Beyond the Checklist

Suzanne Gordon, Patrick Mendenhall, Blair O'toole Bonnie

Description

The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal?Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the relevant lessons of aviation safety and teamwork. In response to a series of human-error caused crashes, the airline industry developed the system of job training and information sharing known as Crew Resource Management (CRM). Under the new industry-wide system of CRM, pilots, flight attendants, and ground crews now communicate and cooperate in ways that have greatly reduced the hazards of commercial air travel.The coauthors of this book sought out the aviation professionals who made this transformation possible. Beyond the Checklist gives us an inside look at CRM training and shows how airline staff interaction that once suffered from the same dysfunction that too often undermines real teamwork in health care today has dramatically improved. Drawing on the experience of doctors, nurses, medical educators, and administrators, this book demonstrates how CRM can be adapted, more widely and effectively, to health care delivery.The authors provide case studies of three institutions that have successfully incorporated CRM-like principles into the fabric of their clinical culture by embracing practices that promote common patient safety knowledge and skills.They infuse this study with their own diverse experience and collaborative spirit: Patrick Mendenhall is a commercial airline pilot who teaches CRM; Suzanne Gordon is a nationally known health care journalist, training consultant, and speaker on issues related to nursing; and Bonnie Blair O'Connor is an ethnographer and medical educator who has spent more than two decades observing medical training and teamwork from the inside.

Sujets

• Médecine
• USA
• États-Unis
• History

Informations

• Publié par: Cornell University Press
• Date de parution: 15 décembre 2012
• Nombre de lectures: 0
• EAN13: 9780801465789
• Langue: English
• Poids de l'ouvrage: 1 Mo

Extrait

Praise for BEYOND THE CHECKLIST

“The deeper I progressed into this terrific book, the more embarrassed I became for my profession of medicine. Behind our casual assumption as airline custom ers that we will arrive safely lies an enormously complex process that addresses all human and system issues that could possibly affect safety in air travel. With a few notable exceptions, we in medicine do not come anywhere remotely close to where we need to be to assure our patients of this same kind of safety commit ment. There can be no excuse for medicine not pursuing this same allengaging, relentless process. Our patients deserve nothing less. This is a mustread book for anyone with any connection at all to the delivery of health care services.” —T ERRY R. R OGERS , MD, The Foundation for Health Care Quality

“Beyond the Checklisttakes us behind an apparently simple tool to lay out the complex social and organizational transformation that makes the checklist effective in aviation and to argue for a similar toptobottom transformation of health care. By shifting our attention to the detailed, sustained, and careful work that will be required to make health care safer, the book moves us forward on a long, difficult, but ultimately rewarding journey.” —R OBERT L. W EARS , MD, University of Florida and Imperial College London

“Beyond the Checklistprovides a timely and insightful assessment of crew resource management (CRM), a key tool for averting disaster in the airline industry. The authors make a compelling case for its application to health care delivery. This book should become an essential text for health care professionals, educators, and policymakers seeking to improve interprofessional training and practice.” —S COTT R EEVES , University of California, San Francisco

“The ideas presented in this book are so clearly developed and the writing so engaging that its audience will not be limited to patient safety experts. Patients, their families, and health care providers of all kinds will also benefit from the authors’ insight into hospital safety improvement. The case studies are rich in detail and full of critical reflections on the connection between quality care and optimally functioning teams. The tone ofBeyond the Checklistis hopeful but, for good reason, very urgent as well.” —S EAN P. C LARKE , RN, PhD, FAAN, McGill University School of Nursing

“Some experts downplay the parallels between health care and aviation, but there is much we can learn from the systemwide change that greatly improved passen ger safety on commercial airlines. This excellent book highlights the innovative programs of pioneering hospitals where better teamwork and effective communi cation guide every interaction—from the bedside to the boardroom.” —J ULIA H ALLISY , DDS, The Empowered Patient Coalition

“This important book brings both a sense of urgency and the hope of clarity in addressing a fundamental and widespread problem in health care. It is a must read for clinicians and students who deliver care and a call for leadership from every member of the interprofessional team. Leadership is required to change the culture and systems of care delivery.Beyond the Checklistprovides the inspiration and a path for that change.” —H EATHER M. Y OUNG , RN, FAAN, Betty Irene Moore School of Nursing, University of California, Davis

“Beyond the Checklistshows us that Crew Resource Management principles help us deal with our human inability to always perform ‘perfectly’ while operating in a complex work environment. Little mistakes in aviation compound into huge problems. In commercial airlines, virtual strangers routinely solve complex problems without making critical mistakes. The culture of CRM provides for this as a normal way of operation. If embraced by the field of medicine, it will totally transform the way the industry operates.” —C APTAIN G REGORY S. N OVOTNY

the Beyond Checklist

A VO LU M E I N TH E S E R I E S

TheCultureandPoliticsofHealthCareWork edited bySuzanne Gordon and Sioban Nelson

Alistoftitlesinthisseriesisavailableatwww.cornellpress.cornell.edu.

the Beyond Checklist WhatElseHealthCareCanLearn from Aviation Teamwork and Safety

SuzanneGordon, Patrick Mendenhall, and Bonnie Blair O’Connor

Foreword by Captain Chesley “Sully” Sullenberger

ILRPress animprintofCPrysesevintisrenroUll IthacaandLondon

Copyright©2013bySuzanneGordon,PatrickMendenhall,andBonnieBlairO’Connor

Foreword copyright © 2013 by Chesley B. Sullenberger III

Allrightsreserved.Exceptforbriefquotationsinareview,thisbook,orpartsthereof,

must not be reproduced in any form without permission in writing from the publisher.

For information, address Cornell University Press, Sage House, 512 East State Street,

Ithaca, New York 14850.

First published 2013 by Cornell University Press

First printing, Cornell Paperbacks, 2013

Printed in the United States of America

Library of Congress CataloginginPublication Data Gordon, Suzanne, 1945–  Beyond the checklist : what else health care can learn from aviation teamwork and safety / Suzanne Gordon, Patrick Mendenhall, and Bonnie Blair O'Connor.  p. cm.  Includes bibliographical references and index.  ISBN 9780801451607 (cloth : alk. paper) —  ISBN 9780801478291 (pbk. : alk. paper) 1. Health care teams. 2. Patients—Safety measures. 3. Medical errors— Prevention. 4. Aeronautics—Safety measures. 5. Aircraft accidents— Prevention. I. Mendenhall, Patrick. II. O'Connor, Bonnie Blair. III. Title.  R729.5.H4G67 2013  363.12'492—dc23 2012034342

Cornell University Press strives to use environmentally responsible suppliers and materials to the fullest extent possible in the publishing of its books. Such materials include vegetablebased, lowVOC inks and acidfree papers that are recycled, totally chlorinefree, or partly composed of nonwood fibers. For further information, visit our website at www.cornellpress.cornell.edu.

Cloth printing

10 9 8 7 6 5 4 3 2 1

Paperback printing

10 9 8 7 6 5 4 3 2 1

Contents

Foreword by Captain Chesley "Sully" Sullenberger vii Acknowledgments ix

Introduction1  1History of Crew Resource Management15  2Communication40  3Case Study: Maimonides Medical Center63  4Team Building79  5lementaryandCneetrofroCpmlacinilCrehsO:dytuSseCa Integrative Medical Therapies102  6Workload Management117  7raPndaonticaduehttaecitcesofprerEalonsitSesaCtnI:ydu University of Toronto135  8Threat and Error Management147  9Why CRM Worked157  10The Problems in Medicine178  11Conclusion206

Appendix:MaimonidesMedicalCenterCodeofMutualRespect225 Glossary235 Notes239 Index251

Foreword

The moment a flock of Canada geese hit the aircraft and we were forced to land US Airways Flight 1549 in the Hudson River, on January 15, 2009, I knew that my life would change forever and I would gain public attention that I had never sought or imagined. What I could not know, but only hope, is that this challenge, successfully han dled, would serve as a catalyst for my becoming a consultant on the problems of patient safety. Aviation safety is a field I know well. But what connection could it have to pa tient safety? Why would workplace protocols and training practices designed to save lives in the airline industry have any relevance to health care? As this book makes clear, the teamwork required to deliver hundreds of pas sengers to their destination safely is the same kind of teamwork needed to avoid lifethreatening mistakes in hospitals. In the aviation industry, I was part of the effort to implement the safety methodology known as crew resource management (CRM) at US Airways. It was our CRM training that enabled my crew—which included my first officer, Jeff Skiles, and three flight attendants—to land on the Hudson River that frigid January day and then safely evacuate 150 passengers without a lifethreatening injury or fatality. As the authors ofBeyond the Checklist point out, there was a method behind this “miracle.” Our unscheduled landing was greatly assisted by the muchchanged practices in our industry related to communication and cooperation among all members of the crew, regardless of their rank or job responsibility. As I have spoken with and observed those who work in the health care field, I have been struck by the many similarities between the early days of CRM forma tion and developments happening today in the patient safety movement. Not long ago, there were captains in our cockpits who acted like gods with a little “g” and cowboys with a capital “C.” You questioned the captain’s authority at