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The origins of healthcare-aviation comparisons

Posted Oct 22 2013 1:32pm

by Jonathan H. Burroughs

Many people both understand and are frustrated by the seemingly endless comparisons between healthcare and the aviation industry .

Many claim such comparisons are short-sighted, superficial and inappropriate, whereas others feel the changes the airline industry had to make several decades ago are strikingly similar to those healthcare grapples with today.

Like healthcare, aviation was founded upon the cultural ideals of individual autonomy, hierarchy, and the pursuit of perfection by individuals dedicated to personal achievement and service. Airline captains, like military test pilots were considered the ultimate source of expertise, knowledge and judgment, and other members of the crew were considered subordinates whose role was to serve the leadership of their captain.

On March 27, 1977, the chief pilot, corporate vice president and director of safety at KLM Royal Dutch Airlines, Jacob Van Zanten, ran the landing gear of his Boeing 747-200 aircraft through the fuselage of a Pan American 747 during takeoff, causing 583 deaths on Tenerife Island off the coast of Portugal.

How did this happen? The results of a multinational aviation investigation team found the causes of the worst aviation disaster up until that time included:

  • Poor communication: There was a language barrier between ground control and the aircraft, and the KLM flight never received proper clearance to take off or depart.
  • Rushed procedures: The flight had been delayed significantly due to fog, weather and poor airport operations, and Captain Van Zanten was not going to wait for further messages.
  • Hierarchy: The first officer and navigation officer suspected another aircraft was on the runway but were intimidated when they attempted to communicate this to their captain and he disparaged their attempts to countermand his decision to take off.
  • Failure to follow operating procedures: The captain failed to perform three-way communication and confirm the control towers instruction not to take off.
  • Assumption that the captain’s perception of the situation was the correct one: This was despite other professionals who did not agree.

That horrific accident and followed by another a year later when a United Airlines flight ran out of fuel over Portland, Ore., changed the airline industry forever. It adopted the ideals of crew resource management (CRM), which United Airlines was the first to do in 1981. These ideals include:

  • Flattened hierarchy where everyone assumes responsibility for an optimum outcome while serving on interdisciplinary teams. The captain is still in charge of the flight but must take team members’ input into consideration when making decisions and respect other members’ specialized expertise.
  • Communication protocols that include pre-briefing, de-briefing and scripted communication when subordinates wish to express a concern.
  • Situational awareness that includes a broader perception of the entire environment and not merely the task at hand. This requires delegation to and trust in others who can focus on specialized issues at different points in time.
  • Flexibility and adaptabilityafter recognizing bad things happen when foundational perceptions turn out to be incorrect. Captain Van Zanten assumed the control tower and his two officers were incorrect and this locked him into fatal actions. Good leadership requires self-awareness and the willingness to question one’s beliefs, particularly when others perceive them differently.
  • Teamwork to ensure the final outcome is greater than the sum of the parts. Highly functional and interdependent teams are far more effective than even the finest experts in performing complex interdisciplinary tasks.

Many in the airline industry resisted these changes and even as late as 1988, most felt a few commercial aviation crashes a year was merely the cost of doing business. However, in 1989, the concept of zero accidents gained ground and up until the Asiana Airlines crash in San Francisco this year, there had not been another commercial aircraft fatality in U.S. airspace for the previous 11 years.

Flash forward to the early 1990s at Beth Israel Hospital in Boston, where a second-year obstetrical resident thought she saw significant decelerations on a fetal monitoring strip and called her attending who was sleep deprived, disagreed with her interpretation and refused to come in. Instead of going up her chain of command she acceded to her attending's judgment.

After the stillborn was delivered, management brought in the Federal Aviation Administration to train physicians and management in CRM to prevent similar errors in the future.

Healthcare is still undergoing the painful transition from individuals to teams, from independence to interdependence, from non-value added variation to only value added variation. This transition does not obviate the responsibility or accountability of physicians, nurses, management and staff from doing the right thing for their patients nor does it marginalize individual responsibility and accountability.

What it does underscore is the need to: standardize to excellence, work in interdisciplinary teams, respect those with expertise, communicate openly and clearly, develop situational awareness, and sublimate ego to mission. Pilots are permitted to circumvent check lists and not follow protocols when appropriate; the difference is today these exceptions are audited and discussed in retrospect to further refine judgment and operating procedures.

Jonathan H. Burroughs, MD, MBA, FACHE, FACPE is a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives. He also is president and CEO of The Burroughs Healthcare Consulting Network.

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