Thursday, 12 November 2015

Credentialing in high stakes industries - why is healthcare exempt?

After 5 years working in a helicopter medical retrieval service, I still can't quite believe how differently healthcare and aviation approach the issue of competency.
To highlight this, let me introduce you to Al.
Al is a veteran pilot, with over 8900 flying hours of experience who now works with a helicopter medical retrieval service.
Al’s competency to perform his work is overseen by the responsible authority in Australia, the Civil Aviation Safety Authority, equivalent to the Federal Aviation Administration in the US.
Pilots are granted a pilot’s licence after completing basic training and proving their proficiency.
Obviously, each aircraft is different. CASA therefore require that pilots are specifically trained for each, known as an endorsement.
Pilots can operate under two broad operating plans – visual flight rules (VFR) and instrument flight rules (IFR). There are multiple instrument-based methods for navigation, and each requires its own rating - if you don't have a rating for that procedure, you can't legally do it. This also applies to certain procedures like winching, acrobatics and over-water operations.
Ratings too are dependent on installed equipment – for example, there are a number of different types of Satellite-Navigation systems, so he needs to demonstrate his skills using the equipment he has available.
Certifications, ratings and accreditations are not open-ended. To continue to use them, Al must have performed them recently (known as “recency”) and been formally assessed in the procedure (known as “currency”).
An example of this is one of his instrument ratings, called an R-NAV, a type of approach he can make to a major airport.
Despite having performed this procedure countless times, to retain the right to perform the approach, Al must have performed it within the past 90 days.
If he doesn’t, he is no longer “recent”. This means he can’t use the procedure to fly by instruments alone, until he has practiced performing one in “visual flight” conditions, or in a CASA approved simulator.
Every year, Al needs to formally re-certify his RNAV rating, along with all his other ratings and certifications, as part of a face to face examination including a “Check-ride”, a practical examination done in flight with the CASA examiner beside him. If he doesn't do this, he can't fly using instruments alone. This is often referred to as his "currency".
The examination is transparent and structured, so that Al is clear on the required standard.
Needless to say, wilfully breaking these rules results in loss of licence, and employment.
All details of Al’s operations, including training flights and simulations, must be included in his logbook.
This is, of course, audited by CASA.
The implications of this are clear.
Pilots who are commonly performing procedures are easily able to maintain recency and currency, and do not need to perform simulated events, either in the air or on the ground. For pilots who are less active, options for maintaining currency are provided. Pilots who do not meet these obligations are not able to perform the procedures without retraining.
Furthermore, at a bare minimum, every IFR pilot is re-certified every 12 months.
So lets compare this with me.
I have my basic medical licence that qualifies me to continue to work as doctor, as long as my medical registration remains up to date, which involves no formal testing of my abilities.
I have been trained (“endorsed”) to perform my craft in ICU. By completing a designated period of training, along with a rigorous exam, it is assumed that I have attained competency in, for example, tracheostomy, regardless of whether or not I have ever been formally tested in my ability to do so (I have not).
Tracheostomy is a procedure I would do with a similar frequency to Al performing an R-NAV. Much like an R-NAV, a poorly performed tracheostomy can have disastrous consequences. Perhaps pointedly, unlike the R-NAV, the immediate consequences are for someone else, and not for myself.
I have no record of the number of procedures I've performed, the number of complications, or when I last performed one. I cannot demonstrate my efforts to improve my performance, and I've never been assessed by anyone since gaining my exam as to whether or not I am practicing to current standards.
And no-one seems to care.
Unlike Al, other than my own self-flagellation, and the possibility of an institution-based review process of an adverse outcome, there is little review, recertification and scheduled up-skilling of this procedure.
So, 10 years after my exam, having performed possibly no more than 60 tracheostomies, I can happily continue performing them, blissfully unaware of current standards, my own technical flaws, or even an awareness of my outcomes.
This situation probably applies then to most of the procedures I'd perform in the ICU :
  • Intubation
  • Lumbar puncture
  • Intercostal catheter insertion
  • Bronchoscopy
  • Transthoracic echo
And then there's the infrequent but potentially life-saving ones :
  • Surgical / percutaneous cricothyroidotomy
  • Transvenous pacing
  • Pericardial drainage
All are procedures performed infrequently in ICU. All are procedures potentially associated with significant harm if I get them wrong.
I can only assume that this also applies to lots of other people.
Isn't it time we did better?
About the Author
Dr Todd Fraser is an intensive care and retrieval medicine specialist, podcast editor of the Society of Critical Care Medicine, and founder of Osler Technology, a clinical performance management platform for acute healthcare providers.