Look at How Safe [Fill in the Blank] Is by Bob Wachter

But is it as simple as that really?  Perhaps not. In the commentary that follows, Bob Wachter has a very different take on the airline analogy. Analogies are useful things, true, he argues. But perhaps not as useful as the cure-healthcare-by-adopting-model-posed-by- [ insert industry / EU member state here ] might have us believe. Who should you believe? That’s up to you. You’ll find more of Bob’s excellent commentary on quality and patient safety in the THCB archives and on his blog, Wachter’s World.

The rate of fatal domestic airline crashes has fallen by 65% in the past decade – from an amazingly low rate of one fatal accident in about 2 million departures in 1997, to a breathtakingly low rate of one in 4.5 million departures this year. Flying just keeps getting safer and safer.

Beginning with the 1999 Institute of Medicine report on medical errors, aviation has become the poster child for patient safety. In fact, it was an aviation analogy – the translation of the 44,000-98,000 deaths per year from medical errors into “the equivalent of a jumbo jet a day crashing” – that jumpstarted the patient safety field in the first place.

On the whole, I like the aviation analogy, because it energizes us and helps illustrate the need for certain safety-oriented practices, such as standardization, simplification, simulation, teamwork training, and effective reporting systems and regulations. It is also uniquely accessible: who would ever fly electively if a big plane went down every day in the U.S.? Yet hundreds of thousands of people check into hospitals and clinics electively daily.

But lately, I’ve sensed gathering pushback against the aviation analogy – as well as against analogies from other industries. “This has nothing to do with us,” I hear from colleagues sometimes. “Healthcare is so different.” And they’re partly right. For example, we have learned that dampening down authority gradients on a med-surg ward is orders of magnitude harder than doing so in a cockpit. Here’s why: to prevent another Tenerife disaster (the horrific 1977 runway incursion/collision of two 747s, ostensibly caused when the flight engineer – who suspected there was a large airplane blocking the way – felt uncomfortable speaking up to his boss, the pilot), aviation had to transform its culture.

Without minimizing the heavy lifting involved, the trick in aviation was getting two people – with similar training, expertise, social status, income, language and, usually, gender, each working inside a hermetically sealed cockpit – to feel comfortable raising concerns. Contrast this to a hospital ward, OR, or ICU, where the challenge may be to persuade a high school educated clerk to speak up to the chief of neurosurgery when she suspects (but isn’t sure) that something is wrong. This is a fundamentally different can of worms.

I continue to find analogies from other industries useful, but we must recognize their limitations. Simple solutions that worked so well in the [fill in the blank] industry often fail in healthcare because our workplace is like a dozen industries rolled into one. For example, a busy hospital and its workers may face these challenges:

  • How to move a part (like a pathology specimen) seamlessly down an assembly line, just like Toyota does.
  • How to get an important piece of data (like a discharge summary) from place to place, just like FedEx does.
  • How to make difficult, weighty decisions (like whether to do open up an abdomen) under conditions of overwhelming uncertainty, just like a field general or a business CEO does.
  • How to deal with major and only partly predictable changes in capacity needs (like when the “bus shows up” at 7 pm in the Emergency Department), like McDonalds does at lunchtime.
  • How to providing “expectation-surpassing” customer service (so that we ace our Press-Ganey survey), just like the Ritz Carlton or Nordstrom does.
  • How to innovate, both with processes and technologies (a consuming interest in an academic medical center like mine), just like Apple does.
  • How to teach wildly disparate learners (like the ones on my team when I’m ward attending), just like a high school teacher does (or would do, if her class included freshman, sophomores, juniors and seniors).

Think about it for a second. Can you conjure up another industry that confronts more than two or three of these challenges? I can’t. And not only are all these conditions present simultaneously in most healthcare organizations, there are times when a single doctor or nurse confronts all of them!

This complexity means that fixes drawn from other industries, as important as they are, can’t just be airlifted (no pun) into healthcare without substantial modification. They’ll inevitably fail. Yet there are graveyards filled with business leaders who stormed into the world of medicine, declared “I know how to fix you – just look at how I fixed XYZ industry!” – and left a couple of years later, shaking their head in bewilderment.

So let’s keep looking outside healthcare for solutions to our safety (and quality and efficiency and service) problems. But let’s also be prepared for the hard work of translating these insights into fixes that will work in our peculiar world.

2 replies »

  1. Hear, hear, Spike. I agree that the health care industry is perhaps the most complex of any – but that’s no excuse for not trying to find something that works to keep patients safe. Just repeating “that won’t work for us; we’re too complex” has retarded progress on this subject for years. It’s way past time for a change in attitude, especially on the part of those of us with M.D. after our names.
    When my medical school alma mater solicited comments on a proposed curriculum revision recently, I suggested incorporating education on system-wide (not individual) patient safety practices and formal quality improvement education into the first 2 years of the curriculum; followed by reinforcement on the wards during the last two. Of course, it’ll be the uneducated leading the educated on the wards, but it’ll be a start.

  2. You have a good point, but I don’t view these challenges as that unique to health care. Every industry has had a point where the old way simply stopped working. In health care, I’d say we’ve been there for years, but somehow it’s like there’s an expectation of failure that is keeping people from thinking outside the box to fix these problems. You have to redefine failure. Failure isn’t when someone dies, it’s when a process doesn’t happen correctly.
    If health care is so unique, how come checklists had the same amazing success in tested hospitals as they have had in airplanes? How come Lean and Six Sigma pilot programs have succeeded dramatically wherever they’ve been tried? Look at Virginia Mason, using the same process improvement techniques as used in the auto industry, the shipping industry, direct mail, etc., and having the same dramatic successes. I understand that health care is complex, but as long as thoughts like those in this post are the prevailing wisdom, it’s hard to see health care rising above “the soft bigotry of low expectations”.