Six Lessons from Beyond

There's no better place to talk quality and innovation than the hallowed halls of Harvard University. I've spent the last three days on the Cambridge, MA, campus attending the annual Quality Colloquium, and Tuesday I listened to a session about what hospitals can learn about quality and safety from other industries.

This panel had four speakers, and all but one had experience in aviation, an industry which, like healthcare, was once plagued by safety issues and distrust from the public. The panelists shared how the industry went from one with dismal safety statistics in the 1950s—almost three quarters of its accidents were caused by human error—to one that has made safety its No. 1 priority. I'll share six key takeaways from the afternoon's discussion.

• Know the mind's shortcuts. Jim Bouey, former director of safety and airworthiness for Boeing Commercial airplanes, said the airline industry recognized that the human brain works in pieces. That's why the Federal Aviation Administration requires that cockpit instruments have standard shapes and locations. For example, the landing gear control knob is always round, while the flap control knob is always square. "We try and take advantage of how the mind works and reinforce what conclusion is going to be drawn," Bouey said. "We've made sure that instruments are not interchangeable or easily confused."
• Have a fail-safe. "Assume that no matter what you do, something or someone will fail," Bouey said. He pointed to examples of potential disasters in the airline industry: an oxygen tank blowing out the side of an aircraft, an engine failing, or damage from hail. All of these instances were unexpected, but because the aircraft was designed to be fail-safe, in each case, the flight was able to land safely. "You can't train your way out of a potentially catastrophic hazard," Bouey said, but by having fail-safes in place, you can make sure that even when a disaster does occur, damage is minimal.
• Make the invisible visible. William Hamman, MD, MPH, who is a captain with United Airlines, a professor at Western Michigan University's College of Aviation, and a cardiovascular surgeon, explained how using simulation techniques can help bring a hospital's quality and patient safety challenges to light. He played a video of a simulation done at a hospital emergency department, where the staff was working on an infant patient who had been thrown from a vehicle while strapped in her car seat. The video showed the interaction between ED, pediatrics, and trauma staff and showed inconsistencies and process failures as the staff was tending to the patient. After the simulation was over, everyone involved gathered in a room together to watch themselves on film and talk about what they found. One major problem discovered during this exercise was the availability of a CT for emergency department patients, especially if the trauma department also needed the service for a patient. "And this, I might add, is a Baldrige Award-winning hospital," Hamman said. It is discoveries like this, Hamman said, that can help hospitals deliver better healthcare.
• Work smarter, not harder. When a company's—or hospital's—executives aren't seeing the performance they desire, it's tempting for them to issue an order telling employees to work harder, said John Carroll, professor of behavior and policy sciences at the Massachusetts Institute of Technology's Sloan School of Management. "Things will get better for a little while, but eventually, your good people will leave, and those who replace them aren't as good," he said. "Instead, work smarter. It may mean for a time that the organization gets worse. But you'll get through it. It will be tempting to go back to 'work harder,' but if you do, all of these nice things you've been implementing will go away." In other words, progress takes time—maybe six months, maybe two years—but improvements are worth waiting for.
• Identify your organization's culture strengths, and use them to develop new ones. "It's hard to change a culture by saying, 'let's change the culture,'" Carroll said. "It's a tough way to get things done." Instead, he says, identify what culture strengths your organization has and "tilt" them. An example is the Millstone Nuclear Power Station in Waterford, CT. The station went through some tough times, and was even shut down for a period of time, Carroll said, but its leaders recognized that its culture deeply valued excellence, professional integrity, and safety. They were able to use these three cultural strengths to introduce two new ones, mutual respect and openness, he said. Instead of "Excellent managers have no problems," the message became, "Excellent managers want to hear about problems and surprises to prevent more serious problems."
• Share stories. When there is a safety incident with an F-18 military plane, a report is prepared outlining what happened, what mistakes were made, and what will be done in the future to prevent these mistakes, said Commander Ken Green, DMD, a senior healthcare analyst for the Bureau of Medicine and Surgery, United States Navy. That report is sent to everyone in the world who flies an F-18 plane. "But if there's an incident at Mass General Hospital, it doesn't mean that Boston [Medical Center] or Beth Israel Deaconess know about it," Green said, "unless it's on the front page of The Boston Globe, or spread by word of mouth."

It's hard sometimes to think outside of the things we do every day, but these six ideas certainly give a lot to think about. I'm at the Quality Colloquium's closing sessions today, and I expect that the conference will offer more ideas to ponder as it comes to an end.