Excerpt: 'Why Hospitals Should Fly'

April 13, 2009 — -- Aviation safety expert John Nance believes medical care could learn a lot from the aviation industry when it comes to safety. And that serves as the thesis of his new book "Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care."

He describes new methods for supporting front-line hospital staff in providing safe, high-quality care for patients.

Read an excerpt of "Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care" below.

The 240-bed not-for-profit hospital hardly looked like the site of a revolution, quiet or otherwise. But the praise that had drawn Dr. Will Jenkins to this suburb of Denver, Colorado, had been unequivocal. St. Michael's, he was told, was the locus of a renaissance.

Designed in the '50s, he concluded, noting the green metal trim of the exterior as he turned into the parking lot. But if it was pedestrian on the outside, somehow on the inside the staff and leadership of St. Michael's Memorial had managed a miracle: three years with no sentinel events, no patient safety incidents, patient and staff satisfaction scores off the chart on the high side, and a mortality rate so low it was attracting a flood of visitors from the far corners of health care.

Will parked the rental car and killed the engine as he looked at the ordinary brick and mortar exterior, squat and undistinguished under the cobalt blue canopy of a June sky. To the west, the front range of the Rockies stood high and imposing like a frosted pastry, still covered with a mantle of late spring snow. He'd barely noticed the snow during the drive from the airport, so intent was his concentration on the telephone exchange that had lured him here.

As promised, Dr. Jack Silverman, the administrator, was waiting for him in the lobby with the no-nonsense air of a busy surgeon. Silverman led the way to his office and plopped himself behind the desk, fixing his medical visitor with a penetrating gaze as Will Jenkins settled in the offered chair.

"Will," he began, "I'm aware that what we've done here is so unusual a growing tide of people want to come study us to death, but frankly, I don't have much time to spend explaining it. Over the next three days I'll spend some time showing you how different our culture is and how we figured it out, but the rest is up to you. Now, you and I are very much alike in that we're two doctors who've gravitated over time into administration, but we're still clinicians at heart, and fixing things—especially patients—is a shared passion. So I think I know what you're after, and I've prepared a reading list for you, plus a folder full of internal papers and explanations. You'll also have a chance to meet and talk with some of our key people, but if you want to get the same results in another hospital, you'll have to start with your own massive culture change."

"I understand," Jenkins answered.

"No, I doubt you do," Silverman said as he came forward, his elbows on the cluttered desk. "Now, this is where we differ in terms of experience. No offense intended, Will, but I doubt that you or even 5 percent of the doctors and hospital leaders out there have the ability to speak the same language we now speak. Here's the problem: everyone who comes here thinks they can just cherry-pick a few of the changed attitudes they observe, drop them into a business-as-usual hospital model, and all will be well, but that doesn't even begin to work. In fact, there's no way I could overemphasize how important a point this is: What we've accomplished here cannot be duplicated by just putting some of our programs in place. What's required is a complete reprogramming of the medical delivery culture. And I do mean a complete cultural overhaul."

"Well, I do understand that the central element of your success was the adoption of the aviation model," Jenkins said

Silverman began with a chuckle that rose to a full laugh as he shook his head. "Yes, the aviation model is the key to the same extent that intubation is the key to a heart-lung transplant—a required, pivotal component, true, but only part of the story. Will, those great procedural things from aviation are just the tip of the iceberg. CRM, for instance—crew resource management—is an incredibly effective way of getting leaders to employ and listen to subordinates as real team members. It revolutionized the airline cockpit by getting rid of the unresponsive, maverick captains who refused to listen to anyone, and it's a principle that's helped us considerably here. But the real brilliance of what aerospace has discovered about human safety systems comes more from a subtle understanding of how to transform an imperfect, mistake-ridden, high-risk human culture into a culture of colleagues who actually can achieve near perfect safety.

"Perfect safety, by the way, doesn't mean eliminating all mistakes. It means structuring a system that expects and safely deals with mistakes. That's the essence of a high reliability organization. The kicker is that even though they discovered it and pioneered the process of taking a dangerous enterprise to HRO status, few aviation leaders even today fully understand how they've achieved such incredible levels of safety. By contrast, most major healthcare leaders do understand it, even though we have yet to achieve HRO status. There's an excellent paper out about that very point I've got for you in the packet.2 But back to the airline leaders. It was almost tragic/comic, when I began this quest, because I started by sitting down with several airline chairmen, only to find that not one of them really understood even the basics of the human revolution that has made their industry so amazingly safe. I had to do some very deep research of my own to learn how to crack the code. Once I realized that safety and quality depend on having unified teams of like-minded people willing to put all normal human and professional differences aside to achieve a common goal, the theory began to come together. Applying that theory and actually changing us was a different story, of course. That was and is a matter of hard and sustained work built around the clearly stated common goal that everything we do here is done for the best interests of the patient."