Portal de Periódicos da CAPES

CREW RESOURCE MANAGEMENT

2006; Wiley; Volume: 13; Issue: 3 Linguagem: Inglês

10.1111/j.1440-1800.2006.00327.x

1440-1800

Suzanne Gordon,

Risk and Safety Analysis

As patient safety gains more attention, creating well functioning teams is often touted as key to reducing medical errors and injuries. In a search for safety lessons from other high-risk industries, aviation — and its implementation of what is known as crew resource management (CRM) — has emerged as a model. CRM is both a concept and a series of training programs that commercial airlines have used to dramatically reduce catastrophic accidents. Although some areas in health-care have utilized some of its techniques, CRM is poorly understood. For the past several years, as I've written more about the problems in doctor–nurse relationships, I've become fascinated with CRM. As a result I have spent months interviewing people who have transformed an industry in which airline captains — known for years as 'skygods' — ruled the cockpit and co-pilots, flight attendants, dispatchers, among others, were assigned deferential roles on the sidelines. Like physicians, these 'skygods' had control over life and death. If, through a bad decision or lack of situational awareness, the captain flew the plane into the proverbial (and sometimes very real) mountain every one went down with the ship. In some instances, as we know from flight data recorders, subordinates didn't challenge a captain's authority even though they were aware of the potential consequences. In others, because pilots were trying to fix a problem, no one was flying the plane or maintaining situational awareness (like the fact that the plane was losing altitude and flying into the Everglades). Then in the late 1970s things slowly began to change and the airline industry began to focus on what is known as 'human factors' — 'the applied science of people working together with devices'. In aviation this has become 'a multidisciplinary field that draws on the methods and principles of the behavioral and social sciences, engineering, and physiology to optimize human performance and reduce human error' (Wiener, Kanki and Helmreich 1993, 3). Today, commercial airlines must maintain some sort of crew resource management curricula that are taught — not just on a one shot basis — but recurrently to pilots and flight attendants and other members of the flight crew. The program is required by the United States Federal Aviation Administration (FAA) and in many other countries. According to Robert T. Francis, former vice chairman of the US National Transportation Safety Board, before CRM the captain's attitude toward first officers, flight engineers and any personnel who lacked the right stuff was, 'I'm the captain. I'm king. Don't do anything. Don't say anything. Don't touch anything. Shut up'. Now it's 'I'm the captain. Please tell me if you see me making a mistake'. How did this transformation occur? Because researchers initiated a systematic study of crew communication and behavior; because regulators mandated training programs; and because all the relevant players, i.e. company administrators, pilots and other personnel, and their unions were included in the planning and implementation process. And because the primary focus of CRM is on safety and error, not on communication. Training programs are not called 'crew communication management' but 'crew resource management'. Their main goal is not getting people to 'work together better' (Helmreich, Merritt and Wilhelm 1999, 5) but to reduce 'the frequency and severity of errors that are crew based'. This is achieved by training crews to 'avoid, trap or mitigate the consequences of error by making better use of human resources' (Helmreich, Merritt and Wilhelm 1999, 8). Evolving CRM programs work because instead of challenging the captain's authority to make decisions they hone in on how team leaders make decisions. In CRM training the role of the team leader, i.e. the captain, is cannily redefined. Instead of all players revolving around what used to be a solo aviator, leadership is now defined as making sure others can do their jobs efficiently and effectively, leading the team by utilizing all available resources, and making decisions based on all available information. This is accompanied by a redefinition of 'subordinates' who are taught the basics of what I've come to think of as 'assertive followership'. Specific lessons on 'followership' stress the triad of Inquiry, Advocacy and Assertion — as in, no I will not fly into the mountain with you because you say so. Although CRM can't be strictly applied to health-care, its lessons should be obvious. Teams aren't born: they're built. If people are to work together productively institutions have to create and maintain the infrastructure that makes teamwork possible. We don't only need leaders who know how to lead: we also need assertive followers. Regulation is central to culture change. Finally, when it comes to either passenger or patient safety, as one pilot recently told me, it's communication that keeps the patient alive and the plane in the air (Gordon 2005).