Peter DeNucci, Apollo Publishing,
Inc.
On April 3, 2009, public testimony on comparative effectiveness
research was given at a meeting of the National Advisory Council
for Healthcare Research and Quality. The testimony represents
the views of the presenter and not necessarily those of the Agency
for Healthcare Research and Quality (AHRQ) or the Department
of Health and Human Services (HHS).
The Council provides advice and recommendations to the Director,
AHRQ, and to the Secretary, HHS, on priorities for a national
health services research agenda.
April 3, 2009
RE: Public Comment on Comparative Effectiveness Program
funding by AHRQ
My name is Peter DeNucci, the president of Apollo Publishing,
Inc. We are an ACCME accredited Florida-based
Patient Safety Organization (PSO) dedicated to saving human lives
by migrating aviation's best safety practices into healthcare. As
a retired US Airways Captain, I was part of the pioneering team,
which created the education program in that airline known as Crew
Resource Management (CRM). CRM training and procedures can
be directly attributed to the quick and skilled actions of both
pilots and three flight attendants of US Airways Flight 1549 on
January 15, 2009, in which Captain "Sully" Sullenberger
successfully landed on the Hudson River saving 155 lives in the
process. The entire flight crew performed exactly as trained
in a very harsh environment to ensure the safety of every passenger. We
know what went right, and why. Empower the leader with authority
and tools to create a communicative environment and effectively
form a team of people in stressful, high stakes conditions, thus,
allowing Captain Sully to talk with his team, see everything, and
be ready to address it. Just as this training helped facilitate
zero-loss of life on the Hudson River, it can create the same cultures
of safety and eliminate preventable medical errors in the healthcare
industry today. If you pick up any medical journal today
inevitably you will find a sufficient amount of articles and commentaries
that point to the safety of commercial flying and human factors
studies as a way to improve patient safety.
The aviation industry experienced a large number of deadly crashes
throughout the 1980's and research by NASA found that 70%
involved human factors, such as communication problems. As
a result, the FAA implemented CRM as a means of achieving high
levels of safety in an industry where safety is paramount. JCAHO
estimated that over 70% of sentinel events reported stem from the
same human factors issues (i.e., communication failure), which reinforces
the fact that hospitals need to implement formal
training in teamwork for healthcare workers, similar to aviation's
CRM to train pilots. In both of these industries,
pilots and healthcare workers operate in complex environments;
not only do teams interact with technology, but a human error can
mean the difference between life and death.
Nearly ten years after the IOM milestone report, To
Err Is Human, which estimated that as many as 98,000 people
die in US hospitals each year due to preventable medical errors,
is healthcare any safer now? The answer is: not really,
we still pay a high price today, not only financially, but in
lives lost or nearly lost. The cost of medical mistakes
is shocking. JAMA (2003) reported $9.3 billion is spent
every year for extra hospital days and unnecessary complications. More
specifically, medication errors alone cost $3.5 billion and harm
an estimated 1.5 million people a year (Patient Safety and Quality
Healthcare, 2006).
Proven successful in the aviation industry to achieve a "zero-accident" standard, commander
and crew leadership is foundational in healthcare to all therapeutic
and clinical areas. From Apollo's
standpoint, current prevention practices that focus on knowledge
and technical skills training is unlikely to change the outcome
of wrong-site surgeries, wrong-patient procedures, surgical
counts errors, blood transfusion oversights, etc. Rather,
Apollo's Commander and Crew CRM and human factors training
offers a uniform approach to patient safety and addresses one
of the major roadblocks—communication barriers. A
team always needs to know who their leader is and that there
is a safety system in place to "catch" potential
errors. This proven curriculum (yes, there is a "science" to
CRM and teamwork) is used to teach pilots how to maintain a
clear-eyed perspective in their ever-changing, high-stakes
environments. The healthcare industry and their patients
can benefit from aviation's failures, their lessons learned,
and their hard-earned success.
Apollo's innovative education/training program is leading
the way in several hospitals and has taken our primary institution,
Flagler Hospital, to the near-zero incident rate. The physicians
and staff are going through a transformation similar to what pilots
at US Airways went through 18 years ago. Following the new
communication protocols (e.g., with the help of knowledgeable O.R.
staff, Apollo designed a visual aid that continues to hang on the
wall in the O.R. today and maintains the central elements of the
time-out concept mandated by JCAHO1),
a dramatic increase in surgeon led time-outs was observed, which
is a most desirable physician attribute. In fact,
effective time-out briefings given by the surgeon were conducted
less than 3% of the time pre-Apollo, and increased to currently
100% mission completion post-Apollo. This result
is not unusual, the same findings occurred almost immediately in
aviation post-CRM. As a result of this improved communication
and leadership from the surgeon, 100% elimination of wrong-site
surgeries and surgical counts errors was also achieved.
Apollo's Commander and Crew CRM program was developed in
an effort to accelerate the improvement of patient-centered care
in healthcare nationwide through increased team efficiency and
improved decision-making. Apollo's Commander and Crew
CRM program teaches leadership responsibilities, how crews can
avoid barriers to effective communication, and how to function
well as teams to increase team efficiency and improve decision-making. The
program includes instruction about human factors and human limitations
and utilizes countermeasures such as effective crew briefings (i.e.,
universal protocol's "time-outs"), and Embedded
Performance Tools (EPTs), such as standardized safety checklists,
read-backs and verifications, and utilization of a common language. Patient
safety is dramatically increasing, as healthcare professionals
acquire the skill sets, tools, and language necessary to create
a culture of safety within their own healthcare institution, thereby "culturing
each other". Therefore, the medical community will
continue to promote safe practices, enhance current safety training,
and move the healthcare environment to a new ‘culture of
safety' and away from the current ‘risk inherent' environment
often experienced.
If the practice of CRM were more widely presented, the likelihood
of lives lost due to preventable medical errors would be diminished
and the patient would most certainly be on the receiving end of
these benefits. In these worsening economic times, hospitals
across the country are finding it more difficult to support training
efforts. The risk of withholding safety training and information
to the medical community is that patient care and safety is reduced. Supporting
industries and organizations involved in promoting excellence in
patient care recognize that no longer can we afford to do nothing. There
is a critical need to save tens of thousands of lives affected
by preventable medical mistakes each year across the country. So,
there is no better time than right now for this funding, available
through the American Recovery and Reinvestment Act of 2009, to
find solutions to the illness plaguing healthcare and to restore
the health of the many patients harmed when mistakes are made at
the very hospitals that are supposed to help them. Let's
put CRM in healthcare to the test! Assessing the outcomes,
effectiveness, and appropriateness of CRM in healthcare will, at
the very least, increase the confidence of those receiving medical
care that hospitals actually make them better, not worse. Here,
before us, we have the first opportunity of its kind to compare
the effectiveness of evidence-based teamwork training strategies
to determine if they can truly facilitate hospitals and healthcare
workers to improve patient care and, in turn save patients' lives
today and for the future.
Thank you,
Peter J. DeNucci
President
1
In
2003, JCAHO began requiring hospitals to implement safe practices
as part of what they call a universal protocol, including improving
staff communications and calling for a "time-out" immediately
before starting a procedure. The "time-out" concept
is borrowed from the field of aviation, CRM "briefs" are "the
fundamental establishment of the team, as a cohesive group" (DeNucci,
2005, p. 45). This crucial step sets the tone
after the initial "flight plan" is developed. The
commander clearly states the objectives of the mission, lays
out the general direction for take-off, and calls out the first
action items. Expected weather conditions are shared,
as well as alternate routes. Finally, input is solicited
from the crew members. Pilots are trained to recognize
that crew members have vital information required to achieve
the mission. Sharing procedures, asking questions, and
enrolling the crew enables effective leaders to flatten the
hierarchy and create trust and a safe environment for input
and a willingness to speak up when they have safety concerns. The
experts recognize that teams must work cooperatively and communicate
effectively to achieve the common goal of safety.
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