David Williams: This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog. Steve Harden started his career as a Navy pilot with more than 300 aircraft carrier landings. Steve eventually co-founded Crew Training International where he brought crew resource management training, sometimes called CRM, to US and overseas air forces and commercial fleets.
More recently, Steve founded LifeWings to bring CRM to health care. Steve spoke with me today about what hospitals can learn from guerilla warfare tactics, how landing on an aircraft carrier compares with his current work, and the importance of bringing a wing man with you to the hospital. Steve, thanks for your time today.
Steve Harden: You’re welcome. Glad to do it.
David: Steve, what is LifeWings?
Steve: LifeWings is a team of pilots, former NASA astronauts, physicians, nurses and risk managers that provide the same teamwork, training and safety tools for health care that have made commercial aviation so safe and reliable. LifeWings is actually an offshoot of Crew Training International. Crew Training International was a company that myself and another FedEx pilot started in 1991 to provide teamwork training, commonly referred to in the aviation world as Crew Resource Management (CRM) training, to military organizations.
And about seven years ago, it became apparent to us that there was beginning to be a little bit of an appetite for it within health care. So we dabbled at it for several years trying to develop a practice of providing CRM training for health care organizations. In 2005, it had grown such that we felt like we needed to split it off and concentrate on it solely. So we actually spun that part of the business off into LifeWings Partners, LLC, and it’s really taken off from there.
David: And if you compare medicine with either commercial or military aviation, how does medicine rank from a safety standpoint?
Steve: I think health care is probably somewhere around 15-20 years behind commercial aviation in its systems for safety, and its culture of safety. I don’t know that it will take 15-20 years for them to catch up; I think that health care is learning very rapidly from the best practices of aviation.
David: What is required to take the CRM techniques from aviation and apply them to health care? How directly do they translate?
Steve: The short answer is that there’s almost a direct application. The underlying bones of a CRM program, the basic training that you do in terms of skills improvement, teamwork skills, communication skills, is pretty much identical in both industries. The safety tools that you try to implement, things like checklists, standard operating procedures, communication protocols, are very similar as well. So the bones are the same. The skin and the muscle that you put on top of those bones clearly have to be a little bit different.
David: How widely can you apply these techniques within health care? I can see a very direct translation to something like doing surgical procedures. How about monitoring patients in an ICU or patients coming into an emergency room? Does it also translate very directly there?
Steve: Actually I think the most successful program we’ve ever had was in an inner-city clinic. And it was a clinic staffed by licensed practical nurses, not many physicians, and lots of turnover among the medical staff. The patient population had a low health IQ, and was mostly a minority population. Not many resources among the patients or the clinic.
They hired us to do the same program that we do for surgical services, an ICU or an ED – training and tools. And the whole intent of it was to try to improve the level of diabetes screening and care that they gave their patients, because there was a high incidence of diabetes among their patients.
We saw some remarkable results, and much better outcomes, in terms of their patients, more compliance in terms of providing the right protocols of care, reduction in turnover among the staff, less time spent per patient, in other words, they were more efficient with their patients, and less time to train new employees.
There is a formula to follow. It’s not ‘smoke and mirrors’, and it’s not hopeful thinking and wishing. There is a very specific formula to follow that can change culture. And we have worked very hard at LifeWings to decipher what that formula is and publish it with the folks that we work for, so that if you follow these instructions and do these things on this day, at this phase of the implementation, you will be successful.
David: There’s been some opposition, at least historically, or skepticism amongst physicians and perhaps surgeons, in particular to the idea of being part of the team. And I wonder whether that’s something that you still run into, and how you deal with it, and if that’s actually similar to what a pilot might feel as well?
Steve: Well in the beginning days of CRM and aviation, we had that resistance from the ‘old-line’ captain. “You’re creating a ‘monster’ first officer that’s going to try to take over that cockpit. This is not a vote mentality. It’s not a democracy. It’s a crew. It’s a team, but there’s only one team leader and that’s me, and quite frankly, I don’t want mutiny on my hands.”
We don’t hear that anymore because that obviously never happened. We were not creating the ‘monster first officer’. We were creating a better team for the captain to work with, to have more resources at his or her disposal and teaching them how to use those resources more effectively, so that they had a better place to be employed and fly airplanes, and we’re able to do a better job of it.
And so we now occasionally hear that same argument from the ‘old-line’ physicians. “I am the captain of the ship. And if I tell you to jump, then you should say how high on the way up.” We don’t really hear a lot of that now. I think there’s just a great sense that health care has gotten so complex and is changing so rapidly that unless you have the full and total support and help of all of your surgical team, that you’re probably going to miss something.
David: Are there other things that are needed besides a CRM or team training approach in order to create a safe overall environment? Are there other things that you depend on happening from a hospital standpoint so that you can walk away and expect the results that you want to see?
Steve: I think the most important is a good leadership structure. I think there is a fundamental lack, in many cases in health care, of ‘Management 101’. Aviation, both military and commercial aviation, is so chock-full of–especially from folks from the military that have been through so many different kinds of leadership and management training courses–I think the level of basic skill at management pervades to a much lower level in aviation than it does in health care.
My experience has been that a hospital will absolutely not be successful at changing their culture and really having sustained success with this program over time unless they’ve got a really good leadership structure, a really good organization in place that can foster and sustain the kinds of things that need to happen for this to work over time.
The other thing, I think, is this whole idea of getting away from blaming the individual and looking at the systems issues. You know, so much of what goes on in health care now is, “Figure out who screwed up and figure out what to do about them,” rather than figuring out the latent system problems that led to that error. I think in health care we tend to look at errors as personnel problems. You know, “That person didn’t know the right thing to do so we have to fix that person.” And really, we need to think of it in terms of what sort of system can we put into place that would either prevent that error altogether or catch the error before it caused some sort of harm to the patient.
David: What kind of role do you see the legal system playing? You hear a lot about defensive medicine and you just described a little bit about assigning blame in medicine. Does that play a role in the mentality or how you approach the training?
Steve: Well, it really doesn’t. You know, we’re not conscious of that, of the legal system or defensive medicine when we’re doing our teamwork training or trying to put our systems in place. The healthcare organization itself may be conscious of it, but if they are they rarely ever mention it.
It is helpful to us, kind of in a perverse way, in the sense that folks make the connection that, if I have better teamwork and better processes, I’m going to make fewer errors, and if I make fewer errors, then I’m going to have less exposure to risk, and therefore less exposure to the legal system.
David: I know there’s been some debate recently I think between Dr. Sachs and Dr. Gaba about the necessity of using real kind of medical simulators in doing the training or whether the training can be done in a classroom environment. Do you have a view on that?
Steve: I think it takes both. I think you need an underlying level of expertise that you can get from the classroom before you go into the simulator, which is the classic aviation model. I mean, you’re going to do some classroom training before you get into the simulator, so that the time spent in the simulator makes sense for you and you can tie together what you’ve learned in the classroom. So, I don’t think you can actually do one without the other.
I do agree that simulation is the best place to teach teamwork training. I think the aviation experience would bear that out. But I don’t think you can just jump into a simulator without doing any sort of pre-work in the classroom and make the best use of your simulator training time. So I’d say you have to have both.
David: As you look around health care, you mentioned the field being 15 or 20 years behind aviation. I’m guessing you’re being charitable about that. But do you see examples, either in particular specialties or hospitals or particular countries, that are maybe a little bit ahead of the curve and, if so, how did they get there?
Steve: Anesthesia is clearly ahead of the curve. And I think they got there because they realized the extent of their errors and the effect of that upon their patients long before the rest of the other specialties did. And I think they took lessons out of the aviation play book a long time ago. So, they’re clearly ahead of the other specialties. And, quite frankly, most of the time when we go into a hospital, it seems that someone from anesthesia always ends up being one of our champions, you know, to help us implement the program in other specialties, especially in surgical services.
Recently, many of our clients are actually starting out in labor and delivery. And I think that’s a function more of need as they have the highest exposure to risk and the highest claims history. But I fully expect that the OB area or the labor-delivery area will catch up pretty rapidly as well.
And other areas that we are gaining a lot of traction in are emergency departments and ICUs. Especially since intensive care is becoming so specialized and so teamwork-dependent, I think they’re going to see the need for it.
I just spent quite a bit of time at the Annual Conference for the Extracorporeal Life Support Organization. So, it’s the profusionists and the physicians and staff that basically run the heart-lung machines, mostly in neo-natal intensive care units for preemies. And they’re really rapidly catching onto this whole, “We’re a team. It takes a huge team to do this well. We’ve really got to get this whole teamwork training and communication thing down and put systems in place that ensure that the teamwork happens.”
David: When a hospital decides that they want to bring LifeWings in, what kind of a commitment is it for them, either in terms of costs or time or commitment on the part of the staff?
Steve: Clearly, there is a financial commitment, because they have to pay for our services. And clearly there is a time commitment, because you have to spend some time doing the training. And you have to spend some time doing the process engineering to put the tools in place. And then there is a time commitment to manage all the moving parts.
I tell our clients that, “You don’t need the support of the entire population to get moving.” To use a risky analogy here, it’s really kind of like conducting a guerilla warfare campaign. You need about three things to get started. You need the support of about 15 percent of the population. You don’t need the support of every nurse and every physician and every staff member and every administrator to get started. You just need the support of some key people.
You need a secure base of operations. And, in this case, a “secure base of operations” means you are under the cover of the support of the highest level of administration, which means your board is supportive of it and your executive suite is supportive of it. Then you need the support of essentially a strong government. And that again is the support of your key administrators.
So, if you’ve got those three things, you can be successful. And then each piece builds on itself going forward.
So, who do you really need to get started? You need the support of someone from the Chief Executive Office and that’s generally the President or the CEO and quite frankly they wouldn’t have funded it if they weren’t supportive of it. And you really need the support of the Chief Medical Officer or the VP of Medical Affairs, and obviously the support of the Chief Nursing Officer. And then in whichever department you start in, you need the support of the Chair of Surgery or the Chief of Surgery or the support of the Chief of ICU, whoever the key medical director is of that particular department. You obviously need his or her support. Then you need the support of your director or your manager, like your Director of Surgical Services.
On top of that, you need one physician champion who does not hold a title or a position, they’re just a physician that works there in that department who can really champion the cause. And, if it’s in surgery, you need the support of one anesthesia champion. So a surgical champion and an anesthesia champion. But, generally, if you have two physician champions, you’ve got enough to get this started.
So you count that up. That’s the support of six, seven, maybe eight people at the most and if they’re supportive and follow the process, then they’ll generate the support among the additional 15 percent and then that 15 percent will generate the support among the rest of the population. And then you’ll end up being successful.
David: As the concept of patient safety has become better known with the IOM reports and then just more of an awareness in the general press, I’ve started to see articles that are recommendations to patients about what they should do to protect themselves in the hospital. And I’ve seen things like advocacy; that patients should make sure to tell physicians to wash their hands and to ask the nurses if the right antibiotics have been started, or whether a particular line can be removed.
And when I said I thought you were charitable with the aviation thing. It’s 15 or 20 years ahead. I’m just wondering, thinking back 15 or 20 years ago, I don’t remember asking if the flight attendant had closed the door, or if the pilot had taken fuel on or if they had their glasses. Is this being unfair, is it more complicated, are there some other pieces, or do people have a right to be upset about the current state of affairs in medicine?
Steve: Well, I think they are. I don’t know if “upset” is the right word. I think “vigilant” is the right word. And I absolutely believe that patients should be vigilant. Absolutely do.
I still fly for FedEx and a lot of my peers know what I do for health care and it always seems to come up in conversation with my piloting peers. And that conversation never starts without them telling me a story about what’s happened to them or what’s happened to their family. It seems like everybody has a story of some sort of huge mistake or difficulty that they’ve had with the healthcare system.
The other area of conversation is always, “Hey, you know, my mom’s got to go in for surgery. What should I tell her?” Or, “I’ve got to take my son in to see a specialist. What should I be looking for?” And my first piece of advice to my friends and peers is, “Never go to a hospital for an invasive procedure without 1: doing your due diligence and, 2: having a wing man. Always have a wing man.”
And the wing man could be your spouse or your parents. Somebody to look out for your interests when you’re under anesthesia or groggy from medicines or recovering. And by that I mean cross-checking medicines, making sure that when folks come in they do wash their hands. All of those things, I think, you have to have a wing man if you can’t do it yourself. And you need to be hyper-vigilant that basic blocking and tackling is done correctly in terms of hygiene and cleanliness and double-checking the meds and all of those sorts of things.
And quite frankly, my most successful clients take to heart our message that the team to provide care doesn’t only consist of the healthcare team. It also includes the patient and the patient’s family. And my best clients actively recruit patients and patients’ family members to be part of the team and to be part of the cross-check.
David: I notice on your bio that you have over 300 aircraft carrier landings. And I have to ask: Is that harder, or is it harder to change the culture in some of the hospitals that you work in?”
Steve: Both are very, very challenging and both have different rewards. In performing a landing on an aircraft carrier, the penalty for failure is most likely my own personal death. And if I’m truly unfortunate, I might take some of the crewmen on board the aircraft carrier’s deck with me. It is a very unforgiving task. Unforgiving of failure.
Now the failure for not being able to help a hospital change its culture is not my personal death, but it is most likely the unnecessary death of many patients who probably would have survived their care had the culture been different. So there are different risks and different rewards.
Quite frankly, I would never trade the ability to do what I’m doing now to go back and be able to do some more aircraft carrier landings. It was a challenge. I’m very glad that I can say that I did that. I’m glad that I survived it. I’m glad that I did it well.
But in terms of leaving the earth in a better state than I found it, this is truly the highest and best use of my time and I really feel like I, and all the people that work with me on this task, are making a difference. And so the intrinsic reward for changing the culture is way better than the intrinsic reward of just being good at aircraft carrier landings.
David: I’ve been a little harsh on the healthcare system and medicine during in this interview. I was wondering if there is anything that you see in medicine that you’ve been able to bring back into the world of aviation.
Steve: Well, I’m always struck, everywhere we go, with the incredible passion and care and concern that physicians and nurses and staff have for their patients, in spite of the fact it’s just an unrelenting stream of people that need help. And, you know, to be able to, day in and day out, carry that level of care and enthusiasm and passion for what you do is something that I have brought back to aviation because, quite frankly, aviation can be, in terms of transport aviation, moving from point A to point B, can be pretty routine.
You know, I do think about that. I do think about what an incredible group of people that are attracted to healthcare and they don’t seem to take their position for granted. So, it reminds me not to take the profession that I love for granted.
David: I’ve been speaking today with Steve Harden, President of LifeWings Partners and co-founder of Crew Training International. Steve, thanks very much for your time today.
Steve: I’ve really enjoyed answering your questions.