Triggering a better team response

July 18, 2009
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The two-month-old baby was found in a car seat along the side of the road after an accident. Just like a scene from the TV show “ER,” an emergency medical technician fires off a string of medical information as he wheels the child into the emergency department of a West Michigan hospital.

But in this scene, no one is listening.

In a treatment room crowded with three doctors, none of them can get a CT scan ordered to check for bleeding in the baby’s brain. It takes 40 minutes before the patient gets to the scanner and then the gurney has to wait in the hallway because, at the same time, another doctor has ordered a CT scan.

Luckily, this pediatric patient is plastic.

“What’s amazing is that these people have been doing this for years and they have no idea,” said Dr. William R. Hamman, a Western Michigan University professor of aviation, a cardiologist and an international pilot for United Airlines who is examining teamwork in health care through the use of simulation techniques.

“This is what we see over and over and over again. We’ve done about 150 of these scenarios, and we have about 300 hours of videotape,” Hamman said. “The ‘in situ’ (on-site simulation) is very powerful to bring out these kinds of systems issues, as well as the team functionality that we’re looking at.”

In 2005, Hamman’s Center of Excellence for Simulation Research received a $2.8 million, three-year grant from the Michigan Economic Development Center, along with $750,000 from economic development corporation Battle Creek Unlimited and another $750,000 from the Forest Park Foundation in Peoria, Ill.

The four years of research has spawned a company, PSO One Inc., to provide in situ simulation services to hospitals. Hamman said at least one insurer has agreed to lower malpractice rates by 10 percent for hospitals that undergo simulation training, which helps to cover the invoice from PSO One.

Federally certified as a Patient Safety Organization, PSO One last fall entered into an agreement with the Lansing-based Risk Management and Patient Safety Institute, an arm of insurer FinCor Holdings Inc. The institute will market PSO One’s services to hospitals and health systems across the country. PSO One will have access to the institute’s team of patient safety experts to conduct the simulations.

Hamman also has been hired by Beaumont Hospitals in the Detroit area as director of medical simulation and research.

His research has drawn attention at Michigan State University, Northwestern University, Trinity Health, Harvard University and the American College of Cardiology. 

“Simulation is really the re-creation of an environment, particularly for an adult learner, in what we call a ‘suspension of disbelief,’ where they can get into a situation of learning and practicing tasks that would normally be done in a very high risk situation,” said Hamman, sipping Diet Coke in a sparse, paneled office at the WMU aviation school on the grounds of the W.K. Kellogg Airport just west of Battle Creek.

Hamman, who grew up in Indiana, learned to fly at Purdue University.

“As college students, we were put in simulation pretty much from the beginning, from day one of our training,” said Hamman. “I still go back every nine months for recertification, and that’s all done in simulation.”

Thousands of pilots and flight attendants go through United’s simulation training center in Denver, he said.

“Up until the late 1970s, it was a very technical focus. It was all about you and your ability to fly through failures and fires and that type of thing. We saw early on — as health care is beginning to realize now, too — that 70 percent  of our accidents were not caused by the technical skill sets; they were caused by the team and the subtle realities of human beings interacting with each other, and communication and workload management and situation awareness.”

A crash in 1978 was a catalyst for a new philosophy in aviation training, Hamman said. On a commercial flight out West, the pilot was so worried about whether the landing gear was functioning that he ignored warnings from the crew that the airplane was running out of fuel. “They crashed and killed several people that day. Here’s three people, in a room the size of your closet, and they couldn’t communicate that they were running out of gas,” Hamman said.

Several years later, the Federal Aviation Administration decided to elevate team skills, changing the way pilots were trained and evaluated in simulated situations. Hamman helped to develop the Advanced Qualification Program for the training and certification process for airlines in the U.S. The process includes dividing the flight experience into chapters, or “event sets,” which are “almost acts of a play,” he said. By choosing a certain set of events, “You can trigger a team response.”

For example, one event set involves a simulation of a commercial airliner which, because of several disparate factors, appears to be headed straight for Mt. Rainier. “Some of the teams wouldn’t even break a sweat, and other teams, you wanted to get out of the simulator and kiss the ground,” Hamman said. “It was really in those differences that we began to understand what our really good teams did.”

In 2000, the Institute of Medicine released its ground-breaking report, “To Err is Human,” which took the health care industry to task for mistakes that caused an estimated 44,000 deaths annually. The report cited the aviation industry’s commitment to safety in the post-World War II era as an example for health care to follow.

“Quite a cottage industry kind of grew up of pilots — well-meaning, I think, for the most part — saying, ‘We have a crew research management model. You take our model and implement it in your health care organization and you’ll be healed,’” he said.

“We felt that that was absolutely wrong. You can’t use a model that was developed for an airliner at 35,000 feet or a nuclear power room and expect it to work on an OB floor or an ED or a pediatric intensive care unit. But what we did theorize is that we could take our process of simulation design, like we did in the air carrier industry, and do the very same work.

“And so that’s what our grant was originally about. We wrote it, the MEDC grant, to bring the concept of that simulation design that was developed in the air carrier world to assess our team and create metrics of performance for a team to health care, to study and understand teams.”

Hamman and his assistants use an array of cameras, microphones, recording equipment, software and high-tech mannekins that mimic heartbeats and other human factors. Occasionally, he hires actors to play “distractors” — distraught friends and family of the “patient” who disrupt the health care professionals. The professionals, including doctors, nurses and technicians, have agreed to participate in a simulated experience, but don’t know the details ahead of time.

Hamman said that despite limitations — one of his scenarios involved a female mannekin whose pregnancy was represented with garbage bags, used fabric for skin and pea soup for meconium — he tries to make it as real as possible. For example, he has dragged an on-call doctor into the hospital in the middle of the night, and he insists that the “patients” have electronic medical records, a task that at times is the most difficult part of the exercise.

“We very carefully detailed out how we were going to integrate into the health care organization as deeply as we could. When we go into an organization to do one of our research experiments … we interface with their electronic records, we interface with the laboratory, imaging. We have all the proper imaging available for the health care professionals so they would do everything they would normally do in their real world,” he said.

He draws a variety of departments into his scenarios, from emergency departments to pediatric intensive care units, surgery and cardiac care.

Originally, Hamman said, he planned to build a simulation center on the WMU campus. Then the University of Minnesota asked him to do a simulation on a patient care unit, and that experience changed his mind. “There’s no way we could create the challenges, the stresses, the complexities of the operational systems that health care professionals work in, in a lab environment,” he said.

The scenarios are designed to test teamwork by using specific triggers, such as the entrance of a nurse into the room. One or two of the participants is wired with an earpiece receiver, and Hamman feeds that person direction on the course of the scenario, for example, the discovery of bleeding around the heart.

As the scenario unfolds, Hamman uses software to capture bits of video that reveal how the care team functions. Those are strung together into a story board, which is presented, along with video, at a debriefing session immediately following the simulation.

The application of the in situ simulations to diagnose hospital systems was a side effect of Hamman’s main goal, which was to study teamwork in health care.

“We were focusing on the team and the team processes with this in situ simulation. The goal of our research was to understand teams,” Hamman said. “Like all research, sometimes you get side benefits you weren’t thinking of at first. That’s exactly what we saw here. It became a very powerful system diagnostic for health care organizations.”

Debriefings have proved to be illuminating. One doctor discovered that colleagues backed off when he violated hospital policy on removing a patient from a backboard, then proceeded to reverse his decision when he left the treatment room. A hospital in the Detroit area learned that the first contact for a heart attack “victim” was a security guard who kept her sitting in the waiting room for a half-hour. An emergency room nurse found out that her attempts to couch her language to avoid alarming a patient meant that the doctor couldn’t understand what she meant.

 “Rosemary Gibson (senior program officer) of the Robert Wood Johnson Foundation said it makes the invisible visible,” Hamman said.

 Hospitals traditionally have been reluctant to use video recording, fearing it could be used against them in litigation, Hamman said. But because PSO One is designated as a Patient Safety Organization under a 2005 federal law, video and other information it collects is confidential and can’t be used in lawsuits.

 Along the way, Hamman did indeed research team processes. He discovered, not to his surprise, that there are some significant differences between aviation and health care:

 *Team stability is fluid in health care. The size and composition of the team can vary greatly during a single incident. “We don’t have a door at 35,000 feet. It’s a very static team.”

 *Leadership variability and authority gradient are less clear in health care. “In aviation, we have a very simple model. The captain dresses in a certain way, sits in the left seat. … In health care, it’s very blurred, who is the leader. It’s very poorly defined in health care and that leads to a lot of issues of complexity.”

*Operational systems and communications are key to patient safety: “How do health care professionals reach out to get what they need for the care of the patient? It can be very complex, and if a team is dysfunctional, it can be devastating for the patient.”

Hamman grew up in Fort Wayne, Ind., the son of a baker and a department store clerk. He had one sister, who became a teacher. He headed straight for Purdue’s aviation program after high school. “I (also) had an interest in health care. I don’t know why; none of my family are pilots or doctors,” he said.

He bounced between aviation jobs and pre-medical classes before finishing the prerequisites in 1981 at Marquette University and enrolling at the University of Wisconsin School of Medicine and Public Health in Madison. He graduated with medical and doctorate degrees in 1986.

“Originally, I was hoping to become a mission specialist with NASA,” he said, adding that Laurel Clark, the astronaut who perished in the 2003 Space Shuttle Columbia accident, was a year behind him in medical school. “We both got accepted as mission specialists. Then, when we were in school, the Challenger (explosion) happened (in 1986), so that shut everything down.” The shuttle program was sidelined for 32 months as NASA investigated the accident.

 He was inspired to follow the footsteps of a friend’s father who was both a doctor and a pilot, and applied to United Airlines after spending about six months on the staff and faculty at U-W.

“I never really went out and practiced (medicine). I don’t know if I would have enjoyed it that much,” Hamman said. “I’m kind of glad it happened like it has with me. I’m involved with health care where I really feel I can make an impact and a difference, probably much more than I could as a cardiologist. I really am enjoying what I’m doing.”

Hamman lives in Battle Creek with his wife, Ashley, who also is a pilot, and their two children, ages 10 and 12. He has two older children, ages 24 and 21, who live in Denver and New York City.

Having spent 15 years in crew training and risk assessment for United Airlines, Hamman still flies international flights for the airline, usually on weekends.

Whether Hamman continues his research at WMU after the grants run out in about a year is still up in the air. While he has accepted a position as director of medical simulation and research for Beaumont Hospitals, he said he’s still in discussions with WMU President John Dunn about continuing his research in Battle Creek. But he said he wants to find the best place for his work to continue, and that may mean an eventual move.

“In health care, about 120 people a day are losing their lives, not because of the disease process but because of mistakes that are happening,” Hamman said. “In the world of air carriers, that would be like crashing a 747 every week. Of course, that’s a big, catastrophic event. But in health care, it happens in ones and twos across the United States, so it never really reaches the surface. It’s not perceived.

“It’s fascinating to me to look at teams and look at the concepts of teams in context. Whether it’s losing one life at a time or 120 a day or crashing an airplane, it’s just as devasting to the families when they have these things happen to them.” HQ

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