When to Wake Up the Doctor – CCIRs for Medicine

At Telluride East today we were all touched by the story of Lewis Blackman.  The care he received suffered during night and weekend hours when coverage was limited to housestaff.  We discussed how making the decision to call an attending about a patient can be a difficult one, especially if the hour is late.  I  was delighted to learn today that at some hospitals, attendings and residents have come together to agree upon a list of ten patient situations that will always always generate a phone call from the resident to the attending, regardless of day or time.  Further, at the end of the call, the attendings have agreed to thank the resident for reporting the situation.

This practice parallels a concept from military doctrine.  In order to succeed in his or her mission, every commander requires up-to-the-minute information about the status of the forces under his or her command, the general situation, an enemy’s activities, and more.  These pieces of information are called the Commander’s Critical Information Requirements or CCIRs, and they are captured in writing by the commander for the entire command.  Since this information is required to make decisions that can determine the success or failure of the mission, an event impacting a CCIR is communicated to the commander immediately, waking him or her up if necessary.  No soldier is reprimanded for communicating a CCIR in accordance with the commander’s orders.  CCIR lists are generally kept as short as practical, and are usually limited to about ten items.

The military has developed many practices for ensuring high-reliability execution of its critical missions.  The CCIR example shows us that some of these practices can be adapted to health care.  As we consider sources for best practices in our efforts to improve the safety and quality of healthcare, we should keep the military in mind.

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