Is the Aviation Model Overplayed in Healthcare?
On August 5, the Sorry Works! Blog and linked in posted an offering asking “Aviation and Medical Errors…This Hand Being Overplayed?” The author, wrote that, “I seriously wonder if the whole approach of comparing/contrasting aviation safety versus medical safety is being overplayed and will have detrimental consequences? I worry how many docs and nurses are tired of hearing how wonderful pilots are and become jaded or resistant to all patient safety initiatives?…
These different fields are dealing with different “input.”
When “Sully” entered a cockpit he was always taking control of a ship that was expertly maintained by highly skilled mechanics. When a doctor gets a patient in his/her care, the ship isn’t always in the greatest shape because the mechanics – us – don’t eat right, don’t exercise enough, smoke and drink too much, don’t listen to doctor’s orders, etc, etc. I recently got myself into trouble with some patient safety advocates by suggesting there are “bad patients” and “bad families.” Never mind that these same patient safety advocates freely labeled doctors and nurses as “bad,” “sloppy,” “arrogant,” etc…how dare I say some patients and families are not so good?!? Again, medicine has different “input” versus aviation.
The fact that people who work in healthcare are flying the patient equivalent of broken planes (i.e. sick patients) only makes learning all of this more important, not less.
One of the barriers to patient safety is an attitude that argues that those in healthcare don’t have anything to learn from other industries because healthcare is so so different. Of course it is. That’s not the point. We all can learn from safety methodology no matter where it originates or in what setting it is successfully utilized. When I hear healthcare professionals insist that the aviation model is not relevant to healthcare because healthcare is so much more complex, I worry about the implicit competitiveness here. I don’t want to speak for Captain Sullenberger, who was kind enough to write the foreword for our book, but I think I am safe in saying that the first thought that entered his mind in the 3 minutes and 28 seconds he had to land his plane in the Hudson was not, “Oh, God, this could be so much worse. I could be a neurosurgeon.’
When recommending learning from the aviation safety model, no one is saying that pilots and flight attendants are so much better than physicians or nurses. They are not, which is why they are trained in safety methodologies over and over again throughout their entire careers. This recurrent teaching reminds them and us that they are fallible human beings who can and do make mistakes and thus need to learn everything they can in order to keep everyone safe.
I agree that people in healthcare are overplaying aviation as a possible role model for our system– not because it isn’t a good model, but because we keep harping on only certain aspects of aviation safety. I too become annoyed when someone mentions checklists–there are parts of healthcare that are “checklist-able” and parts that aren’t.
Where we have a long way to go in healthcare is recognizing that culture/behaviour/relationships can pretty much veto whatever safety process you would like to implement. The airline industry dealt with this using crew resource management (CRM)–while we may well not lift CRM directly from the cockpit to the ward, we should be lifting the concept that focusing on these issues is absolutely essential for us to improve.
By all means we should checklist, LEAN, PDSA etc. whatever process it makes sense to do these with, but we also must focus on how we work with each other. We keep looking for the easy fixes (process improvements) but these are only one part of the process.
To learn from aviation, we need to make sure that the deeper understanding of *why* it works in aviation is embedded in the translation to healthcare; moreover, aviation is simply one ‘high risk’ industry from which we might learn. There are many others where the same lessons apply. I’ve used the ‘motor racing pit stop’ example [1]
Dependence on the aviation model has in some way lead to a ‘Cargo Cult’ [2] where well meaning but poorly informed QI efforts (some of them lead by aviators) mimic the aviation model in healthcare, without really understanding how and why things work. For example, anyone who claims a checklist is a ‘simple piece of paper’ does not understand how they work – much like South Pacific Islanders building bamboo shapes that resemble the aircraft that once brought them riches. In promoting the ‘simple’ ideas from aviation, we’ve created something that looks and feels to the uninitiated like it should work, but hasn’t embedded the deeper understanding of the mechanism of effect.
The ‘aviation model’ is moot – what we really mean is that we need to translate what we’ve learned about human/system integration from a whole host of high-risk industries into healthcare. The science behind all this is called Human Factors (or Ergomomics). It’s lead to a huge wealth of information around how to avoid errors and generate optimal system performance by designing around human abilities and capabilities. Well before CRM, for example, cockpits and controls were being designed based on an understanding of things that go wrong [Atul Gawande uses the experience of early B17 bomber crashes to illustrate how important checklists are – conveniently omitting the fact that the flap and gear controls were redesigned]. Similarly, my own studies have suggested that delivering CRM style courses within a system that is broken (or even where task or role definition is poor) is useless.
I’ve been at the forefront of human factors research and development in healthcare for about 10 years – and have seen the positive and the negative influence of the aviation model – but still struggle to be taken serious (or have much job security) in the face of people who think a simple checklist or CRM training is all we need[3].
Refs:
[1] http://www.ncbi.nlm.nih.gov/pubmed/17474955
[2] p.8 in http://www.health.org.uk/media_manager/public/75/publications_pdfs/The%20problem%20of%20context%20in%20quality%20improvement%20-%20Dixon-Woods.pdf
[3] http://www.ncbi.nlm.nih.gov/pubmed/23592761
I do agree that not at all of Aviation Safety model can be applied to heathcare. But majority of Aviation Safety concepts can be easily done.
Let’s answer my question.
1. Do the pilot fly to the same airport , weather and traffic condition in everyday?
2. How about the mandatory annual medical exam for pilot , can it be implemented for doctors ? If not, next time pls. request for a highly experience captain with no record of medical exam and got a 50% ticket discount 🙂 I ve lost one of my patient with wrong report of fibroadenoma instead of invasive ductal cell CA from poor eyesight pathologist!!!
3. Crew Resource management training is talking about how we can effectively use non technical skill in routine daily life . Every airman must be trained and refresh annually. How about surgeon who always show his disruptive behavior in O.R. and no one dare to warn him when he is doing the wrong thing.
4. Standard phraseology A-Alfa B-Bravo , Not at all in healthcare have been using. Then P or B, M or N misspelling , How to pronounce digit with standard never says eleven thousand feet just says “one one thousand”
5. Checklist in Airlines is “done and check concept” unlike the time out in O.R. it’s looked like a cocktail mixing of briefing + procedure + checklist that’s why it does not work at all. Instead of Airbus “before start checklist” that 100% compliance and very effective.
6. Effective Communication course do we have it in all medical schools around the world?
These are just 1% of my questions comparing between 2 organization.
super response thank you so much