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.

Chapter One

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."

"You're telling me the airlines don't even understand why they've been so successful?"

"They understood the tactics—the courses and training and principles of cooperating in the cockpit—but what they'd forgotten, or never realized, was that none of those tactics would have worked if they hadn't changed their culture. Now, Boeing understood it."

"Boeing?"

"Boeing took everything their airline customers knew about the tactics of creating teamwork and clear communication in the cockpit and combined it with a brilliant stroke of common sense to create a breakthrough example," Silverman explained. "In Boeing's case, the strategy was both incredibly simple and incredibly difficult, because it involved changing a hierarchical, hidebound culture that had evolved over nearly a century. There was real arrogance in the idea that aeronautical engineers were too good to dirty their hands by dealing directly with mere customers, or even with those who cut the metal to build the airplanes they designed. In many respects, those senior engineers were acting exactly the way we physicians act. But Boeing's leaders, and especially a gifted engineer and leader named Alan Mulally, crafted a new concept called "Working Together" to kickoff the design of a critical new jetliner that became the Boeing 777. Now, Working Together is similar to a thousand phrases we've used in health care, but Mulally made it the battle cry of cultural change, and he went for no less than a cultural renaissance. The whole approach was wildly opposite to the traditional way they'd done things, and it's wildly different from and almost assaultive to the way we've always done things in medicine. But I can tell you that it's the only method I've ever experienced that can take a gaggle of independent, ego-driven, mutually-suspicious professional humans and turn them into a real team truly dedicated to the same common purpose."

"Are you sure you're running a hospital here?" Jenkins laughed.

"Not like one you've ever experienced, I'll bet. For instance, Will, one of the things we do here is study every failure and near-miss to the point that all of us become truly eager to share our mistakes for the common good. And, while none of us like to dwell on our failures, we constantly discuss the fact that we owe it to those we've injured or killed in the past to never forget that we have a duty to fix the system that failed them. I imagine as a former CEO you've got a few sad stories of your own."

The memory of the disaster that had propelled Will here filled his mind for the briefest of moments, but it was enough to contract his stomach again. He pushed the feeling away and pulled out a small, silver object and gestured to it. "May I run my digital voice recorder? I don't want to miss a word of this."

Getting to his feet, Silverman nodded, well aware of his younger colleague's ashen expression and suspecting what had probably prompted it. After all, he thought to himself, Jenkins had been far too relentless in getting this appointment to be driven by mere academic interest.

"You can run the recorder, or even bring in a camera crew, but until you've spent some time watching us, you haven't a prayer of understanding how it works. You got the suggested schedule, right?"

"Yes. Spend the rest of today observing..."

"Well, tonight at least. First the ER, then some clinical settings. Jack Silverman's patented three-day course."

"And, if I wasn't serious enough to want to learn..."

"Right, you'd never put up with this curriculum. Weeds out the insincere." Will followed Silverman into the corridor, his mind unable to set aside the memory that had been triggered moments before. Never mind that years had passed, it was still fresh and painful and mortifying.

Never in his 16 years as a physician had Will Jenkins felt as helpless and depressed as he had on that terrible night in 2003. Of course, as a doctor, he'd lost patients before without knowing why, and as a CEO and administrator he'd presided over many more tragedies. But this one was different, and he had mishandled virtually every aspect of it.

For the three years immediately preceding that night—from the first day he'd been appointed CEO—he'd worked tirelessly and with growing confidence to build an entirely new era of quality and accountability into the suburban community hospital near Portland, Oregon. The earthshaking 1999 report of the Institute of Medicine had shocked him profoundly. The title of the IOM's seminal work was To Err is Human, and its premise nothing less than bringing the previously shunned subject of medical error into the glaring light of public and professional scrutiny. But it was the part of the report that said American hospitals were killing just under 100,000 patients annually from avoidable medical mistakes that had moved Will to face down his board to get the necessary money to start changing things. He had dived in fearlessly by hiring consultants, holding meetings, and even bringing in an energetic group of former fighter pilots to train his physicians in OR teamwork. He'd mandated the use of "time-outs" in the hospital's surgical suites (although the rumors persisted that the surgeons were ignoring the directive), and threatened to pull privileges for physicians who failed to attend his training sessions. He'd even weathered a furious lawsuit by one of the physician groups and forced a change in the medical bylaws to give him the unquestioned authority to throw out a physician who refused to comply, and he'd used much of his credibility with the board in the process. His staff members and even the charge nurses had been Six Sigmaed, Lean-Meaned, Studered, Joint Commissioned, trained in Toyota's methods, and lectured by a dizzying variety of experts. They'd filled notebooks with the six steps to this and the seven deadly problems to that, and his reports to the board of everyone's determination to "zero out" professional mistakes had been glowing and full of promise. It might be true, he'd told his board members, that up to 96,000 patients were being killed by mistakes in America's hospitals, but being killed by avoidable medical errors was no longer a probability at Memorial. And then the roof fell in, and despite all his efforts, yet another completely avoidable medical mistake in one terrible evening took the life of a young patient, garnered the undivided attention and excoriation of the media, and effectively canceled everything they'd accomplished. After two years of public shame, litigation, and a ruinous verdict against his hospital, he could bear it no longer. Will's embarrassed resignation had followed. It seemed the only honorable course of action, but it hurt to have had it accepted so quickly by the panicked board. Chastened and filled with self-doubt, he had packed up his wife and three kids and found a different state, doubting that he'd ever been competent to run a hospital again.

For years after, it haunted him, as did the obvious inability of the medical community to put a substantial dent in the death rates from medical mistakes that were clearly caused by a combination of human errors and flawed systems. The thought was always with him that somehow he'd missed something in applying all the accepted solutions at his former hospital. Even as he resumed an uninteresting private practice, he found himself frequenting the nearest medical library, determined to figure out how he had failed.

The research left him amazed at how many thousands of hospital leaders across the nation had apparently tried to handle the challenges of medical mistakes the same way he had, and with the same disheartening results. Patient safety, he realized belatedly, had been treated like a specific disease for which a specific vaccine could be formulated. But by 2005, two things had become painfully apparent. Despite six long years of sound and fury in health care about the emergency need to improve patient safety, just as many patients seemed to be dying as the result of medical mistakes. Equally disheartening, many uncounted others had lost significant quality of life to wrong-site disasters, unnecessary surgeries, and a horror-writer's laundry list of other heartrending human tragedies. He searched for but could never find the evidence that would suggest that the mass of American hospitals had changed for the better, though he heard rumors from time to time about various institutions that were taking maverick action and making significant inroads. The field was awash with hospital executives just as puzzled and frustrated as he, all of them wondering why the "fixes" they tried had barely made a dent in the unconscionable rate of accidental deaths and injuries. Yet month after month physicians were still cutting on the wrong appendage or the wrong patient, good nurses were still grabbing lethal doses of the wrong medications, and across the nation many of the procedures, such as surgical "time-outs" and other double-checking procedures were failing from lack of standardization.

If there were a "magic bullet" to use on the specter of medical error, Will had lost faith in its existence, until the small article about a tiny Denver area hospital caught his attention.

It was a nondescript facility called St. Michael's Memorial, the writer said, and it was being hailed as providing a true glimmer of light in an otherwise dark landscape of poor progress. Apparently, where others were failing wholesale across the nation, St. Michael's was succeeding by standing routine medical expectations on their head. It wasn't the only hospital to show patient safety improvement in the nation by any means, but St. Michael's did seem to be the only institution to have so totally altered the model and the ethos of a modern hospital that it was turning heads.

The author of the article had been amazed at the unheard-of attitude that no matter what else they did to minimize error, every procedure, diagnosis, test, or other professional interaction with their patients at St. Michael's was still presumed to have at least a 50-50 chance of going wrong. "Here," she wrote, "...are the best and the brightest doctors and nurses not only admitting they are capable of making life-threatening mistakes, they've created an entirely new culture that routinely anticipates such mistakes, and thereby catches life-threatening mistakes others routinely miss." If there was a precedent for such a complete overhaul in thinking, Will had never encountered it.

In addition, St. Michael's seemed to have created an entirely new definition of what "teamwork" really meant. "The trick," its CEO, who was also a physician, had been quoted as saying, "is understanding that only a special type of teamwork and camaraderie can catch in time the types of medical errors a hospital will always generate."

"Catch," not "prevent." The shift in emphasis practically screamed at him from the page, all but mocking the fact that all his efforts as a CEO had centered on prevention. His operative assumption had been that once safety system problems were repaired, errors didn't need to be anticipated because they simply weren't going to happen. The last quote had rung a bell in his head. "In other words," Silverman had said, "what we can accomplish as a team of mutually-respectful and supportive colleagues checking one another for the common good of keeping our patients safe from unnecessary harm we could never accomplish working alone."

Will had called Silverman that very afternoon, and now, as he pulled himself from the memory, he saw the senior physician stopping in front of a double-door entry to the emergency department.

"Okay, here's the deal. I'm going to introduce you to the ER staff, and I'm going to get back to my day. What I want you to do is go back to your hotel, have dinner, read some things I've got for you in this envelope, and get back here at 8 p.m. and stay until 1 a.m. I want you to observe, ask questions, take notes, then get some sleep and meet me for a very early breakfast at 7 tomorrow, ready to tell me what you saw and what it means."

"Sounds like a good plan."

Silverman pushed at the door and stopped, hesitating as he watched Will's face. "You remember the bronze bust of our founder I showed you a minute ago as we passed the lobby? The late Dr. Martin, one of the pioneers of emergency medicine?"

"Yes."

"He's our equivalent of Captain Jacob van Zanten."

"Excuse me?

"The best and the brightest, and yet he was still all too human. You ever hear of a place called Tenerife and the world's deadliest airline accident that happened there in '77?"

Will was nodding now, embarrassed to have forgotten the name.

"Yes. I've...studied it."

"Well, Dr. Martin had his Tenerife right here in the early '70s, and it killed him. The story is in that folder. Essentially, it was a wrong-site surgery that so devastated him he left practice and died a year later."

"You knew him, then?"

"He's the reason I carry a stethoscope. He was my grandfather."