ASQ - Team and Workplace Excellence Forum

Online Edition - March 2000

Issue Highlight - The Hunt For Next November

April in the state of Missouri is turkey-hunting season...For some reason the experience, despite its discomforts, is spiritually renewing and leaves you a little more optimistic about life.

In This Issue...
Angels With Rotary Wings
Reality Mirrors Movie
Stop The Merry-Go-Round
Peter Block Column
Views for a Change

Diary of a Shutdown

Angels With Rotary Wings
Flight Nurses-Providing Quality Service in the Toughest Places

--Barb Serrano knows nothing about quality and participation. But, if quality springs from workers who love their work, feel autonomous and hold themselves and their coworkers accountable for providing outstanding service —then Barb Serrano knows everything.
As the head, high-risk obstetrics nurse for the Arizona-based AirEvac, Serrano’s 12-hour shifts are always unpredictable. Serrano, a respiratory therapist and a pilot must work together to bring their patients the finest medical care, often under the worse possible conditions in remote desert locations.

--In 1969, AirEvac was formed in response to the need for rapid transport of rural Arizona patients—it was the nation’s first civilian hospital-based, 24-hour medical air emergency transport service. AirEvac is one of the fastest-growing air medical transport providers in the country and is a wholly-owned subsidiary of Petroleum Helicopters Inc.—the world’s largest commercial helicopter provider. With over 250 employees in Arizona, the company has managed to create a true espirit de corps with open, honest and authentic communication. From a careful and rigorous selection process, to monthly “chart meetings,” the focus of all employees is to continue to provide a high-level of service. The rewards—jobs people love, respect from their peers and saved lives.
Five minutes into a conversation with Serrano and one knows they are talking with someone who loves what she does and does it well. News for a Change Editor Bill Brewer recently had the privilege of speaking with Serrano about her experiences with AirEvac—the stress and success of the flight nurse what one might call angels with wings.

NFC: What exactly does AirEvac do?

Serrano: Arizona has many remote areas. We have lots of Indian reservations here and lots of open desert. In a lot of those remote places there are very tiny hospitals and clinics. Unfortunately lots of those people out there are very high-risk patients when it comes obstetrics. We fly to these outlying facilities when there is a patient with a problem. Actually most of these places don’t even do deliveries, so when there’s going to be a delivery, we’ll fly out and actually do the delivery. Then bring the patient, the mother and the baby back to Phoenix with us.

NFC: You work on a team?

Serrano: I’m kind of the person in control. There’s also a respiratory therapist and the pilot. We don’t fly with doctors. In the state of Arizona, the people that work for AirEvac practice under what is called an extended scope. I can go out and do a delivery. I can administer medication. I can decide what medication to give, perform a minor medical procedure because I’m practicing under an extended scope of my practice. The pilots are not involved with the medical care. They try to help us out when they can, but usually they are there just to fly the aircraft.

NFC: Are you always with the same three people?

Serrano: No. No, it changes all the time.

NFC: Is that bad or good?

Serrano: It’s actually good. We have a very specialized team. There aren’t a lot of us. For the maternal team, there are five maternal nurses. We usually work 12-hour shifts. I think there are probably about 10 different respiratory therapists we work with. So, we work with a couple different people, but it’s not like there’s a big, huge variety of them.

NFC: What’s the hardest thing about working on this team?

Serrano: Well, I’d say the most difficult and the most challenging thing is when a call comes in from one of these outlying hospitals to our dispatcher. The incoming caller will say, “We have this patient that has a certain problem.” Then the dispatcher will relay that message to a perinatalogist-a high risk obstetrician-that is on call. They will then decide what’s going on with the patient and if the teams needs to be sent. Then they will call us back and say, “OK, launch the maternal team to get this patient.” Then, when we hear the sound—it’s like an alar—we are launched for the flight and have seven minutes to be in the air. The challenging part is, you never know what you’re going for. You never know what kind of patient you’re going for. You never know where you’re going to go. You always have to be ready to think on your feet.

NFC: Do you ever get frustrated with the people you work with?

Serrano: No, not with the people I work with. We work very well as a team. That is one of the key factors in this job: You have to be a team player.
--I think something that is frustrating for me is the way they practice medicine in many of these outlaying areas. I just want to say, “What do you think you are doing out here?” That kind of stuff is frustrating. However, you never act that way. You might think those thoughts, but you keep them to yourself. We just try to do the best with what we have to work with. We stabilize our patients and get them moved as quickly as we can.

NFC: So what do you do when things go wrong?

Serrano: Well, if you get into a situation where you are in over your head, the first thing we do is what we call “patch.” That’s where you call back to the dispatch center and the perinatalogist and tell them what’s going on; tell them you need a certain doctor. Then theperinatalogist will call you and you can tell them the situation.

--They teach you to always have a plan; try to have a plan so that when you call us, you can tell us what your plan is and then we can work with it. But yes, it has happened to me before where I’ve gotten out to these remote little areas and something is vastly wrong and I’ve had to reroute flights, I’ve had to take people into other facilities for emergency surgery.

NFC: Do you ever talk about how, as a team, you could have done this better?

Serrano: We do. We have debriefing committees if there’s a stressful flight. You can talk to somebody or they will have group meetings that are actually mandatory that you go to and talk about stressful things.
Several years ago there was a train derailment and all the helicopters for AirEvac were dispatched to that scene. I also have all the certification to do trauma patients. So I was one of the nurses on the ground triaging patients and it was an all night affair—running up and down a dry riverbed, pulling people out of the train and trying to assess their injuries in the dark. There were probably 20 helicopters flying in and out. That was an overall stressful thing. Fortunately there was only one fatality. After that we did have a big debriefing meeting for everybody that was involved. It also involved the FBI because it was under investigation by them.

--We’ve had massive car accidents. People come over the border here illegally. They will pile a bunch of people in a van and the van rolls over and then there are moms and kids and everybody scattered all over the place. That is very stressful for the crews that handle those kinds of flights. Then they’ll have debriefings for them.

NFC: Do you discuss how to improve your processes?

Serrano: Yes. We have meetings every month, which are mandatory for everybody. We call it chart review. We pull a couple of flights and we discuss them all with the medical directors who are there. We discuss how the flight was handled, what was done, whether you did a good job and what could you have done differently. Everybody’s flights are picked apart. Lots of times it ends up with applause because people did such a good job. Then, other times, they will say, “Why did you give this much of a drug when, maybe, you should have given this much of a drug.”

NFC: How do those meetings make people feel?

Serrano: It is constructive criticism. It is a learning thing for everybody. I don’t think there are hard feelings at all. The interview process and the hiring process for AirEvac is very arduous. It seems like there are only certain people who can get through it. If you can get through it, you will be part of the team without any problem at all.

NFC: If you are going to apply this to other businesses or even hospitals, could you foresee problems with how people work together in hospitals?

Serrano: Yes. I work part-time at a hospital too. I am in a nursing pool. There are so many things that I see happening in the hospital that I think, “Wow, I sure wouldn’t want this to happen at AirEvac.” Nobody is willing to help you out. It is not a real team effort at all.

NFC: So, in a hospital, one of the differences is that it is not as much a life and death situation?

Serrano: Not even that. It is just that, “It’s not my patient. It is your patient. You handle it.” Where at AirEvac it is everybody’s patient. We all work together to have the best outcome that we can.

NFC: What makes the selection so unique that you are able to get 75 people that can work as an interchangeable team, at any time, with everybody getting along and also doing good work?

Serrano: Well, everyone must have a minimum of three years of experience in their specialty field. I had to come with a minimum of three years experience, not just working in any old labor and delivery—in a high-risk obstetrical unit. If you have the experience and can apply it to the job, you are granted an interview. The interviews are panel interviews, which I think are a little bit intimidating. There are usually several medical directors, several people that work for the company and usually a couple of people that work in the same type of position you are applying for. I remember my interview was in a boardroom at one of the big long tables and at the end of the table was my pad of paper, pencil and a glass of water. Everyone else sat at the other end. The interview was probably about an hour and a half long. The medical director gave me all kinds of scenarios and situations. He wanted to know what I would do. He portrayed the part of a doctor who was not happy. He portrayed the part of a patient who was having a baby and screaming at me, “What am I going to do?” They wanted to see how I reacted and how I thought.

--Once the interview is over, you get to sit down and take a written test. The written test is very difficult. If you pass and they decide to hire you, you have three months of training. Six weeks is didactic—classroom—you learn to do your job all over again, along with extra training that you will be expected to do. We go to the operating rooms in the big hospitals. We work right with the doctors. We do deliveries. We do all of those things to get this experience, and then we start flying. We fly for about six weeks with someone else. After three months, they conduct oral boards. It is basically your interview all over again. This time you better have all the right answers and say the right stuff—if you do it all right, you get your wings and you can fly.

NFC: What is the best part of your job?

Serrano: I would say that the best part of my job is the autonomy that we have and the respect that we get—the respect from everybody. When we go into a facility that has called us to do a transport, they are so glad to see us. We walk in and people think, “Oh, we can relax. AirEvac is here.” It is kind of like a hero thing. We get great respect. My nursing job that I work at—a labor and delivery here in the valley—it is a high-risk obstetrical place. I fly patients in there when I’m flying. When I am working it seems like they’ll say, “This is a very sick patient. We can give this patient to Serrano because she is a flight nurse for AirEvac. She can do anything.”

NFC: Then the other thing you said was autonomy—autonomy from?

Serrano: Autonomy because we are really extensions of the doctors’ hands. Since we don’t fly with doctors, we are basically the doctors when we are doing a transport. That is why they are very picky about who they hire. I think it is a great honor to be selected to work for the company when that is how it works.

NFC: Why can’t this be created in other health care settings?

Serrano: I don’t know. I think that there are a lot of people in health care that still just go to work, try to do as little as they can and take as many breaks as possible, get paid and go home. I think if everyone had the attitude that people at AirEvac have, health care would be great.

NFC: Would you agree that attitude is created by the environment?

Serrano: Right—attitude is created by the environment. Plus, I think you have to really like what you do. I am somebody who loves what I do.

NFC: Even the 12-hour shifts?

Serrano: Even the 12-hour shifts; sometimes we even work 24-hour shifts. You can work a 24-hour shift when the person who is going to relieve you gets sick and you have to stay. You say, “Well, OK, I’ll take a shower and maybe someone can bring me some clean underwear.” Otherwise, you just do it—it is just part of a job and we don’t mind it at all.

NFC: Do you think you are ever going to get tired of this?

Serrano: Oh yes. I don’t know if I will ever get tired of it. I actually work with a guy who has been flying with AirEvac since the company started in 1969. He is a neonatal flight nurse. He said, “You never get tired of it, but your body is going to get tired of it.” Flying is a big stressor—the noise, the vibration and the heat here in the summertime—it can really take a toll on you. I think that jumping in and out of airplanes and helicopters is something that you can’t do when you are 60 years old. I’m 40. I love it now and I am sure that I will love it for another 5-10 years.

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