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(Jon DePaolis) Hello, and welcome to Take 5 with The Joint Commission.
I'm Jon DePaolis, and I'll be your host for this episode.
Today, we're continuing our multi-episode celebration
of the John M. Eisenberg Patient Safety and Quality Award recipients.
These awards recognize major achievements
to improve patient safety and healthcare quality.
There are three recipients each year,
for an individual,
an organization impacting quality care at a national level,
and an organization impacting quality care at a local level.
In this episode,
we're going to talk to Dr. David M. Gaba,
who received the Eisenberg Award for his individual achievements
in promoting patient safety and high-quality care.
Dr. Gaba is Staff Anesthesiologist and founder and director
of the Simulation Center at VA Palo Alto Health Care System.
He also is a Professor of Anesthesiology, Perioperative and Pain Medicine,
as well as the Associate Dean
for Immersive and Simulation-based Learning
at Stanford University School of Medicine.
He has made seminal contributions in patient safety research,
innovation, and dissemination.
His work and experience includes safety experimentation,
developing and advancing theory, teaching, editing,
as well as being a scholar and an institutional leader.
He has more than 125 peer-reviewed publications
in organizational safety theory, human factors, and safety culture.
Dr. Gaba, thank you so much for coming on the show today to discuss your work.
(Dr. Gaba) It's my pleasure.
(Jon DePaolis) To start us off,
you've been pioneering different methods of simulation-based training
throughout your career.
What were you seeing in traditional training methods
that simply didn't work as well?
How did you go about improving those processes?
(Dr. Gaba) From the beginning of my own training in medicine
in the 1970s, through my internship and residency,
we mostly relied on the apprenticeship model,
doing clinical care on real patients
but under the direct supervision of those more senior.
A common mantra was "see one, do one, teach one,"
which is a laudable thought, but not so well suited
to the ever more complex kinds of healthcare,
and particularly, as I saw it,
for fields of what I call high intrinsic hazard,
like my own field of anesthesiology.
In part due to my lifelong passion about aviation and space flight,
I started looking at how these and other fields
addressed similar kinds of issues.
Among many aspects, two stood out to me.
One, the use of simulation, both for training and for research,
to understand the human factors and decision-making of the personnel,
as we say, in the hot seat.
And second, the uniform use of cognitive aids,
which includes checklists and emergency manuals,
in order to get past the blind reliance on so-called information in the head,
which, even under stress, is hard to come by.
And hence, my group's pioneering work in both of these areas.
(Jon DePaolis) Can you tell me a little bit about how you adapted
the crew resource management from aviation into the healthcare field?
(Dr. Gaba) In the late 1980s,
I somehow started to hear a little bit
about what then was called cockpit resource management, or CRM.
And this was about the decision-making and management components
of handling tough situations,
as opposed to the stick and rudder skills of flying the plane.
In 1987, I saw the new episode of the PBS science show Nova,
titled Why Planes Crash,
and it had a major portion describing
the emergence of CRM for training in commercial aviation.
One of the talking heads on the show was Dr. Clay Foushee
at the NASA Ames Research Center,
which is just a few miles down the road from my house.
I contacted him and went to visit.
He gave me more documents and citations,
and a lot of good advice, and I was off to the races.
The analogies of cognition in the cockpit versus the operating room where striking,
and we readily adapted the key CRM principles
into a curriculum for anesthesiologists.
Along with my colleague Dr. Steve Howard,
we already had a simulator,
which we created to conduct research on anesthesiologist decision-making,
and here now is sort of the key application
of that modality for clinicians to learn and practice CRM skills.
(Jon DePaolis) You've developed some cognitive aids
for use in critical life-threatening situations.
Would you be able to explain those to our audience,
as well as how they work?
(Dr. Gaba) As I mentioned earlier,
it was clear that we in healthcare were ignoring,
in fact, often dismissing
a critical aspect of safety that's used
in most other domains of complex work and risk.
We expected clinicians to memorize everything,
to rarely have to look up anything,
and to conduct their work without any way to check
that the important things have been done.
Well, pilots aren't stupid,
but they rely heavily on checklists and manuals
for routine activities in crises.
And why shouldn't clinicians do the same?
Around 1990 or so,
we created our first catalog of critical events in anesthesiology
to go along with in the syllabus
of our Anesthesia Crisis Resource Management courses.
This morphed into a textbook about safety and CRM for anesthesiologists
that contained a newer version of this catalog,
but it was never really designed to be easy to use in a crisis.
And over the years, my colleagues and I developed and disseminated
a variety of both small and simple,
as well as larger and more complex or comprehensive cards or manuals
that were designed to be easy to use in challenging settings.
Ultimately, we created a formal group
to develop the Stanford Anesthesia Emergency Manual--
and we're just now about to release version 4 of that--
with major attention to making it easy to use.
Over the last decade,
we've added a robust collaboration with the human factors expert at Nasa Ames
to further tailor the design to suit this purpose.
The manual gives structured guidance
on how to recognize serious problems
and what should be done about each of them.
But note that these manuals are only aids to clinical expertise,
not a replacement,
and some situations don't leave time,
at least not at first, to consult the manual.
But many situations do,
and other members of the clinical team can themselves be the reader of the manual
who works closely with the clinician in charge.
These kinds of synergies can be very powerful.
(Jon DePaolis) Dr. Gaba, what are some of the most important takeaways
from your training methods?
(Dr. Gaba) Well, being a professional in healthcare is a lifelong endeavor,
combining didactic knowledge, science, and technique
with the constant honing of clinical abilities and approaches.
The so-called knowledge skills, the attitudes, must be integrated,
and the best way to continually improve such integration
is to build mindfully from clinical experience
and our belief to undergo simulated experiences
that can present, at will, challenges that were not encountered every day.
I like to say that if you are a healthcare professional,
you should forever be doing such activities
in a variety of ways,
with many different modalities of learning, including simulation.
And the only way to stop doing these things would be to retire or die.
That's the way it is in aviation, nuclear power plant operation,
and other such fields.
And I think that's the way it should be in healthcare too.
(Jon DePaolis) You've had such an impressive career so far
and you just won the Eisenberg Award.
But maybe, along the lines of healthcare being a lifelong pursuit,
what's next for you?
What are you hoping you can accomplish as you move forward?
(Dr. Gaba) Well, for one thing, I'm not retiring anytime soon.
(Jon DePaolis) That's good.
(Dr. Gaba) Receiving an award for lifetime achievement
is often seen as meaning you're retired or about to be.
I'm heavily involved in research projects
on assessing the performance and decision-making of clinicians
in challenging situations,
now with multicenter studies using simulation as a tool,
and these are projects over the past decade
with my friend and colleague Dr. Matt Weinger.
Vanderbilt is the principal investigator.
And these activities are far bigger, better funded, and more rigorous
than those that we did in the late '80s.
And this current project still has several years to go.
As for the cognitive aid side of things,
we're really thrilled at the dissemination and uptake of a variety of aids,
not just our own Stanford manual.
I'm a founding member of the Emergency Manual Implementation Collaborative,
or EMIC,
which is a hub for learning more about this notion of cognitive aids
and has links to many manuals and other aids.
And we're hoping to have everyone in healthcare
learn about, adopt, and seriously implement these things
in their own institutions and practices.
I've also been working
on using head-mounted display kinds of virtual reality
to present clinical scenarios
that would be hard or impossible to offer in physical simulation.
While COVID put a damper on this project,
hopefully, we're soon going to be ready to get back to it.
And finally,
I've also been heavily involved in mentoring the next generation
of patient safety researchers and simulation instructors,
and hopefully one or more of them will receive an Eisenberg Award
sometime in the future.
(Jon DePaolis) It certainly sounds like you have a lot going on.
Where can listeners go to learn more about your work?
(Dr. Gaba) As you indicated in the introduction,
I have many journal publications,
most of which are searchable through PubMed,
Scopus, Web of Science, or Google Scholar.
There are very few other Gabas in the world,
and even few Gaba, DM, or Gaba, D. authors.
And some of my many book chapters
will also show up in searches in the more expansive search sites.
A fair amount of my work is captured in the textbook
that I and several of my colleagues wrote
called Crisis Management in Anesthesiology,
which is now in its second edition.
I have to disclose that my three co-authors and I
share the 10% royalties on the sale of the books, which the authors get.
That amounts to about $2 for each of us per book sold,
which might or might not barely cover the price of a small cup of coffee
at your favorite coffee shop.
So none of us has quit our day jobs.
(Jon DePaolis) (laughs) Well, Dr. Gaba,
it's been a pleasure talking with you today.
Thank you for coming on the show to talk to us.
(Dr. Gaba) Oh, well, thank you very much.
(Jon DePaolis) And as always, thank you all for listening.
You can find more episodes of this program
on The Joint Commission's website
at www.jointcommission.org
This has been Take 5 with The Joint Commission.
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