The pilots assemble each Friday morning with their colleagues for their “flight plan” assessment. They discuss, map and critique their performance.

The goal? Make each future passenger’s journey safer, smoother and successful.

The team is gathered in-person and virtually in the cardiac command center at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida. They will discuss each pediatric cardiac surgery case from the past week from a multidisciplinary standpoint.

“The flight plan provides a great objective visual to the hospital course, one removed from the day-to-day management,” says cardiac intensivist Arabela Stock, M.D., co-director of patient safety and quality in the Johns Hopkins All Children’s Heart Institute. “It is a great tool to see gaps or where we could have changed the course for a shorter and less complicated ‘descent.’”

Origin of the Flight Plan

Physicians at the Hospital for Sick Children — known as “SickKids” — in Toronto initially adapted aviation safety assessment techniques for use in evaluating pediatric heart surgery. The “flight plan” concept has been adapted and tailored for use at several medical centers.

The aviation industry established an impressive safety record after developing systems of checklists, simulation and system evaluations. A core element of the aviation-safety mindset is to avoid assigning individual blame for errors and instead to identify and avoid systemic flaws and failures. Increasingly, health care organizations have adopted similar techniques to improve their safety record.

“Using that model applied to medicine, we analyze every step in the process that helps get the patients into, through and out of the operating room, and helps them recover,” says pediatric cardiologist Ashish Shah, M.D., M.B.A., also co-director of patient safety and quality in the Heart Institute. “We have a meeting every week where we analyze these systems and how we performed. It gives us nearly real-time opportunities to analyze and adjust systems so they are working well. It makes our team better, our Heart Institute better and leads to better care for our patients.”

Bringing the Flight Plan to All Children’s

James Quintessenza, M.D., co-director of the Heart Institute, encountered the “flight plan” while working at Cincinnati Children’s Hospital Medical Center and Kentucky Children’s Hospital. He previously had worked as a cardiovascular surgeon for 26 years at Johns Hopkins All Children’s.

When Quintessenza returned in 2020 to again lead the Heart Institute and the cardiovascular surgery program, he brought the “flight plan” concept with him.

“I thought it was a valuable tool for evaluating performance in a non-judgmental way and building a team,” Quintessenza says. “We have adapted it for our program. It has been useful in creating and clarifying communication and improving procedures and outcomes.”

How It Works

The five “pilots” in the program are Stock, representing the cardiovascular intensive care unit (CVICU); Frankie Gilliland, D.N.P., representing advanced practice providers in CVICU; Shah (cardiology); physician assistant Jennifer Davis, P.A.-C., (cardiothoracic surgery) and Vyas Kartha, M.D., (anesthesiology). They are responsible for data entry and scoring each area on a four-point scale with four as the highest.

Stock generally leads the weekly discussion, which might include one to six cases, depending on the number of surgeries and discharges before Friday morning. Each patient outcome is assigned a color, taking into account risk factors: green (better than expected), yellow or red.

Each case includes a brief patient cardiac history, including previous surgeries if any, current cardiac condition or defect that led to surgery or catheterization palliation, and any associated health conditions or risk factors. Then, Stock describes the surgical procedure, any anesthesia events, postoperative course — including events that changed the expected course (cardiac arrest, need for mechanical circulatory support/extracorporeal membrane oxygenation (ECMO)/ventricular assist device (VAD), infections, any hospital acquired conditions) — and finally the discharge. The discussion includes a graphical illustration of expected and unexpected clinical events. They report on any significant findings from echocardiogram, CT scans or any other studies, such as MRI/MRA. After the presentation, an open discussion allows team members to give input and raise concerns. This could be anything from surgical decision making, missed diagnosis, quality of equipment, personnel, quality of data interpretation or discharge issues. After the meeting, the pilots create a score on the four-point scale for each area.

“The plan is undergoing constant modifications to accommodate for quality improvement questions, administrative questions and potential research,” Stock says.

One change borne out of the “flight plan” discussions was the addition of a discharge coordinator to smooth out the process of sending patients home. Another involved a modification of a surgical technique to reduce the frequency of a complication that had led to an increase in length of stay. The team currently has a quality improvement project underway related to reducing surgical site infections.

The Heart Institute Flight Plan team won the Innovations in Clinical Care Award for Johns Hopkins All Children’s in the 2021 Johns Hopkins Medicine Clinical Awards.

“The flight plan continues to evolve, but it already has made valuable contributions toward patient safety,” Shah says. “The framework allows for discussion that makes us all better.”