Introduction
The healthcare industry has been confronted with many challenges; among one of the major ones is an increased demand for medical services by the population. Healthcare providers are under an ever-increasing pressure to provide adequate and quality services to a population whose demographics are shifting both in terms of size and conformation; and to concurrently grapple with the challenge of reducing the cost of care. This pressure has brought the need to increase the efficiency of medical personnel individuals and teams; and the drive to reduce errors which commonly result in formation of bottlenecks in the system.
The healthcare industry has sought to borrow some of the solutions from another industry, aviation, which when faced with challenges of increasing air travel safety, developed Crew Resource Management as a tool to improve the efficiency of their various crews through the prevention, detection and mitigation of human errors which cause 50% of all aviation accidents. These two industries share unique features which make them ideal to share solutions; such include the fact that both deal directly with the public; and where the safety of the client is of outmost importance and permanently at risk.
Additionally, both industries are run by teams made up of specifically trained and specialized teams; and where there is a stiff hierarchy through which decisions are made. This structure has made it necessary to have a system of communication which would be able to work for the benefit of the client without being impeded by bureaucracy and hierarchy.
Crew Resource Management
The concept of Crew Resource Management was developed by the aviation industry; and with time, has developed into a core concept in both basic and continued education of aviation workers. Originally formed as a response to a NASA led identification of human error in air crashes in 1979, CRM has grown in stature a widely accepted concept to mitigate this factor.
As such, CRM places human error at the center of its operation; and aims at reducing errors by training of staff in carrying out of simulation to drill the crews into efficient response; improving methods and routes of communications and measurement of the improvements in the levels of safety gained on the side of the patient. The aviation industry operates in different scenarios; for example, commercial airlines operate in different market, each with its unique blend of clients and safety challenge.
Additionally, aviation for military, scientific, astronomical and civilian purposes each has its quirks that make the safety needs significantly different from all the others. Consequently, despite the concept of CRM being around for over two decades, a universal method of training has yet to emerge since each setting independently develops its own version to best suit its unique and specific needs.
The typical CRM framework is aimed specifically at remedying human limitations of performance by putting in checks and balances which go into action when an individual or team reach these limitations. This is embodied into three countermeasures which come into effect on three levels; the first level involves training of crew to avoid errors; the second level involves the detection of errors before they have their effect on the performance of the system; the final level aims at reducing or mitigating the consequences of the error.
A major component of CRM in the aviation industry is the use of simulators to reproduce real life situation; the outcome of the simulation is two fold; both to asses how the crew would respond to situations of crisis and to train the staff on the effective and appropriate responses. The crews are also assessed on a regular basis to achieve a baseline data for the before-and-after comparison of the application of CRM training and practice (Gaba, 2004 p. i2-i10).
A key component of client safety in the aviation industry is the attitude of the crew towards aspects which affected this safety. For example, how does the maintenance crew view their role in inspecting the planes for mechanical soundness before they take off; CRM seeks to place a mechanism to ensure that such attitude would not be in play during this inspection; for example by putting in place a mechanism of accountability and review. CRM also seeks to break down barriers of communication created by administrative hierarchy; for example, how would a junior officer question the thoroughness of his/her seniors without being penalized by the system.
The CRM training and practice experience decay over time. This is often seen even in cases whereby the crews are put through repeated training periods (Pizzi et al, 2001). This has made sure that the need to reduce human error and improve aviation safety remains an unsolved issue and a constant expenditure on the firms’ and organizations’ respective tab. Whether this may also be true in the medical sectors is also debatable; however, there is a consensus that the healthcare services delivery sector needs to adopt new and radical methods of accomplishing their goals vis-à-vis patient safety and efficient services.
Application to the Healthcare Delivery Teams
As mentioned before, there are several similarities between the healthcare and the aviation sectors which make the application of CRM principles applicable and ideal to the healthcare sector. Indeed, human error is one of the aspects which can not only result in gross inefficiency in service delivery but can also cause devastating effects to the client that the sectors share (Oriol, 2006 p.402-406).
The healthcare sector, however, is disadvantaged in one aspect compared to the aviation industry; this is in the aspect of the orientation of the training which the staff receives. Traditionally and currently, medical training emphasizes on basic science education; whereby an individual is expected to assimilate a large amount of information about the biological functions and the practice of medicine. The practical training is not however structured to reflect some system of development. On the contrary, medical apprenticeship aims at testing whether the individual has mastered the information; after which s/he is released to serve the public.
From then on, there are no official structures to compel the individual to seek some information for continuous education or training. Additionally contrary to the situation in the aviation industry, there is no emphasis on the completion of tasks as team; and thus the need to improve communication and coordination among its members (Gaba, 2004 p. i2-i10).
However, there is an emerging trend in the healthcare industry that seeks to focus on the communication, leadership, planning and vigilance as the causes of accidents and inefficiency; rather than focusing entirely on technical failures (Hunt & Kathleen, 2008 p.690-693). The need to mitigate human factors has highlighted CRM as a viable method of doing so.
However, it would not be practical and viable to transplant the methods and approaches of the aviation industry directly onto the healthcare set up due to various reasons. Despite the many similarities that have been pointed out, a simple comparison is not enough; and deeper issues need to be addressed before full adaptation can take place. For example, the context of operation between medical and aviation crews is not the same; the former commonly operate in environments which are more complicated; and whose outcome is more difficult to predict.
The aviation and medical scenarios also differ greatly in terms of organizational structure; as such the aviation setup is highly hierarchical with the members of each team having a specific designation which is easily perceived as is depicted by visible insignia such as stripes. Consequently, there is no ambiguity regarding the ranking of members; however, aviation teams have a characteristically flat hierarchy when it comes to decision-making; with the officially higher ranking officers often opting to make major decision after consulting with their team.
This can be attributed to the fact that aviation is a highly technical practice; with team members being made up of specialized technicians; each with his/her own functions, qualifications and duties. Additionally, these duties do not overlap. During a flight, the last authority is the pilot-in-command (PIC) or the captain; this authority is vested on him/her by the law (Hunt & Kathleen, 2008 p.690-693).
On the contrary, hierarchy in medical teams is comparatively ambiguous; with several members of the team having a full authority by his/her own right. For example, in a surgical team, several authorities may be required in the same procedure; each exercising decision-making power at his/her own discretion. Additionally, titles or ranks defined by official methods may not be strictly followed; as such, the position of a member on a team in terms of hierarchy is defined only when all the individuals in the team interact. Since also there is not outward sign, gear or insignia depicting the rank of a team member, then newly formed teams commonly undergo longer periods of accommodation compared to aviation ones.
Aviation teams commonly operate according to a certain set scenario as determined by the model of aircraft which the team will be operating. Additionally, to transfer a team or an individual from one model to another is commonly preceded by a period of additional training. The aviation sector has also benefited enormously from technological advances making aircraft significantly safer and more predictable; this has resulted in the development of decision-making protocols and handbooks. Decision are therefore made in form of trouble shooting with members of the team participating in parts of the trouble-shoot which is relevant to them.
On the contrary, medical teams deal with situations which are highly unpredictable; making the probability of making an error more. Additionally, even for highly specialized practices, human beings cannot be compared with aircraft models (which come off a factory line). Medical professionals often have to deal with situations which are completely new to them; that they have not prepared for; that give very little time for consultation; and which require improvisation and experimentation.
Among the most important differences which separate the aviation and the healthcare practice is the process and outcome of decisions. In a flight, the passengers are never consulted before any decision regarding their safety is made. The farthest they can go is to advise them to take some precautionary measures such as to tie their seatbelts. Medical decisions are commonly accompanied by significant inputs by the patients (Hunt & Kathleen, 2008 p.690-693).
Additionally, the outcome often carries significant social, political and economic repercussions (McKinlay et al, 1996: p.69–76). Currently, apart from making decisions on the regime of treatment through which a patient will go through, medical professionals are also encumbered with the other factors such as cost-reduction, insurance cover, social welfare, political fallouts and legal ramifications.
For example, in a case where a patient has taken a turn for the worse, the decision to resuscitate him/her is not governed only by the need to save a life. Indeed, in such a case, the attending individual or team may meet the challenge of determining whether resuscitation would have any value to the quality of life of the patient. Such a decision will be fortified or weakened by legal and social issue; such as the opinion of the next of kin. In such a case, the protocols and checklists so common in the aviation industry would be completely useless.
Conclusion
Even in the aviation industry, the effectiveness of Crew Resource Management is not supported by any empirical evidence. However, the culture of CRM has been adopted as a core component of the industry; and is hailed to have reduced aircraft accidents. By extension, there also is no empirical evidence linking the benefits of CRM in a healthcare setting. Indeed, the vast differences between the aviation and health setups would make it wasteful to directly transfer aspects of CRM from the former to the latter.
We must, however, not escape from the fact that changes are needed in the way medical personnel operate. As such, the CRM should be adopted in a manner which will take into consideration the difference between the two industries.
Reference List
Gaba, D. M. (2004). The future vision of simulation in health care. Quality and Safety in Health; 13; i2-i10.
Hunt J. F. Graham and Kathleen S. N Callaghan. (2008) Comparative Issues In Aviation and Surgical Crew Resource Management: (1) Are We Too Solution Focused? ANZ Journal of Surgery. Volume 78, Issue 8, Pages 690-693.
McKinlay JB, Potter DA and Feldman HA. (1996). Non-medical influences on medical decision-making. Social Science and Medicine. 42: pp.69–76.
Oriol, M. D. (2006). Crew Resource Management: Applications in Healthcare Organizations. The Journal of Nursing Administration. Volume 36 – Issue 9 – pp 402-406.
Pizzi L., Neil I. Goldfarb and David B. Nash (2001). Chapter 44. Crew Resource Management and its Applications in Medicine. Thomas Jefferson University School of Medicine and Office of Health Policy & Clinical Outcomes. Web.