Wednesday, October 28, 2009

Health Care and Aviation: Zero Tolerance for Sub-Par Performance?

Some aviation-related events and conversations this week prompt this post.
Two pilots have their licenses revoked by the FAA for overflying the Minneapolis airport, being out of radio contact for more than an hour, and lacking situational awareness. No one was hurt. No alcohol or drugs were involved. By all accounts, the pilots are nice people without any previous disciplinary issues. Did the punishment fit the situation, where safety of passengers and flight crew was at risk? Yes. There’s no tolerance for certain behaviors in aviation.

Next week, our survey of disruptive behavior in health care will be published. Many of you contributed powerful anecdotes on the current state of our culture, and how we behave in stressful situations. What would be the response in the health care system to a physician throwing an object at a nurse, or operating on the wrong limb because a time-out wasn’t done? Do we have zero tolerance for certain behaviors in health care, or do we find a way to avoid confronting these dangerous situations?

In a discussion with a national leader of airline pilots last weekend, he pointed out that aviation realized about two decades ago that fatal accidents were occurring that were not equipment or technologic failures, but communication failures. In one incident, people died needlessly because a captain was not receptive to safety concerns of other pilots, flight attendants, or ground crew team members. He cited an example of a pilot who was “checklist driven” instead of listening to the more accurate analysis of his co-pilot and flight engineer regarding the relative risks in the situation they were dealing with. In the end, running out of fuel on approach was the risk that he wasn’t seeing on his checklist. In health care, checklists or “cookbook medicine” are valuable, but equally as important is the judgment and input of everyone on the health care team during the safety-critical events of patient care. We need both to be ultra safe.

My oldest son, a commercial pilot, says that the cockpit crew must verify altitude, airspeed, airport and runway at a certain point before landing. It’s a low risk situation, much like a timeout prior to a procedure, or two-person independent verification of a patient’s ID before administering blood or blood products. If something bad happens during the high risk situation (landing), the pilots can be forgiven if they carried out the pre-landing checklist diligently and seriously. But if they didn’t, there may not be any excuse for an adverse event on landing. In other words, the consequences for the professionals may not be related to the outcome.

Such is the case for the NWA pilots. It seems to me that we often tie the consequences to the outcomes in health care: “Yes, she called the nurse stupid, and threw a needle and syringe at her, but the patient wasn’t affected. We just have to understand that Dr. X is our biggest admitter.”
Finally, in a discussion with physicians at a medical executive committee/health system board retreat recently, one physician commented that it’s hard to see how what happens in the cockpit has any relationship to health care. He thought if a comparison was made to the entire aviation experience – ticketing, baggage handling, dealing with intoxicated, frail, or extremely obese passengers – it would be a better analogy to the variability we deal with in health care. I think that’s correct, but can’t stop thinking about how much better off we’d be in health care if the professionals highest in the hierarchy (physicians) encouraged questions from other professionals, and had zero tolerance for intimidating and threatening behaviors directed toward those lower in the hierarchy.

Tuesday, October 6, 2009

Celebrating the Passing of Time on a Train

When I was an oncology fellow many years ago, two other residents/fellows and their significant others joined my wife Janet and me for a ride on an old, narrow-gauge steam train that chugs up and down the Rockies on the Colorado-New Mexico border between Antonito, CO and Chama, NM. Every year since then, we’ve marked the passages of our professional and personal lives, and prepared for the transition from fall to winter, by renting a parlor car and caboose to enjoy the fall colors and catching up with friends and families. Moving at the pace of the century-old steam engine that pulls the train, conversations are unhurried.

Over the years, the group grew to include several more docs and their families. Children were born between each annual train trip. As they grew, the kids always grabbed seats in the cupola (the small windowed projection above the caboose). That made it easy for their parents to have adult conversations without having to keep a constant eye on the kids. My secret for getting to ride for awhile in the cupola with the youngsters was agreeing to tell stories featuring the Lone Ranger, Tonto -- and ghosts. I learned that saving the scariest part of a ghost story for the moment the train entered a tunnel was a surefire way to be invited back up to the cupola by the kids, year after year!

Now those kids are college students, just out of grad school, or starting their careers. They’re bringing their significant others to meet families and friends. Young physicians and their children have again become part of the annual fall ritual in the Rockies. It’s hard to get a seat in the cupola again.

The aspens were spectacular this year. The chill of early October at 10,000 feet, along with the autumnal light in the high country and the aroma of coal smoke, are familiar and memorable experiences every year. The appreciation of long-time friends, making new friends, sharing the stories of our lives – that’s what makes the train ride so special.