly what requirements we imposed on pilots for crew and simulation
training. Since we spent the last 24 hours discussing the comparison of
aviation and patient safety I felt I needed to inquire. They stated that within
their organization all training is uniform. The FAA has specific requirements
regarding training modules but otherwise training may differ amongst airlines.
They are required to attend simulation with a co-pilot from their organization
every 9 months. Once a year they join up with the entire airline team for an
afternoon to go thru emergency procedures - the entire flight and ground crew
(no the pilots are not replace by actors because the pilots are too busy and
not incentivized to participate, but actual pilots are engaged in this
simulation exercise).
When asked their
opinion about mandated training it was clear that it was not viewed as
burdensome. When I had an incredulous look, he reminded me about the flight
that ran out of fuel when the crew was totally fixated on the landing gear
light that would not turn off. He said that it is now viewed as a
partnership between the pilots, the FAA and the airlines so they are not
reluctant to disclose and discuss near misses and mistakes as compared to the
past punitive process. They said they would definitely do the training annually
voluntarily because it is a valuable educational experience. http://crisislead.blogspot.com/2016/08/post-nspss-interview-with-airline.html
Other interviews with pilots:
http://crisislead.blogspot.com/2016/03/lessons-from-sam-elfassy-senior_29.html
------------------------------
Kenneth Lipshy MD FACS
Hampton VA
www.crisismanagementleadership.com
Kenneth Lipshy MD FACS
Hampton VA
www.crisismanagementleadership.com
Community
Divided: ACS Communities response to Lipshy Post Aug 27 2016 regarding NSPS
Summit Aug 2016.
To be honest I was worried no one would be responding to this post. The fact
that some have responded means there is hope for us. The fact that we are clearly
divided in our interpretation of this facet in medical history, means we need
to collaborate more than ever. As History teaches us, if we don’t make a
responsible decision for how we manage public care, the public will decide for
us. Everything everyone said on these posts was clearly noted by surgical
leaders at the Joint ACS-AAOS NSPSS meeting earlier this month. Believe me when
I say that Dr. Hoyt is clearly concerned as well. He made it crystal clear that
the teams who made the recommendations prior to the meeting established these
recommendations as a latticework for ongoing collaboration and improvement with
the ultimate goal of producing guidelines that represented tried and true
methods of improving patient safety without compromising overall operative
safety or efficiency. But they want our input!!!! If you have constructive
advice on how to fix this contact Dr. Hoyt ASAP! He has heard all the criticism
but not many viable solutions.
Yes, we have a lot to be concerned about. Dr. Pellegrini and I discussed this
last Summer when the surgical community was divided over the Canadian study by
Baxter on lack of apparent effects of sleep deprivation on surgeons in their
study. Following that I talked with Dr. Baxter and the FAA (http://crisislead.blogspot.com/2016/03/myth-or-reality-2-fatigue-and_29.html).
I quickly discovered that while on the surface the data for sleep deprivation
in pilots seemed reasonable, the facts were not all that clear. Public outrage
after mishaps reportedly due to distracted pilots inevitably forced the FAA's
hand to make a decision. The FAA was already working on the issue, but with
public concern on the line, a decision was made sooner than they intended. I
believe we have seen this pattern before in resident education. The writing is
on the wall. If we don't develop protocols based on proven methodologies,
someone else will, then we will have no course but to comply.
The bottom line is that data indicates the trend in sentinel events is not
changing for the better. I discussed this with LD Britt last month (hope to
have our manuscript with that interview published sometime soon -maybe the ACS
Bulletin). Dr. Britt was crystal clear in noting that surgeons are missing
an opportunity here. Unlike aviation, nuclear power, etc, no single HRO model
will work in medicine. We all agree it is too complex. No single step will
work- not one standardized process- but a series of protocols will- but only
with physician buy-in. No, the pilots don’t kick the tires or check the engines
prior to take off, but surgeons don’t inspect the anesthesia machines before
surgery (and we all complain when something on the case card is not in the room
but seldom go thru the entire card to make sure everything is there prior to
takeoff). It is a community effort. It takes a team. Having said that, if we
don't want the FAA equivalent in medicine (CMS?) mandating protocols that don't
make sense, then surgeons need to design the preflight check system, team
training/communication simulation, video based coaching ( http://crisislead.blogspot.com/2016/05/innovative-strategies-for-improving_25.html),
certification processes and the like. Our opportunity is here but that is
only transient as the public will likely not be patient for long. If you
have solutions, then Call or write Dr Hoyt NOW! State boards are already
mandating sentinel event reporting. Caprice Greenberg made it clear that in the
right hands, video based coaching can improve performance, but dissent about
recording operations was clear in the NSPSS audience as laws are being
considered to force physicians to record procedures when patients ask- and then
hand the discs over! Some states are considering laws mandating surgeons
reporting to patients when they have experienced excessive hours awake prior to
operating. I am working with one state that has 130 hospitals who is
considering a statewide implementation of the WHO protocol similar to South
Carolina- the SC project was developed by – yes you better believe it- the
state Hospital Association. Mandated annual simulation and other competency training
for physicians is being considered in many states. The public does not want to
wait any longer. The public wants-get ready for this- ZERO ERROR.
Imagine what that will do for attempting to implement a safety culture if
every single error we make is documented at the state or national
level. How much more difficult will honest disclosure and performance
improvement become if state legislatures report and track online every
mistake made in medicine? If we want transparency, then we need to take
control. We need to come to common ground and agree on goals, methods,
validation, certification, whatever.
So unless we simple want to throw up our hands and accept what others mandate
for us, the time to design this process is here and now, but rapidly dissipating
as hospital administrators and other professionals -as well as the public
- are growing impatient. They simply will not sit on their hands for long.
Surgeons Stand up and figure out what will work that will provide safe care and
not impede the flow of surgery. Lord knows we already do not have enough
surgeons to go around and cannot afford to slow things down and reduce our
productivity or we will then experience delays in care.
So
let’s team up and figure out what will improve patient safety, garner team
spirit, and not reduce efficiency. There simply has to be a better way.
Kenneth Lipshy, MD, FACS
www.crisismanagementleadership.com
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