As many of you know, last week I participated with Tulane University and The American Hospital Association in New Orleans in a TeamSTEPPS course or Team Strategies and Tools to Enhance Performance and Safety Course. The attendance was excellent and we shared far too many stories of avoidable harm in healthcare; actual patient stories related to some form of failure whether systems related, environmental, human or culture. Everyone considered the stories of harm disturbing, and yet motivating as a symbol of change with a renewed vow to improve healthcare quality outcomes.
During my flight I shared in a enlightening conversation with my passenger partner named "Ron". I truly enjoyed the dialogue and found Ron to be transparent in his communication and inquisitive in nature. Once I found out that Ron was a retired aviation pilot with 41 years of experience under his belt it was game on to discuss quality and safety. There was no holding me back and regretfully far less flight time to explore his full perceptions related to healthcare.
We discussed Crew Resource Management in the "early" days of its birth and application to healthcare. Ron described the level of commitment to safety by the airline industry, noting "the airlines knew everything about the pilots, when they slept, how many hours they worked, what they ate, their emotional, physical and mental state". He added that when there was the slightest hint of an error, it was immediately investigated, discussed and action plans implemented with all involved to ensure it would not occur again. He leaned over to me and looked me straight in the eye and asked with the most sober tone, "why is it not this way in healthcare?" I reluctantly nodded and said yes, we are far behind the curve in patient safety, but we are catching up with the airline industry and often make the comparison to Crew Resource Management. Ron shared several pearls of wisdom with me that can be applied to healthcare, for example if the aircraft mechanic is using 10 wrenches, there had better be 10 wrenches remaining when he is done repairing the aircraft, otherwise a foreign object in motion would be a catastrophic safety issue. The flight would be halted, and an alternate aircraft would be readied. This reminded me of perioperative sentinel events, and specifically the surgical count; do we have the same level of commitment to the surgical count and fully comprehend the untoward critical consequences of a retained foreign body? Does the surgical team feel empowered to "stop the line", similarly to the airline in stopping flight?
In terms of post event debriefings, are we consistent in our approach to debriefings? Do we conduct immediate post event debriefings that are standardized, reviewed and then actually apply the lessons learned. Lastly, do we monitor and measure for improvement, and are the changes sustainable? When was the last time an organization's leadership or the governing board went back a year prior and asked the hard question, "are we confident that the loop is closed on this safety event?"
I believe we have to step back and also consider the patient's perception of healthcare quality, and ask ourselves "does the patient feel safe in my healthcare organization". I can assure you that Ron has concerns about the lack of rigor in safety systems in healthcare, and he is not alone in his perception. The next step is to evaluate your current, and desired state related to healthcare quality outcomes, and previous risk events and then consider the following:
Would I wholeheartedly trust my organization to keep my family member safe throughout the healthcare continuum?
Who is accountable to keeping my family and patients safe?
What is the vision for healthcare quality outcomes for my family member?
What needs to change?
What next steps need to be prioritized to make this change?
Who will take the lead in working with the teams to make this change?
When you have been looking through the same lens, complacency and opportunity are hard to put in perspective. As the flock of birds fly together in alignment, streamlining the path, what would it look like for healthcare to follow the same mental model as the airline industry; could truly two birds of a feather flock together in safety?
To gain your fresh new perspective through the Restoration Healthcare Design Model, email firstname.lastname@example.org for a free initial culture of safety assessment.