On a winter day in 1982, Air Florida Flight 90 took off from Washington National Airport en route to Florida. It flew only about a mile before stalling, crashing into the 14th Street Bridge, striking several occupied vehicles and falling into the Potomac River. Seventy-eight people died in the accident, which was determined to be the result of improper deicing. The crash became a seminal moment in the study of teamwork in “high-reliability organizations”—companies in high-risk occupations and environments, from aviation and aerospace to power generation and the military. Now, learnings from high-reliability organizations are being applied to medical education to improve health outcomes and reduce the number of harm events.
“Aviation is an industry that used to have a very high accident rate, but now plane crashes are very rare,” said Jason Higginson, MD, chief of pediatrics at the Brody School of Medicine at East Carolina University and co-author of “Principles of Teamwork and Team Science,” a chapter in the new Health Systems Science textbook. “The reason is the industry has devised structured ways to organize workflow.”
High-reliability organizations are increasingly becoming a focus of health systems science because, due to their focus on teams, they represent a model approach to this “third pillar” of medical education.
One of the things teams focus on is eliminating steps that do not need to be negotiated, Dr. Higginson explained. (Think of deicing a plane in cold weather, for example.) They figure out what is simple and they standardize it.
“In medicine, I think one of our failures is that we reject the idea of standardization,” he said. “High-reliability organizations have shown very clearly through decreased accident rates and decreased harm events that standardization of some things is required for you not to have errors.”
Making change at East Carolina University
Dr. Higginson had been a physician in the Navy, where he was first exposed to the team-science concepts he would later write about. His co-author on the chapter, Donna M. Lake, PhD, RN, also served in the military, as a nurse in the Air Force.
“Watching how they [in the military] structure their interactions and conversations—whether things go well or things go poorly—was really eye-opening to me with regard to how we do things in medicine,” he said.
When he joined East Carolina, in 2012, Dr. Higginson was the director of the neonatal intensive care unit, which had long had a siloed culture. The unit had a physician service and a nurse practitioner service, but they were completely separate.
“Some of that was justified by the differences between the two professions—nurse practitioners are trained to a different standard than physicians,” Dr. Higginson said. “Still, I thought that was a waste of talent. Our nurse practitioners were very skilled, but most of the teaching was done by residents, because they were MDs, even though they had very limited exposure to the ICU. And outcomes were not good.”
So he combined the teams. He got buy-in for the change by first sharing data showing members of the physician team that they had slightly worse outcomes than the nurse practitioner team.
“I said, ‘Look, they’re having really good outcomes on the other team. They must be doing something right,’” he said. “It took a lot of work to convince people that the letters after their names didn’t necessarily tell the whole story, but once they bought into it, outcomes improved. Actually, the outcomes got better for both physicians and nurse practitioners.”
Creating the medical school of the future
“If you look at medical schools and hospitals now, health safety science is something people are thinking about, but it’s not the fabric of who they are,” Dr. Higginson said. “There’s definitely resistance to some of these things. The ‘MD’ carries a lot of power, but it doesn’t necessarily make you right in all situations. That’s what we’re trying to inculcate in our medical students—that you do rely on other professionals, that they bring things to the table too.”
The “Principles of Teamwork and Team Science” chapter focuses largely on the promise of interprofessional education, with sections devoted to defining, constructing and leading teams, as well as the four stages of team development:
- Forming: exploration and building trust
- Storming: attitude changes, competitiveness and tension, disunity
- Norming: satisfaction, respect development, decision-making
- Performing: high level of interaction, increased and optimized performance, confidence within the team
“Most people want to be part of a team, and they want to be part of a functional team,” Dr. Higginson said. “The feedback I’ve received from most people is, ‘This is a good thing. This is something we should have on our minds because it just makes life easier and more enjoyable.’”
Health Systems Science was co-authored by experts from the AMA and faculty from 11 of the 32 member schools in the AMA’s Accelerating Change in Medical Education Consortium. The textbook retails for $59.99 and can be ordered from the AMA Store and the publisher, Elsevier, as well as from Amazon and other online booksellers. AMA members may order it from the AMA Store for $54.99. Individual chapters are also available from Elsevier for $6.99 each.
In 2012, the AMA adopted policy on the structure and function of interprofessional care teams, which highlights the aviation industry's approach to team-based work and how surgeons and intensivists have adapted it to improve patient safety.