Hard Lessons – “Why Hospitals Should Fly”

“Why Hospitals Should Fly – The Ultimate Flight Plan to Patient Safety and Quality Care,” by John Nance

Captain Jacob van Zanten was at the top of the airline industry. Chief pilot of an airline. Corporate vice president. Director of safety and an unblemished flying record.

He was also responsible for the largest airline disaster in the history of aviation.

On March 27, 1977, Captain van Zanten’s KLM 747 collided with a Pan Am 747 on the Tenerife runway in the Canary Islands – killing 583 people. The disaster was caused by a myriad of factors – massive delays, bad weather, miscommunication between the KLM flight crew and the flight control tower. But the worst of the story is what happened – or didn’t happen – inside the KLM cockpit.

It’s a story every health system and hospital needs to hear, says John Nance, author of “Why Hospitals Should Fly – The Ultimate Flight Plan to Patient Safety and Quality Care”. The book recently won the 2009 Book of the Year award from the American College of Healthcare Executives.

“It is one of the most powerful teaching tools in healthcare,” says Nance. “The reason why is because the guy in the left seat was just like every good senior physician who has ever walked the earth. These are people who want to do the right thing, they are dedicated to healthcare, dedicated to their patients. And yet if someone can fail that badly in aviation, the crossover is very much the same.”

From the cockpit to the hospital floor
Nance is a former professional pilot and one of the founding members of the National Patient Safety Foundation. He has been speaking to the medical community about safety initiatives for nearly two decades, and more specifically to JHC readers, he spoke at Medline Industries’ “Prevention Above All” conference last fall.

In “Why Hospitals Should Fly,” Nance uses the aviation example to transition into a discussion of the disconnect between physicians, the nurses and staff that work around them, and the hospital itself. In the KLM cockpit, the disconnect turned tragic when neither the co-pilot or flight engineer interjected during the takeoff when certain danger signs presented themselves for fear of violating “the old-style pecking order that led to excessive deference to a captain,” as Nance puts it in his book. The subordinates could have prevented the crash, but were too afraid to appear to be challenging the captain’s authority. In the same way, oftentimes nurses and staff members are in a position to interject when a physician is about to make a mistake, but don’t, out of the same type of fear.

“The culture that [the captain] was brought up in had essentially given him less capability of being able to get the information he needed,” says Nance, who spoke with JHC recently. “Every physician has been there. Every nurse has been there in one form or another. That’s why these lessons are so powerful.”

If you want to fix patient safety in hospitals, you have to start with transforming the interaction between staff, Nance contends.

There is certainly a need for it. Even a decade after the infamous “To Err is Human Report,” published by the Institute of Medicine, hospitals are still just now waking up to the realization that the practices they have in place are not producing satisfactory patient safety outcomes. Look no further than CMS’ rules revisions putting the burden of payment for so-called “never events,” such as bed falls and MRSA infections, on the hospitals themselves. According to Nance’s numbers, “at least 10 percent of patients admitted to hospitals are injured by things going wrong in their care.”

The perfect model
So what does improving patient safety look like? To illustrate the best model of patient care, Nance found the perfect hospital – the fictional St. Michael’s Memorial, located in suburban Denver. Readers follow Dr. Will Jenkins, a visiting physician looking for answers as to why St. Michael’s Memorial has gone three years without any patient safety incidents. Dr. Jack Silverman, the CEO, walks him through St. Michael’s culture and how it differs from other hospitals and health systems. Here’s a hint: open communication.

In St. Michael’s, everything is transparent. Dr. Jenkins is given carte blanche access to the ER, OR, ICU, C suite and individual care givers to discover why St. Michael’s model is so successful at preventing errors. Nance is very clear in his writing, however, that St. Michael’s model does not eliminate human error. But the creation of Collegial Interactive Teams (CITs), where team members and the leader can work toward an acceptable plan of care with barrier-less communication, is “the only chance to keep human errors from hurting patients.”

“All of the lessons that Dr. Silverman is trying to get across in this book resonate because people have known this instinctively,” says Nance. “But there has never been a structure in American healthcare, which, in a systemic way, acknowledged the need for Collegial Interactive Teams, and knowing the role of horizontal hostility, for instance, in denigrating patient care and the opposite – collegiality – in elevating patient care. All these unspoken things that we know are true in medicine, we could not talk about transparently.”

Up to the challenge?
Nance’s tale amounts to an open forum on patient safety reform. It’s worthy reading for anyone that works in or with hospitals, and it will hopefully open up a more meaningful dialogue between all departments of hospitals – from nurses, doctors, administrators to the C suite – to collaborate instead of delegate an effective patient safety formula.

“Why haven’t health care leaders, so far, been up to the challenge?” asks Lucian L. Leape, M.D., in the introduction to the book. “In part, perhaps because they haven’t recognized that the problem is one of relationships, not of know-how or resources.”

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