This guest blog post by Richard Corder, Certified in The Accountability Experience training by Linda Galindo, speaks to the lessons healthcare leaders can learn from other industries that are focused on mitigating risk, reducing harm and creating safe, accountable cultures…
The Story Of The Dreamliner
The stories have now been relegated to the back pages. “… Smoldering batteries forced safety regulators to ground Boeing’s new 787 Dreamliner jets.” This is a glimpse into the challenges that this aircraft and company seem to have been besieged by. The recent grounding of the fleet comes on the heels of other safety related incidents that while “typical” with a new plane have caused some concern given the rapid sequencing of events.
December 2012, a 787 headed from Houston to Newark NJ was forced to land in New Orleans after a warning light indicated that a generator had failed, Boeing later discovered that a faulty circuit board had resulted in a false reading. In Boston several weeks ago, a valve opened on the wing of a plane that caused 40 of the planes 35,000 gallons of fuel (0.1%) to leak onto the runway.
Why, you might ask, are these incidents garnering so much attention? Perhaps it is partly because Boeing has invested so much money in the development of this plane; it’s fair to say that much of the airlines non-military financial performance is riding on the success of the Dreamliner. With 800 of these approximately $206 million planes on order, Boeing is mindful of jeopardizing $164 trillion in top line revenue…
Perhaps, in the opinion of the public, the thought of a plane (especially a bright shiny new one) not working properly and possibly falling out of the sky is simply outrageous. And it is. Outrageous, heartbreaking and tragic to even imagine a fully loaded Boeing 787 dropping out of the sky with its 250 passengers and 6 crewmembers on board…
The Story Of Medical Mistakes
By the estimates made by the Institute of Medicine in early 2000, deaths from mistakes in healthcare are associated with the equivalent of one of these planes falling out of the sky every single day. The high estimate was of 98,000 people a year dying as a result of preventable harm and error.
What has been remarkable to me about the Boeing story, is not so much the incidents, not so much that the fuel leaked, or that the cockpit alarm went off or that it took forty minutes for a fire to be extinguished, what’s remarkable to me is that these are the stories, these are the headlines that we are reading and that the TV networks are carrying.
These “incidents”, for those of us who work in healthcare, are what we refer to as “near misses” and “good catches”. No one has died, no one has been injured, and no one has suffered anything more I suspect than a delay in getting to his or her destination. Oh, and some bruised pride and quarterly earnings impact for Boeing I expect.
When you dig a little deeper into one of these incidents, you hear the soft spoken female voice of the Boston-based air traffic controller telling the pilot of the Japan Airlines 787 that he must stop at the end of the runway; she is sending emergency vehicles out to deal with the fuel leak. She doesn’t have to argue, the conversation is calm, clear and concise, she stops the plane. There is no way that plane is leaving Boston, not on her watch. She owns stopping that plane; she is responsible for her behavior before she knows how it will all turn out. She is, by definition, personally accountable
In our hospitals, these “incidents”, these “near misses” rarely get reported internally; the associated press and the national evening news certainly don’t pick them up as front page stories.
If we are obsessed with safety, like the human factors focused airline industry, our near misses and our good catches would be enough for us to stop the line, stand back and work to develop safer systems.
I know that the analogy is not perfect, our clinicians and care givers are tending to the complex human system that we cannot treat like the machine that is a plane, that being said there are lessons to be learned.
So What Can Leaders Do?
Lead a culture where you model that it is safe to speak up and encourage people to call out near misses, report good catches and model the mindset and actions of being personally accountable.
Make it known that while clear roles and clarity around authority are important, everyone is personally empowered to speak up or call an unsafe or potentially unsafe behavior to the attention of their colleagues.
Use all meetings, from the board to the bedside, to tell stories of how a mistake was avoided and how, when things go wrong, you recovered.
When things do go wrong because they will, we are human beings caring for human beings, don’t point fingers and blame people. Own the outcome, work to learn from the failure, apologize, atone and remain open to feedback.
Adopt some of the human error mitigation systems that the airlines have embraced. First names only and the sterile cockpit rule require that people only address each other by their first names in the cockpit and that during specific times only conversations pertinent to flying the plane are permitted. We have a choice to hold ourselves to these relatively simple agreements in our operating rooms and exam rooms.
So yes, I wish my hospital was a Dreamliner. Because Dreamliner’s are not falling out of the sky, they are being stopped, checked, called back and inspected. We can publically tell the stories of the small voice of the air-traffic controller when she speaks up and gets the pilot to stop his plane, and the story of the cockpit alarm, that we suspect might be a false alarm but we divert anyway.
Why? Because these are peoples lives we are entrusted with, and planes falling out of the sky are no longer acceptable…