Fu interview with United Airlines Pilots regarding Pilot and Crew Training

Once again I was able to chat with two United Pilots today regarding their annual training. My questions were- do you train with the entire crew (ground crew, attendants, etc) and is the training amongst all their airlines's Pilots consistent and is the training across airlines consistent?
1. "No we never train with the flight attendants
2. "We pair up with another pilot for simulation every 9 months" "we may never have worked with the pilot we ar training with
3. "Training between different airline is not the same. We have different protocols from other airlines for handling different circumstances."
The goal of our training is to focus on errors, not to eliminate errors, but to manage them when they occur. You cannot eliminate all errors. 
"I would suggest you all get flight surgeons involved in this discussion. They can tell you how flight crews and goals and management differ between medicine and aviation.

Kenneth A Lipshy, MD, FACS
Www.crisismanagementleadership.com

“THE SOUTH CAROLINA SAFE SURGERY 2015 INITIATIVE” ADJUNCTS AND BARRIERS TO IMPLEMENTING A STATEWIDE SURGICAL SAFETY CHECKLIST FU Interview with William Berry

“THE SOUTH CAROLINA SAFE SURGERY 2015 INITIATIVE” ADJUNCTS AND BARRIERS TO IMPLEMENTING A STATEWIDE SURGICAL SAFETY CHECKLIST FU Interview with William Berry

A few months back I spoke with multiple folks responsible for the South Carolina Safety Initiative (for details see: http://crisislead.blogspot.com/2016/08/the-south-carolina-safe-surgery-2015.html)

With several years of experience in implementation of the WHO Surgical Safety project, the Harvard team lead by Atul Gawande, MD, MPH and William Berry, MD, MPA, MPH (Chief Medical Officer at Ariadne Labs) was a natural advisory component for this project.

When I began to inquire more, Dr. Gawande referred me to Dr. Berry, who was gracious to talk with me a few weeks ago about this project and his experience in surgical safety.

 How did you get involved in this project?

Dr. Berry:

I was an actively practicing cardiac surgeon and as I approached 50, I decided I wanted a change in career. That led me to become a student at the Harvard Kennedy School and after that, the Harvard School of Public Health. After graduation I started to work for CRICO – Harvard’s Malpractice Carrier and through met  Dr. Atul Gawande.  Because of that connection, when Dr. Gawande was asked by the WHO to do a project to improve surgical safety globally, he asked me if I could help.  That project led to the creation of WHO surgical safety checklist.  After the checklist project had been launched, a private foundation approached Dr. Gawande with funding and the work in South Carolina with the hospital association and the SC hospitals was begun.

 

What do you see as the major difference between the WHO surgical checklist implementation in third world countries and places like the US and UK?

Dr. Berry:

The biggest difference I think, is the baseline level of quality improvement work that has already been done in the developed world. In an sub-Saharan African country, while there may be a University/Academic Medical Center, that facility will usually not have the same resources devoted to quality improvement. Outside of the academic centers in those settings, primarily because of constrained resources, quality improvement experience is even more limited.  Again, because of resource limitations, they may not even have access to basic surgical supplies. In many countries, certain surgical safety processes like routine sponge counting are not performed.  There are many other drastic differences.  While the surgeons are often very well trained in American/European training programs, they suffer a lack of infrastructure and supplies. In some parts of the world, the availability of well-trained professions is also limited forcing surgical needs to be met with less trained providers.

Finally, while hierarchy in developed world operating rooms can pose challenges to teamwork and patient safety,  in developing world countries where the educational difference between the surgeons and other staff can be much greater, these issues can present even greater challenges.

 

The literature is wrought with reports that surgeons and anesthesiologists remain as major barriers to implementation in Surgical Safety projects. In the Harvard / Mass General Studies on implementation of the crisis checklist simulation project the attending surgeons were noticeably absent (replaced by fill-ins).   How do you get surgeons motivated to participate?

Dr. Berry:

We learned that a major challenge to doing a simulation trial with clinical team is the difficulty in getting teams to participate without compensating them for lost clinical time. Attending anesthesiologists were easier to recruit because one of the principle investigators could backfill them clinically. The similar approach could be used for nursing staff – substituting one nurse for another.   It was impossible to use that strategy with surgeons – their clinical roles are not easily backfilled. 

We have since published a paper where we were able to recruit surgeons (vascular, CVT, etc.) to participate in a team training program in part by including a 10% reduction in their malpractice premium.  Many surgeons want to be involved but we need to be creative in finding ways to make it easier – more convenient for them.  We need to find a way to use the time that is already put aside outside of the operating room – like grand rounds or departmental meetings.  This is time that is already “paid for” and can sometimes be repurposed to great effect. We have also found that trying “bite sized” training (short lunch time sessions) seems to be more successful. The feedback has been positive. Ideally, it would be great to get into every hospital surgery staff meeting but that is often logistically impossible.

For certain kinds of programs, like those that are webinar based, it can often be easier to reach the nurses and try to use them as a connector to the surgeons- if you help the nurses figure out how to effectively approach the surgeons you may have success.

 

In your experience how does your group gain the interest in participation by very busy surgeons/anesthesia providers who have a low expectation of change from these projects with high expectations of creating more inefficient processes? How do we find ways to implore these very busy surgeons to participate in these exercises and in the implementation phases? If you don’t have the surgeon’s buy in AND support, you will not have success.

Dr. Berry:

I don’t think that we are always making the right arguments to the surgeons and anesthesiologists. We need to promote better checklists use as a way for surgeons and anesthesiologists to lead the team and make care better for their patients. Many surgeons, in particular, believe that they are already doing everything that they can to provide the very best care to their patients even when there is convincing evidence that even the best can improve. To make that point to operating room teams, we designed a safety culture survey to identify the gaps in the existing OR culture prior to the implementation of the checklist. This is based on the work of two pioneers in patient safety, Dr. Marty Makary and Peter Pronovost, who have previously shown a disconnect between perceptions of team members about the level of safety and teamwork in operating rooms – with the surgeons being the most “optimistic”.  This disconnect is further magnified by the difficulty that surgeons have understanding that they are not the only critically important people in an OR.  Every team member is important and surgery cannot take place without that team.   Making matters worse, many surgeons act as if those around them can read minds – making assumptions about things that may not be true. I have found sometimes that surgeons can be convinced to support checklist use – not because it wioll necessarily help them – but because they are convinced that there are other surgeons who do need it.   When I was early in my clinical experience, I had what I called a “ need-know policy” – which translated to – “Don’t ask me so many questions about things that you don’t need to know”. I eventually realized that many times – they did need to know and that even if they didn’t, they needed to know because they were interested and so they felt more a part of the patient’s care. I then started a routine habit of beginning each case making sure everyone knew something about the patient as a person and why the surgery was so important to them.  This eventually became my “preop” briefing too.

 

What surprises you most during these projects? What was most expected?

Dr. Berry:

How hard the projects can be and how much time it can take to change practice and culture.  Before we started the work in South Carolina, I had extensive experience in quality improvement and patient safety work through IHI and CRICO – and I knew already that change was hard. But every time I am involved in work like this – I learn again that moving practice and the culture along with it – is really hard.  I think that I have also been surprised by how hard it can be to change things even with very simple tools. Simple doesn’t mean easy.

 

What has been the biggest disappointment thus far?

Dr. Berry:

The checklist is a way to help patients get better care and teams to provide that care.  It is filled things that we should do, with process checks and prompts for discussions that stand on evidence – sometimes evidence that is decades old.  That gap – between things that we know we should do – and what we actually do – needs to be closed. My greatest disappointment is in how hard it is to close that gap and get change implemented.  Getting physicians actively involved in closing these care gaps is also difficult and that is disappointing too.  That said, it is getting better. I think that we are on the right road and that the next generation may have it easier.

 

Kenneth A. Lipshy, MD, FACS

www.crisismanagementleadership.com –

 

NICK SABAN INTERVIEW- Life lessons on Leadership and Work - Life balance -an interview of Nick Saban by Tim Teebow and Marty Smith (UNFORTUNATELY NOT by ME)

NICK SABAN INTERVIEW- Life lessons on Leadership and Work - Life balance -an interview of Nick Saban by Tim Teebow and Marty Smith (UNFORTUNATELY NOT by ME)

      A while back I WAS fortunate to interview Coach Brad McCoy. We had a long conversation about leadership mentoring in coaching. We discussed his life lessons he gives to young players which I could pass onto our young surgical trainees. (http://crisislead.blogspot.com/2016/08/coach-brad-mccoy-interview-on.html)

     I wish I was able to interview Coach Saban but Tim Teebow and Marty Smith (ESPN) were lucky enough to do so on an ESPN broadcast today “on the lake with Saban”. They asked Coach Saban the same questions I would have. We are constantly struggling in surgery to identify key leadership aspects to mold our uprising surgical leaders and once again another great football coach has stated it so well, I felt the need to pass this along. (Go to http://broadband.espn.go.com/video/clip?id=17383517)

    MS- coach what are your favorite memories here?

    NS- the kids growing up. One thing about it is when you move around a lot...family memories are really important to your children. .... I tell everybody, we are always so worried about getting ahead, the games your gonna win and all that.. but when you get to my age at this station and you look back and say I wish I spent a little bit more time doing that. ...you can't relive it. ....As you get older some times you realize that some things are more important than when you are coming up and you are trying to make it and you didn't value the memories as much as you do now... And for everybody out there you gotta enjoy the moment.

  

    MS-how far away from football will you let yourself go (at the lake house)

    NS- I don't feel like I get away from football when I am out here.... I don't really get away from it completely, like it doesn't exist, I know that maybe for a couple of hours maybe I can go back to it, but the rest of the time my mind is completely clear of it. The level of relaxation is so important to me and if I didn't do that I could not have coached as long as I had.

  

    TT- when in your career did you learn to compartmentalize and put football in its place and family and the rest of your life in its place.

     NS- The last couple of years when I was at Michigan state I had a philosophical change in my approach. Up to that point it was all about winning...like I had to win, like I had to prove myself all the time... And sometimes I feel like I affected the team and made them feel that way. Where when I went to LSU I adopted the philosophy that hey we are going to play one play at a time ... It was more fun for me, it was more fun for the players..and we got a lot better results.

{This reminded me of a conversation I had after the Duke Faegin leadership conference in May 2016, With Dr Sottile where he explained to me that work life balance is not possible and you must find that happy medium where you can accomplish what you need to regarding your work and then let it go because you cannot be engaged simultaneously with your family and work or both will suffer.

http://crisislead.blogspot.com/2016/08/lessons-on-resilience-and-burnoutdr.html}

      MS- what is the greatest threat to excellence?

       NS-complacency, being satisfied with where you are. Complacency creates a complete disregard for doing what's right. You can't just do what you feel like doin you gotta chose to do what helps you accomplish the goals that you have and when you get complacent you lose respect for winning. ..... I don't spend much time on the past, I really spend all my time thinking about the next challenge.

    

     MS - how important is it to you to be a compass for these young men...as a man, much less as a football player?

    NS- my number one goal for our players...is that they can be more successful in life because they were involved in the program. And when they commit I tell them I don't want them to commit to Alabama, I want them to commit to all the things we do to be successful.

    

     MS- what do you expect when you get back

      NS leadership comes from the power of one, you affect one person by the example you set, being somebody they can emulate, caring about somebody, and tomorrow you affect two more guys...and then next thing you know everybody is affecting everybody in a positive way.

     

     TT. How much harder is it to get to the top of the mountain verses staying at the top of the mountain?

      NS it's a whole different set of challenges. In terms of getting people to buy in to doing the things they need to do to accomplish the goals that they have and not be satisfied with the goal they just accomplished. You gotta recalibrate every bodies thinking.

On a side note, shortly after this broadcast ESPN held another Interview with Coach Saban by correspondent Rece Davis later that afternoon.

     RD (regarding quarterback leadership) how much of that is innate and how much can be taught?

     NS sometimes people think leadership is that you stand up in front of a room and you influence a hundred people with the speech that you give, or the enthusiasm that you approach it with but really there is a power of one to me. Taking the time

Influencing a person here and a person there. And next thing you know that spreads throughout your organization and people are buying into the right things and next thing you know that works well from a team perspective.

https://twitter.com/martysmithespn,

Kenneth A. Lipshy, MD, FACS

www.crisismanagementleadership.com

LESSONS ON RESILIENCE AND BURNOUT:DR. WAYNE SOTILE PHD AT THE ANNUAL FEAGIN LEADERSHIP CONFERENCE DUKE UNIVERSITY.

LESSONS ON RESILIENCE AND BURNOUT:DR. WAYNE SOTILE PHD AT THE ANNUAL FEAGIN LEADERSHIP CONFERENCE DUKE UNIVERSITY.

    I am indebted to Dean Taylor, MD for inviting me to the Feagin Leadership Program Annual meeting at Duke University. The topic on RESILENCY was one that I often pondered but was seldom able to locate real experts to learn from. After our surprise visit from Coach Mike Krzyzewski, Wayne Sotile, PhD, discussed the role of building resistance to BURNOUT as a key process when developing a resilient leader.

    The first shocker came when Dr. Sotile explained that the development of a ‘balanced’ life is a MYTH. All we ever hear is how we need to balance our lives. He stated that inevitably what occurs when one tries to balance out work, family, themselves and an intimate relationship, is that you and those around you end up feeling angry, guilty or anxious, which is certainly not the model of a “balanced” life. Unfortunately, surgical professionals are at the top of the “most likely to be burnt out” list, so it behooves us to understand and take charge of this process. So why are medical professionals and especially surgeons so prone to burnout? As expected we are all high producers used to high demands. When we have high control we do great, but when we begin to lose control, then the stress levels go up. What happens when we are stressed? We get temperamental, angry, distressed and develop reduced mental processing powers: we “get mean and stupid”. What happens when we become mean, stupid and narcissistic? Those around us hate us and then we fight each other.

        So who suffers when physicians hit the burnout threshold? Well asides from us and our families, it turns out that our patients and teammates suffer. There have been multiple studies that correlate signs and symptoms of burnout to reduced quality of care due to an increase in medical errors, increase in litigations, and decrease in patient compliance and satisfaction.

    How do we know if we are burnt out? Dr. Sotile said that is easy, just look into the eyes of the ones we love, our teammates and our patients. If you see a look of distrust, then rest assured you are burnt out. If you are feeling guilty over or stressed over or arguing over priorities in your daily life…. You are burnt out.

    Is there anything we can do about this? The obvious choice is to blame and correct the system: increase efficiency and support, reduce documentation burden, develop leaders who foster engagement, work on our community,…. And on and on…. Dr. Sotile said that ultimately, you need to look into yourself and find what you personally can do for any real change to occur. Sure, you cannot control 90% of the stuff going on around you but if you really want to make a stance, figure out what 10% you can change. To make any changes you need to: “use realistic roadmaps. Honestly assess yourself. Counter hassles with uplifts, and deepen your relationships.”

At the end of it all Dr. Sotile left us with these messages to take home:

“Face what is beneath your feet not what you are grasping for.”

“ You don't just decide to be resilient…You need health, You need collaboration, you need career satisfaction, you need family satisfaction and to have that you must be satisfied at work.”

“It's not the number of hours you work but your attitude when you come home that affects your family- in the end you will see that, how you treat someone at work affects how they react when they get home.” So be nice to one another.

“Little changes (in your thinking, behavior, self-care, and ways of dealing with others) go a long way.”

“Find meaning- see the familiar in unfamiliar way”

“Rethink balance- only inanimate objects have balance. Don't mix your obligations - switch rocks regularly.”

“Look for joy in others- don't ruin it.”

“Don't share irritability, anger...”

“Give gratitude.”

“Enjoy moments of serenity.”

“Believe, have hope and have Interest.”

“Find Amusement, wonderment, pride, awe, and love as often as you can”.

After discussing this summary with Dr. Sotile, I had a few questions

·         In dealing w very busy, very focused, and very skeptical physicians- what's the one thing you do that captures their attention to instill the desire to make a change (assuming they were not deemed a disruptive physician and this was recommended to them)?

·         As one takes on additional roles from being a clinician and family partner and parent to include major leadership roles (Department Chair or Chief Surgery) you essentially have gone from two to three "competing" interests all of which are equally important. What's your advice to the leaders about making sure everyone senses that you have not deprioritized them- that is you are not even more distant?

·         It's easy to say "I don't sweat the small stuff" but in family, clinical care and organizational leadership, what you class as the "small" stuff likely is not small to your patients, family, or organization. So how does one prioritize three seemingly non-intertwined worlds?

RESILIENCE AND BURNOUT: DR. WAYNE SOTILE PHD ANSWERS OUR QUESTIONS ABOUT LIFESTYLE CHANGES.

Great questions…with no easy answers. See red ink, below

1.      Q. So in dealing w very busy, very focused, and very skeptical physicians- what's the one thing you do that captures their attention to instill the desire to make a change?
A. Show how their lack of positive engagement (or happiness) with work puts both their personal and family health and wellbeing at risk.

2.      Q. As one takes on additional roles from being a clinician and family partner and parent to include major leadership roles (department chair or chief surgery) you essentially have gone from two to three "competing" interests all of which are equally important. What's your advice to the leaders about making sure everyone senses that you have not deprioritized them?
A. Whether or not to accept that sort of career-changing promotion is best treated as a family/marital decision. Research has shown that burnout of Chairs, specifically, co-varies with perception of marital support. (See the work of Steven Gabbe.) Secondly, key to family satisfaction with the physician leader is the leader’s conveying that whatever is important to each family member is just as important to him/her (the Chair) as is the busy professional work he/she is engaged in…even if he/she can’t be present as much as desired.

3.      Q. It's easy to say "I don't sweat the small stuff" but in family, clinical care and organizational leadership, what you class as the "small" stuff likely is not small to your patients, family, or organization. So how does one prioritize three seemingly non-intertwined worlds?

A.      This is a particularly difficult one. One key is managing one’s own perfectionism; differentiating the arenas of life – and realizing that absolute perfectionism (re: self-expectations and expectations of others) is not adaptive, at minimum, in both organizational and family life. Also helpful is adapting to the “infinite sloppiness” that is both the family developmental and organizational developmental courses.  

Kenneth A. Lipshy, MD, FACS

www.crisismanagementleadership.com

COACH BRAD MCCOY INTERVIEW ON SITUATIONAL AWARENESS, RISK TAKING, LEADERSHIP DEVELOPMENT …. IN FOOTBALL- HOW DOES THIS RELATE TO SURGERY?

SITUATIONAL AWARENESS, RISK TAKING, LEADERSHIP DEVELOPMENT …. IN FOOTBALL- AN INTERVIEW WITH COACH BRAD MCCOY. HOW DOES THIS RELATE TO SURGERY?

"With 14:38 to go in the second quarter of the 2015 AFC Championship Game against the Denver Broncos, Tom Brady tried to get the ball to Rob Gronkowski, but was picked off by Denver linebacker Von Miller." That's what the headlines said but I watched...

"With 14:38 to go in the second quarter of the 2015 AFC Championship Game against the Denver Broncos, Tom Brady tried to get the ball to Rob Gronkowski, but was picked off by Denver linebacker Von Miller." That's what the headlines said but I watched that play over and over I thought “wow, that was a great throw- if that was the intended receiver”. It was as though Tom Brady did not recognize Von Miller was even there. That triggered the question in my mind: hey coach, how do you train star quarterbacks to maintain full situational awareness of their receivers and defenders. In surgery we have to simultaneously keep situational awareness and focus. Pilots practice load shedding where they eliminate distractions and focus on specific gauges etc but separate the tasks out so that they are sure one person is monitoring all the gauges. We try to do this in surgery but have to keep aware of what is going on in the periphery without over distraction. So my question is, how do you as a coach/quarterback train to keep awareness of both your receivers and the defenders who are attempting to thwart your plans. How do you focus on the tight ends and wide receivers but not forget the defenders. I thought about this as I watch Tom Brady and a few others throw right into the arms of wide open defenders during the playoffs.....I teach the residents to not forget about the Gorilla-- from the Harvard Gorilla - basketball studies from the 80s. Others warn me to not overwhelm trainees with watching for everything or it will paralyze them. Now all I had to do was find a coach to answer that question. I already asked Colt McCoy these questions and he succinctly explained that they do this through a “lot of practice”, but I hoped to delve into that deeper. He deferred this to his father, Coach Brad McCoy who was gracious to take time to explain this to me. The conversation however quickly turned to leadership development.
SITUATIONAL AWARENESS:
Our conversation started off on my original question of how does a Coach teach a player to have simultaneous situational awareness, but be able to maintain focus on their intended receiver? Pilots practice load shedding to avoid distractions by inconsequential gauges but need to maintain situational awareness at the same time- of course they do this by allocating attention to one person specifically to assure that both the pilot and copilot are not focused on the same problem, averting the attention from a more significant one. Well, I got a great answer:
“In football we do a lot of presnap evaluation. You call the play and the receivers know exactly where they are supposed to be. The quarterback assesses the defense to see if they are going to be routed where he thinks they will be and if something happens and you are uncertain, you call an audible”.
“It takes a lot of prep and identification of the defense structure before the snap”
“It is all about teamwork and trust. It is a learned process. You practice till you are sure your receiver is going to be in the exact window of opportunity he is supposed to be in. He is supposed to be there at the exact time you expect him there. That window of opportunity may be the size of house in high school, but in college it shrinks to the size of a room and if you make it to the pros, that window of opportunity is the size of a basketball.”
“it is likely the same in surgery as one is in training, the type of cases become more complex, so your skill set must increase, and the windows of opportunity to succeed become smaller and smaller as you tackle more difficult procedures. Like surgery as the levels get tighter, the windows of opportunity to succeed are smaller”. (Brilliant man)
“Before the snap the quarterback expects that his receiver will be where he is supposed to be, so he no longer worries about where the receiver is after the play (huddle or audible) is called. He now spends time looking for that one person in the defense who tells him the defense is where he thinks they should be. A great defensive coach can disguise his defense and take advantage of that tiny window of opportunity. When a quarterback throws an interception and you see they looked perplexed, eight times out of ten, it is because the receiver was in the wrong location and the defense took advantage over that. The quarterback is NOT looking for the receiver but throwing exactly where the receiver is supposed to be. When a mistake happens it is because the receiver is supposed to run 7 yards but ran 8 or 10 instead. It is all about the timing. Now, where the receiver is supposed to be, there is a defender there. Other times the defender did not do what the quarterback predicted. He miscalculated what the defender’s intentions were. Some teams are REALLY good at this. In some cases the quarterback can pick up that the intended receiver is not open so they must then rely on the back side receiver to be open.”
Ok that was interesting, no doubt, but does that pertain to surgery? Well somewhat yes. We know what surgery we plan to do and we know what we need, but certainly if the team is not mentally in synch with us, the opportunity for a mistake to occur happens. If we huddle briefly before the case (it takes 30 seconds) then if someone is not fully on board, we can figure that out and avoid unnecessary distractions during the case. We ought to call audibles during the case when the situation changes, but we become overly afraid that the audible we call is misinterpreted, it can be taken out of context and broadcasted erroneously around the hospital (Dr. Lipshy said he thought he injured the ureter….!!!) which I have seen done. Having said that, when we are sure there may be a problem, an audible needs to be called as a critical pause so we can be sure everyone is focused and not distracted by inconsequential things. Well I tried to tie it into surgery, but likely failed.
DEALING WITH FAILURE:
I quickly came up with a question that I had not thought of: “how does one brush off their mistakes (their bad outcomes) and come back to work on the next possession?” I immediately remembered a conversation regarding risk taking and risk avoidance, I had with Dr. Moulton back in December on their paper: “Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone.” Certainly having a bad outcome in surgery can shape our mentality about tackling a similarly difficult case in the future- that is, we become risk aversive.
“Risk tasking after a bad encounter—that’s an “age old question”, the great ones, the Peyton’s and Tom Brady’s have a balance. They obviously have a certain element of self-confidence based on their skills. The higher the skills the more risk you are willing to take. In some quarterbacks, it is based on self-esteem and they figure out later they don’t have the skills. That Quarterback has no anticipation, and eventually they begin to hesitate and fail or they have too much confidence and are being cocky and that will catch up to them.”
“Some quarterbacks are at risk for blocking if they have too many mistakes after taking risk and that can shut you down”.
“I taught my young sons to learn there are layers to skill sets- you must have footwork, ‘if my feet are not in the right position, then the ball handling won’t matter’. They learned that a good quarterback needs a lot of layers of fundamental skills that need to be in place before you gain the mental part. You need the basic skills of footwork, then ball handling and then the mental parts.”
OK, well that is even more like surgery. If you learn and rely on your basic surgical skills first, then when you gain the knowledge you should be able to handle the stress of a setback. If all you have is the knowledge but not a bank of skill sets, then you could be in trouble especially if your peer support crumbles.
LEADERSHIP TRAINING IN COACHING: SKILLS FOR A LIFETIME
This then brought up my thoughts about leadership and mentorship: what type of coaching mentality works best? You have the paternal nurturing figure of some coaches as opposed to the stricter fearing tactics of other coaches.
Coach McCoy stated that it “has to do with recruiting to that exact level. Surprisingly it is typically opposite how the kid was brought up. You have to have the right kid in the right environment. The way they react to the different styles is different. A kid in a tough strict environment may actually do better in a paternal environment, while a kid brought up in loosely controlled family environment may be better off in a very strict controlled coaching style.”
In the end all coaches must be more “concerned about what happens with the athlete after the football is over for them. You must work to mold an adult who can function in the world no matter what they chose to become. If all you worry about is your successes, then you may have missed the opportunity to mold the student into a functioning member of society. You must be there to nurture them some, or you have failed.”
“This is where the Coaches leadership training comes in. The coach must teach the boys leadership skills they can use on the field and off. We at the Flippen group utilized professional development raising high performance professionals. We focus leadership- command control and structure vs relational control. This works in all environments. A good coach or leader needs to keep a fine balance between the two. If I have too much command control that can be overwhelming and end up being a constraint to the people around me, then I need to work on my perception on my team. It’s not always about where I see myself, but where others see me.”
“After coaching for 28 years, including my boys Colt and Case, I realized the potential to use my love of teaching leadership skills for use in other areas. The Flippen group uses measures of BEHAVIOR TENDENCIES (self-control, nurturing, deference level, etc ) as a profiling process and not PERSONALITIES (Meyers Briggs)- personality profiles do not induce change but move you to a like personality or teach you how to deal with other personalities– I looked at what are the constraints preventing our being the best? When the going gets tough, we tend to focus not on our weakness but focus on our reliance on our strength too much. Well, maybe that strength was actually what led us in the wrong direction, or maybe if I understood my weaknesses I could capitalize on that or utilize another person who is stronger in that area for us to succeed. We don’t focus on changing your personality, but changing your behavior.”
Ah, well this brought to mind several things…. We as surgical teachers should focus more on providing the surgical trainees with the skill sets needed to be leaders in whatever environment they are in. Just this week we learned that the APDS is asking our Program directors to assume more responsibility for our students when they have completed training….Well, that is in actuality what a Coach should be doing with his or her athletes…. Sure racking up five national championships brings in alumnus dollars, but teaching the players to leaders in society, PRICELESS, and that should be a focus in our training programs. I understand that many sites have avid leadership programs (Dukes Feagin leadership program for one) but every resident should be able to state that not only can they function in the hospital without supervision, but that they have the capacity to lead at their Hospital.

Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com

DISCUSSION ON ACS COMMUNITY RE. POST NSPSS INTERVIEW WITH AIRLINE PILOTS REGARDING AVIATION CREW TRAINING REQUIREMENTS.

DISCUSSION ON ACS COMMUNITY RE. POST NSPSS INTERVIEW WITH AIRLINE PILOTS REGARDING AVIATION CREW TRAINING REQUIREMENTS.

(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

http://crisislead.blogspot.com/2016/03/what-or-can-learn-from-cockpit-chat_29.html

http://crisislead.blogspot.com/2016/05/post-mission-performance-improvement_2.html

http://crisislead.blogspot.com/2016/03/myth-or-reality-2-fatigue-and_29.html

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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

SURGEONS’ DISCLOSURE OF CLINICAL ADVERSE EVENTS- INTERVIEW WITH THE BOSTON VA STUDY GROUP

SURGEONS’ DISCLOSURE OF CLINICAL ADVERSE EVENTS

        On July 21^st 2016 a tweet went out with the subject line: “Disclosure of harm is a must-Would a surgeon tell you if something went wrong?” followed by the commentary “new survey of surgeons reveals the truth about disclosure and medical errors”. My immediate assumption was that this must be a bad news release revealing that surgeons do not inform their patients when mistakes or complications happen (and assume d that the public likely had the same perception).  To my relief the CBS website - Disclosure of harm is a must - Would a surgeon tell you if something went wrong?Disclosure of harm is a must - Would a surgeon tell you if something went wrong?July 20^th news feed “would a surgeon tell you if something went wrong during your operation?” reported that the study revealed that most Veterans Health Administration (VHA) surgeons do follow guidelines for disclosure when a procedure has an associated adverse event.  On that note I retrieved the VHA study, contacted the authors (Elwy, Itani and Perkal) to discuss this further and reviewed the VHA policies on disclosure of adverse events.  I learned that the process for making recommendations and the institution of policy within VHA and elsewhere on the disclosure of adverse events has been relatively slow, but while there is clearly a ways to go in this endeavor, progress is being made.

While a local policy on disclosure of adverse events was published at the Lexington VAMC in 1987, it was not until 1995 that VHA published a National VHA policy requiring disclosure to patients. The process was relatively unknown to most until the National VHA Ethics Committee published a Disclosure of Adverse Events report in 2003. This report recommended the disclosure of adverse events to the patients and/or their families when the following criteria existed:

·         The adverse event has a perceptible effect on the patient that was not discussed in advance as a known risk.

·         The adverse event necessitates a change in the patient’s care.

·         The adverse event potentially poses a significant risk to the patient’s future health, even if the likelihood of that risk is extremely small.

·         The adverse event involves providing a treatment or procedure without the patient’s consent.

In this report the definition of Adverse Events was “untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided within the jurisdiction of a medical center, outpatient clinic, or other VHA facility. Adverse Events may result from acts of commission or omission (e.g., administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, adverse reactions or negative outcomes of treatment). Some examples of more common Adverse Events include: patient falls, adverse drug events, procedural errors and/or complications, completed suicides, parasuicidal behaviors (attempts, gestures, and/or threats), and missing patient events.”

Even in 2003, disclosure policies were viewed as extreme and followed less than whole-heartedly. Physicians were very skeptical about disclosure policies leading many compelled to disclose incomplete or inaccurate information. This reluctance was centered on legitimate and unfounded concerns about legal and financial ramifications. In addition, physicians were concerned about the negative consequences of the emotional stress on the family or patient by revealing that information (‘too much information can be harmful on the spirit’).

Subsequent to that 2003 report several VHA Handbooks on disclosure of adverse events to patients were published- the most recent of which is VHA HANDBOOK 1004.08 October 2012. In this document Adverse Events were defined as “untoward incidents, diagnostic or therapeutic misadventures, iatrogenic injuries, or other occurrences of harm or potential harm directly associated with care or services provided within the jurisdiction of the Veterans Healthcare System.”

VHA HANDBOOK 1004.08 stipulates that institutional disclosure must be initiated “as soon as reasonably possible and generally within 72 hours. This timeframe does not apply to adverse events that are only recognized after the associated episode of care (e.g., through investigation of a sentinel event, a routine quality review, or a look-back). Under such circumstances, if the adverse event has resulted in or is reasonably expected to result in death or serious injury, institutional disclosure is required, but disclosure may be delayed to allow for a thorough investigation of the facts provided.”

According to the 2012 Handbook, Institutional disclosure of adverse events must document the following SEVEN steps in the medical director:

(1) An expression of concern and an apology, including an explanation of the facts to the extent that they are known.

(2) An outline of treatment options, if appropriate.

(3) Arrangements for a second opinion, additional monitoring, expediting clinical consultations, bereavement support, or whatever might be appropriate depending on the circumstances and within the constraints of VA’s statutory and regulatory authority.

(4) Contact information regarding designated staff who are to respond to questions

(5) Notification that the patient or personal representative has the option of obtaining outside medical or legal advice for further guidance.

(6) Offering information about potential compensation under 38 U.S.C. § 1151 and the Federal Tort Claims Act where the patient is a Veteran or under the Federal Tort Claims Act where the patient is a non-Veteran.

(7) Ongoing communication whereby the Risk Manager or organizational leaders engage the patient or personal representative to keep them apprised, as appropriate, of information that emerges from investigation of the facts related to the adverse event.

Literature discussion, regarding the physician experience relating to disclosure of adverse events to patients, spans the spectrum from positive (provision of an outlet for the emotional toll) to negative (concerns of repercussions, shame guilt) emotions. Few studies have assessed the emotional experience of physicians after exposure to disclosure of an adverse event by survey. By gaining this knowledge educating physicians on disclosing adverse events may become more effective thereby improving the outcome of the disclosure process with patients and physicians.  Elwy et al set out to assess

A.   The compliance with each of the eight elements recommended by the National Quality Forum and The VA (see inset RATE OF COMPLETION OF EIGHT RECOMMENDED DISCLOSURE STEPS ACCORDING TO INTERVIEWED PHYSICIANS below) as well as the relative likelihood of disclosure based on the risk of harm due to the adverse event (literature supports that surgeons are more likely to disclose if the event has a risk for high harm than with low harm).

B. the emotional experience of physicians who provided such disclosure to determine if those physicians that followed the disclosure policy were more or less likely to experience negative effects as suspected above.

C. The relationship of physician attitude regarding disclosure with the effect on that physician following disclosure.

 

Before discussing this with the lead author, Dr. Elwy, I researched the question: What makes it so difficult to disclose adverse events to patients? The obvious reason for anxiety in this process is the fear of repercussions. The not so obvious reason is our response and recognition of failure. Amy Edmondson reminds us in her book (p. 155) that success in business comes with a risk of failure and that it is important to accept failure as an outcome. This may be much more difficult in practice than in principle however. Humans have a natural aversion to failure itself causing public discussion of their failure extremely difficult. It is our fundamental nature to preserve our self-esteem. Compounding that is our innate heuristic trait of confirmation bias which prevents our dismissing any early conception of an event and instead leads to distortion of the facts to support our conclusion that this was "not my fault". We find it easier to diminish our responsibility and blame others to preserve our dignity in front of our peers. This then strengthens the emotion surrounding any discussion of failure. For us to analyze and discuss failure we must be open, patient and tolerate ambiguity. For this to occur we must be taught humility in our training. To be fair, when we fail, we theoretically risk punishment in medicine either by our peers at the medical executive board, hospital leadership, state licensing boards or ultimately in the courts. Furthermore, the public is quick to equate failure with liability. Frankly it is difficult to blame them for that preconceived notion given the volume of commercialism focused on class action litigation and the like in the media.

On that note, Dr. Elwy was very gracious to talk with me about this paper and her processes of implementing this study:

Dr. Elwy, I agree we need to rethink how we disclose adverse events in medicine but it is a very emotional process that appears to instill anxiety in most of us for one reason or another as I alluded to in my discussion of this paper. What prompted this study? What prompted your group to look at this?

·         Dr. Elwy- let me start with a disclaimer that I am not a surgeon, I am a psychologist.  I have always had an interest in the disclosure process. In my PhD dissertation I began with a discussion about how physicians disclose bad information to parents who have deliveries of babies with challenging medical conditions. I had an emotional experience personally regarding a child in which a surgeon presented to me an eloquent discussion about an adverse event. I became interested in how patients feel and what surgeons feel during this process. When I moved here I wanted to begin a study assessing this further. I approached Dr. Itani in 2007 and he was very engaging. He suggested we start with a pilot study because everyone doubted surgeons would be willing to participate. There was skepticism that the IRB would approve a study where we discussed this with surgeons. Everyone was concerned about surgeons as a vulnerable population and about confidentiality, and coercion - enrollment issues. We were relieved that the pilot confirmed these concerns were unfounded. What we found was that Surgeons in this small group were not aware of VHA guidelines but did disclose what they said to patients.

What were some of your take home messages from this study?

Dr. Elwy-

1.    Surgeons who were more likely to be negatively affected by the event were less likely to discuss prevention, as they felt that that the event was serious and found it very difficult to discuss the event.

2.    Surgeons noted that they frequently told the family more than was required. Many noted they did apologize but it was clear that perhaps the definition of what is an apology is not well defined.  We learned that patients want to hear an expression of concern. They want the surgeons to be honest and transparent. They want to know the surgeon is concerned about what happened to them. It turns out that simply saying ‘I am sorry you have to go thru this’ is sufficient in most cases. They do not want a very formal apology. They don’t even expect that I take the responsibility for the incident, just that I am empathetic. It is not clear that the surgeons understood what an apology really was because the patients frequently said they were given an apology and several surgeons stated they did not offer a formal apology. All the patients conveyed that they were satisfied when the surgeon was concerned about them and their condition and that the surgeon was as concerned about the patient as the patient was. Surgeons often equated an apology to a formal acceptance of responsibility for the patient’s condition and that actually was not what the patients were looking for.

3.    Many noted that the negative connotation of this process arises from the fact that Risk Management typically institutes or manages this process instead of Quality management. One of the biggest suggestions was that this process was best managed by quality and probably not risk management. If the connotation is risk management, this creates a significant barrier in these frank conversations. We need to move away from the perception that these conversations are a bad thing. “it matters more what the patient hears and it is apparent they want to hear the surgeon is concerned and want the patient to be better.”

What do we need to do to break down the barrier to surgeons feeling comfortable in this process especially given the inherent nature of these events and surgeon personalities in general (as noted above)?

Dr. Elwy: There is a lot of anxiety about disclosure. There is a lot of fear. There are many misperceptions. We need to teach that this is positive. We need to teach that the surgeon just needs to be open and honest. Even in the Surgeons who agreed to do the study, had some negative attitudes so we can infer that those who did not volunteer possibly had a more significant negative attitude. Those that had a negative attitude, had more anxiety about disclosure.

Were you able to assess surgeon exposure personally to negative responses they may have experienced during this process following a negative patient outcome such as bad publicity, bad exposure in the hospital peer review process, legal action, to see if that may explain the reaction? I discussed risk aversion and risk taking previously with Dr. Moulton after they wrote about why we are risk averse or bold when we take on surgical cases (http://crisislead.blogspot.com/2016/08/comfort-zones-and-risk-taking-in.html)

Dr. Elwy: Because the survey was short and we wanted to encourage participation this was not specifically asked but there was a block to discuss this. The interviews were about a very specific case and the study designed prevented more expansive disclosure. The surgeons were asked to account how they managed specific cases. Family members were then contacted and interviewed- thru patient safety. Plus we had to keep the surgeon interviews to less than 20-25 minutes to respect their time.

Any final message about this you wanted to convey?

Dr. Elwy: Unfortunately there is no avenue for surgeons to discuss this. M&M is not the place. This sets the surgeons up for burnout. We need this process to build up resilience. Would recommend we think about what others have said on this topic.

Marjorie Siegler wrote a piece about this in JAMA, where she notes that after a catastrophic event all other professionals have period of time to regroup prior to going back on duty. Further studies need to be done to assess what support is needed after a traumatic event. Physicians do not want to discuss this with a mental health provider. Physicians want to talk to a peer who has had that same experience. Jo Shapiro’s, Brigham Women’s, Center for Professionalism and Peer Support designed for that purpose. http://www.brighamandwomens.org/medical_professionals/career/cpps/default.aspx

Kenneth A. Lipshy, MD, FACS
www.crisisleadershipmanagement.com

·         http://www.cbsnews.com/news/would-a-surgeon-tell-you-if-something-went-wrong-during-an-operation/

·         Rani Elwy, Kamal M. F. Itani, Barbara G. Bokhour, Nora M. Mueller, Mark E. Glickman, Shibei Zhao, Amy K. Rosen, Dana Lynge, Melissa Perkal, Erica A. Brotschi, Vivian M. Sanchez, Thomas H. Gallagher. Surgeons’ Disclosures of Clinical Adverse Events. JAMA Surgery, 2016; DOI: 10.1001/jamasurg.2016.1787

·         Disclosing Adverse Events to Patients A Report by the National Ethics Committee of the Veterans Health Administration March 2003 http://www.ethics.va.gov/docs/necrpts/NEC_Report_20030301_Disclosing_Adverse_Events.pdf