Crew management yields good results

Crew resource management has been the key improvement that led to the significant improvements in patient safety in the obstetrics unit at Beth Israel Deaconess Medical Center (BIDMC) in Boston. The dramatic changes in the obstetrics unit have been recognized with the John M. Eisenberg Patient Safety and Quality Award from the National Quality Forum in Washington, DC, and The Joint Commission.

The award recognizes BIDMC for its adaptation and implementation of military and commercial aviation crew resource management methods. More than 200 staff received training in crew resource management, which resulted in a dramatic reduction in major adverse obstetric events. That reduction cut malpractice liability exposure and improved overall patient safety and the quality of obstetric care, reports Barbara Lightizer, CPHRM, director of risk management at BIDMC.

"We did an incredibly thorough root-cause analysis after we had a death in the OB, and the main improvement that resulted was the adoption of crew resource management," Lightizer says. "We also improved staff training, staff hours, and handoffs. The results show that these efforts worked."

Between 1999 and 2005, the department experienced a 35% reduction in adverse events among patients and a 50% decline among high-risk patients, she says. The unit achieved a 25.4% reduction in the Adverse Outcomes Index (a measure developed for the project), and the severity of adverse events was reduced by 13.4% between 1999 and 2005. When the Eisenberg award was announced, Joint Commission president Dennis S. O'Leary, MD, noted that BIDMC's experience has prompted other institutions to adopt similar strategies. "Their demonstrated commitment to patient safety and innovative efforts are inspirations to the American health care community," he says.

Blue Cross Blue Cross Blue Shield of Massachusetts (BCBSMA), the state's largest health insurer, also named BIDMC the recipient of its first Health Care Excellence Award for the same effort. BCBSMA has awarded BIDMC a $100,000 prize for its "groundbreaking approach to reducing medical errors." Blue Cross president Cleve Killingsworth said in a statement that the hospital "successfully changed its culture and achieved significant results" through the initiative.

BIDMC used the $100,000 award to pay for obstetrics nurses to attend a national patient safety conference, development of an online continuing medical education course in crew resource management, and research in patient safety. The work was spurred by a stillbirth in the BIDMC obstetrics unit in 2000, Lightizer says. (See article, bottom right, for more on that incident.)

Aviation lessons used in OB

Lightizer says the root-cause analysis found two overall causes of the adverse event: communication failures and system failures. The communication failures concerned physicians and staff not adequately addressing their concerns about the patient's condition, so part of the hospital's response was to improve the way clinicians communicate.

The hospital used crew resource management techniques to train the staff in teamwork and conflict resolution, and limited the workloads of obstetricians. The Risk Management Foundation, the malpractice insurer for doctors at Harvard teaching hospitals, suggested crew resource management, which has been widely credited with reducing plane crashes by improving how aviation crews interact. BIDMC hired two pilots to train the staff in such skills as the "'two-challenge rule," which calls for a staff member who disagrees with a colleague's decision to politely state his or her concerns twice and then seek a superior if not satisfied.

The department set up three types of teams. The core teams treat patients, while a coordinating team led by a nurse and senior physician oversees the core teams' decisions and workload. A contingency team is activated for emergencies. The unit holds at least two team meetings a day to discuss the plan for all patients. Previously, when doctors and nurses changed shifts, they updated only replacements about their specific patients. Now all staff are responsible for all patients, Lightizer explains.

The obstetrics department also made major changes in the way it monitored patients. Rather than doctors and nurses knowing the medical situations only of patients directly under their care, the entire department now is knowledgeable about all patients.

The hospital prohibits obstetricians from caring for more than three patients in labor at once. The OB unit also encourages doctors to sign up for 12-hour, rather than 24-hour, on-call shifts.

Trained to work as teams

Lightizer says the crew resource management plan improves care by relying on a layering of staff and physicians so that there are backstops and additional resources if one layer of the team makes an error. Previously, the patient's care was divided more like silos in which there was little opportunity for anyone else to oversee care or resources for a staff member who disagrees with a colleague.

"The training helps everyone in the unit work more as a team, whereas in the past you might not even know everyone in the unit or understand their roles," Lightizer says. "Now people are part of specific teams that work together. Instead of just trying to grab an anesthesiologist when you need one, you know which one is part of your team and he or she should be familiar with your patient."

Since the changes were implemented, legal claims have declined significantly enough that BIDMC's insurer reduced its premium. She says the staff have embraced the new approach to teamwork in the unit.

"People say it's the best thing that ever happened on the unit," she says. "In fact, we have very little turnover on that unit, and when we do have an opening, people jump at the chance to join that unit."


For more information on patient safety improvements, contact:

  • Barbara Lightizer, CPHRM, Director of Risk Management, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215. Telephone: (617) 667-7000.