Sunday, August 28, 2016



(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: )

            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.

Other interviews with pilots:

Kenneth Lipshy MD FACS
Hampton VA

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 ( 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 (, 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

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