Mark's note: I am thrilled to be able to bring you this guest post from my friend and fellow lean healthcare author
At the 10th Annual HIMSS conference in Atlanta on March 4, Captain Chesley B. “Sully” Sullenberger, who famously landed his crippled Airbus on the Hudson River on January 15, 2009, described the lessons that medicine has to learn from aviation safety. In his address, Sully described the three key safety areas that have helped transform aviation safety over the last 30 years, but from which healthcare has not yet benefited. At several points in the address, Sullenberger also noted the congruence between these three key points and Lean philosophy and practice.
Briefly, the three requirements for a safety revolution are:
1. A national, non-punitive, independent incident reporting system. Any crew member may report any problem, potential or actual error to an independent agency – only one – and will be assured of a response and action. Lessons learned from this Aviation Safety Reporting System (ASRS) are disseminated far and wide to help others avoid the same problems.
Captain Sullenberger pointed to medicine's chaotic patchwork of reporting mechanisms, some of which generate sanctions for the reporter, and heartily recommended an ASRS-like approach to reporting. Sullenberger points out that the ASRS is “much more than a reporting system: it's a rich and continuous source of data that constantly informs our procedures and training.” He called for such a system to be both manageable (very simple, user-friendly) and well-managed. (Lean designers, take note!)
2. Standardized work, and crew resource management (CRM). A safety expert long before the defining incident on the Hudson, Sullenberger was one of the first to instruct US Airways pilots in the 1980s in CRM – training that increases crews' effectiveness by allowing them to share the responsibility for a successful outcome. CRM flattens the hierarchy. It makes every crew member effective leaders and teammates, better communicators, decision makers, and risk managers.
Sullenberger pointedly noted the analogy of “captain's authority” and “physician's autonomy.” Sullenberger described the bad old days of aviation, when captains were often cowboys or gods. But that attitude was finally dismantled when, through hard data, CRM showed that when pilots yielded some of their false “authority,” they became much more effective leaders. While many physicians naturally embrace such a leadership style, many cling to outmoded power hierarchies. CRM, a powerful leadership tool, should be part of routine and recurrent training for all healthcare workers and clinicians.
As for standardized work, Sullenberger pointed out that, while aviation has many complex systems, medicine has a lot more – and relying on fallible human memory to do the right thing every time is just “untenable.” He said, “If you think you're infallible, you're kidding yourself.”
Hence, the checklist.
Sullenberger noted that the checklist is not a laundry list of “to do” items, but a way to make sure critical items get done every time, a way to create effective discipline, teamwork, and the behaviors that go along with it.
Far from making participants into robots, a checklist paradoxically creates the flexibility to deal with the unexpected, as he and First Officer Jeffrey Skiles faced that January day. “The checklist,” said Sullenberger, “promotes teamwork, creates a shared sense of responsibility for the outcome, formalizes best practices, encourages two-way communication, and requires effective leadership and followership. Who knew a piece of paper could do all that? “
3. Culture change. In aviation or patient safety, the organizational culture has to support safety as a core business function, with all levels of management, and ultimately every employee, must be accountable for achieving the highest levels of safety. Although in this tough economic climate, it may be tempting to say that safety is “too expensive,” Sullenberger cited example after example where failures, errors, and mistakes were far more costly than getting it right the first time. Viewing the occasional disaster as “inevitable” is no longer acceptable. Saving lives, he said, will save money.
Sullenberger acknowledged the usual objections to drawing parallels between aviation and health care. Planes may not be as “sick” as patients, and medicine deals with more uncertainty. However, aviation deals with more uncertainty than is generally recognized.
For example, he said, nobody could have predicted that his Airbus would hit a flock of geese 100 seconds after takeoff, giving the crew about three and a half minutes until “touchdown”…in the Hudson River. It took all of the training, crew resource management, standardized practices and discipline of every crew member to deal with that unexpected event and bring it to such a successful outcome. To those who doubt the parallel between aviation safety and medical safety, he said, “Patient selection simply does not explain away all – or even most – of the differences between the outcomes in my domain and yours.”
“After seventy-five years,” said Sullenberger in closing, “we [in aviation] have benefited from lessons learned at great cost, bought in blood – lessons that we now offer up to the medical profession for the taking.”
The question is this: Is anyone listening?
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This is a timely and helpful posting to your Lean Blog, Mark. I have been in Chicago these past 4 days at the American College of Healthcare Executives (ACHE) annual congress meeting. The good news – there were several presentations on this and related topics (more so than in past years). One in particular that cited Captain Sullenberger’s actions and also his background that prepared him on the day he needed to make the decision to land that plane on the Hudson River. The bad news – of the 5000+ Congress attendees, there were only about 100 to hear this particular presentation on high reliability organizing (which health care needs to learn about). There are many things that compete for senior leadership’s time and attention, and patient safety gets some of that attention, but it is not enough to truly transform healthcare. I see it every day in my work, and the current work for healthcare reform on a national political level only adds to the list of competing priorities by folks “in the trenches”. The primary topic in almost every hospital board room and C-Suite discussion is about “operating margin”, not creating a culture of high reliability and safety at the bedside. I said “almost” every hospital, because I’m a “glass is half full” kind of guy. The HRO presentation also cited a recent article featuring Dr. John Toussaint from Thedacare and other leaders in lean thinking. This line (attributed to Dr. Toussaint) was highlighted, “The ability to create lasting improvement improvement in patient care while reducing waste and managing costs has required nothing short of a cultural upheaval.”
.-= Mike Stoecklein ´s last blog ..More Thoughts on Innovation =-.
From an old friend on Facebook:
“Great blog. Education has also studied aviation for ways to improve success rates (especially in poorly-performing, highly disadvantaged schools). The idea is that, like in airline safety, we cannot afford to fail these students. The same principles noted here are applied to schools as organizations (well, in theory). I think this is a really fruitful way to think about school quality…wish it were more than just theory for most schools.
HROs – high reliability organizations. That’s the phrase I couldn’t remember. Schools should be HROs, much like the airline industry. Interesting idea.”
More data to back up what you’re saying, Mike:
http://runningahospital.blogspot.com/2010/03/still-missing-boat.html
From Paul Levy:
“You might expect that ranking of quality and safety would have risen over the past several years. But there was a major disappointment in 2009, as its place was lowered substantially.”
GREAT stuff, Mark and Naida. I see many parallels between the culture of the airlines and the culture of hospitals. We need to work to turn the tide and make standardized work the rule rather than the exception in healthcare.
[…] Captain Sully talks about Lean and Healthcare Safety dal Lean Blog, guest post di Naida Grunden: Sicurezza aerea spiegata da capitano Sully (Hudson River Miracle) e applicabile in tutti i settori: sanità , industria o ovunque altro. Si parla dell’importanza della condivisione delle procedure di sicurezza, del significato delle checklist e del lavoro standardizzato (traduzione automatica) […]
Sorry I’m so far behind in commenting here Mark… I’ll simply invoke one of my 5 plebe responses, “No excuse sir.”
As to an ASRS-type reporting system, AHRQ has been designating Patient Safety Organizations for over a year now with the intent of providing such a system. PSO’s fall well short of ASRS, but they’re a start. Lawsuits, shame, and blame are difficult to shed.
There is no question that lean and CRM are absolutely necessary in healthcare. Standardized workplace, standardized work, standardized teamwork is simply better.
Culture change: as you and I have discussed several times, doing is becoming. The change to a safety first culture is achieved by safety first actions, or standardized best practices.
The good news is that yes, people are listening. I think that Dr. Don Berwick at CMS will help, and Drs. Gawande and Pronovost are no longer lone voices crying in the wilderness. They are part of a growing chorus calling for greater structure and mandatory compliance with best practices.
Keep the faith!
[…] Guest Post: Captain Sully Talks about Lean and Healthcare Safety […]