The role of the AMM is to maintain a watch for error producing behaviors. This is a person who has a good situational awareness and familiarity with all the roles and responsibilities in the room.  They of course will have their own duties; so how do we safely add more?

In aviation there is the Pilot Flying (PF) and the Pilot Monitoring (PM). The PM has responsibilities and tasks that need to be accomplished as the non-flying pilot yet their designated role as PM requires them to go outside their duties to maintain an awareness of the overall state of the flight.  The frequency and intensity of the monitoring is based on the phase of flight and the vulnerability to errors.  Takeoff and landing are very vulnerable areas so the frequency and intensity are very high.  Cruise on autopilot at altitude allows low frequency low intensity monitoring.

There are two distinct monitoring behaviors, active and passive.  We are all familiar with passive monitoring, we are just “along for the ride”.  We watch the things going on around us as a spectator and we react, after the fact, to what we have observed.  Active monitoring is very different.  We observe our environment and the actions occurring based on a plan of action. We compare what is occurring to what we expected to occur and evaluate any differences within the scope of standard practice and safe outcome.  We have all probably experienced active monitoring with poor execution and just didn’t realize it! Consider the “back seat driver”.  They are constantly driving the car from their seat and have no qualms about directing what should be done next.  The problem, is, they have their own standards and procedures which may not be safe, standard or appropriate. In addition, the guidance is usually delivered very poorly!   What they are doing, however, is thinking ahead of the car. What would they do, what would happen if this or that is done, what is the faster way, the shorter way, and so on.

What would that ride have been like had the driver explained the exact route and planned speeds and other details of the trip. First, the passenger would have had the opportunity to share their knowledge of short cuts, delays, or speed traps before ever departing. That in and of itself would reduce the volume of unwanted or unnecessary discourse during the trip. It also would have offered valuable information so the driver might alter their plans for a better outcome.  Now the passenger will be watching to be sure the driver does what they said they would do since there is a defined expectation.

That is the foundational essence of Monitoring, having a plan. If there is no plan, then the best observer is only a back seat driver reacting rather than evaluating.  Sharing the plan in advance creates what is called the “shared mental model”, everyone in the event has the same expectation of process and behavior.  This is commonality of expectation is critical because it allows for immediate identification of deviations from the plan.  In developing the plan, it is important to have the greatest input possible to insure the plan covers all possible requirements.  In aviation it is called gathering “untainted” input.  The Captain, will ask the crew what they see as the problem, or what options they think are appropriate, before offering his own plan.  The Captain will take all the best ideas from the crew and integrate them into his or her plan.  This is part of good Crew Resource Management (CRM).  Your team is a resource with vast experience and different perspectives. You must access that value to the greatest extent possible.

Before we go further it needs to be understood that what we are discussing is situational.  As we spoke earlier about phases of flight, so too, there are phases in any medical procedure.  The time available and criticality of response will dictate how much planning is available. So in a critical event, the basis for active monitoring is standardization and team continuity which will be addressed in another post.