Aviation & Healthcare : Polish President Air Accident

Just finished watching an episode on Discovery Channel about aviation disaster in Poland, in which their President died.  The scenario looked so similar to errors in healthcare, about which I was reading today itself.  In that incident a Russian made plane crashed while landing at a Polish military airport.  It was flying low and brushed over trees and overturned and crashed before it could touch the runway.  It was foggy and the pilots were faced with very poor visibility.  Now, I will highlight the errors that were made on that flight

  1. Their altitude indicator was not working properly.  From the flight data recorder it was found that they were flying lower than what their instruments told.  It was found that as it was a military airport, its elevation above ground was not in plane’s database.  On top of that the pilot had deliberately set the elevation a bit higher, to avoid “nuisance” warning that go off when the plane is dangerously low.  A sure sign of over confidence by probably the best trained pilots.
  2. From the cockpit voice recorder they found that there was some unauthorized person in the cockpit.  Most likely it was some senior official as it was a VIP flight.  It could be concurred that that person was putting indirect pressure on the pilots, adding to their stress.
  3. Also, the captain of the plane was also doubling up as navigator, which added to his workload. 
  4. In addition to the altimeter, which was faultily set, the navigator also had radio altimeter.  Investigators wondered why the faulted when they had redundancy in the form of radio altimeter.  They later found that the plane encountered a valley on its approach to the runway, and then sudden elevation.  That fooled the pilots into believing that they were flying high when they were not.
  5. The investigators also wondered why the captain didn’t decide against landing in such weather, even thought it was his final call.  They wondered that he was under indirect pressure from officials in the cockpit.   Also, he has had a previous experience as a co-pilot, where the captain refused to land a VIP flight due to safety, and the latter was reprimanded for it.  Surely, this thing was lingering in his mind and didn’t want anything to affect his career.
  6. They wondered why the air traffic controller (ATC) at the airport didn’t warn the pilot against landing and suggest a go-around.  It was later found that the instruments at ATC weren’t working properly.  More importantly, even though ATC was acutely aware of the risks involved, they didn’t have the authority to divert the flight.  Had it been any other flight, they would have, but not the one with VIP onboard. 

Now coming to similarities with errors in healthcare industry.  This seems to be a classic case of “Swiss cheese” theory, where multiple errors, all happening at the same time and redundancies not working.  Interpreting each point individually,

  1. No matter how well trained and experiences a professional you are, you must not ignore the safety built into standard operating procedure.  Errors often happen by most experienced people, as less experienced exercise caution.
  2. This point emphasized the importance of stress-free environment at workplace.  Like aviation, efforts should be taken in hospitals such that staff does not get stressed.  Also, management should leave the technical stuff at the hands of the experts, and be in a more of a supportive role.
  3. Efforts should be made such that workload is evenly distributed among workforce.  In LEAN terminology, it is called leveling.
  4. It is again a case of Swiss cheese theory, where two holes were aligned and they contributed towards the accident.
  5. Clubbing point 5 & 6 together:  There was indirect pressure on both pilot and ATC.  Unlike the workers of Toyota Motor Co, who are empowered to stop the production line, they had no say in such a critical matter.

Ultimately, errors happen when redundancies built in go wrong and it is too late to act.

Dealing with B Team Members

Was reading Thom Mayer’s article in Healthcare Executive Sept/Oct 2010 edition about how to deal with B team members, and he makes important observations.  He quotes former CEO of Southwest Airlines, Herb Kelleher that it is more important to make employees happy, as that is how customers will be happy.  Carrying this point forward, the questions comes how to deal with Team B in your hospital.  By Team B, we mean those who are negative, reactive, constant complainers, and all that makes them underperformers. 

He uses the phrase “holding up the mirror” to describe the first step in dealing with such members.  In every likelihood they don’t even realize the importance of the actions.  The next step, which is counseling these members, is a real challenge.  The general approach is to begin the discussion with something positive, then give the bad news, and finally end the discussion with a good new.  It may should savvy and diplomatic, but the staff members walks out of the meeting confused.  The recommended approach is the decide beforehand what is to be conveyed, not to exchange pleasantries as it a business meeting and present facts.  This way the staff member will realize the seriousness of the meeting.  This meeting should be clear and concise, and should include attribute or behavior followed by Team A members.

In addition, such members should be buddied up with Team A members.  And lastly, leaders should have courage and conviction to replace B members who cannot make a transition to A. 

Developing a Culture-Based Workforce: Top Healthcare Workplaces Share Best Practices

ref: Developing a Culture-Based Workforce: Top Healthcare Workplaces Share Best Practices

Needless to say how important is it to have a positive work environment, and how it impacts patient experience.  Carrying forward from the previous article about how to move from culture of accountability to execution, here we talk about the essential component that is employee motivation.  There would be the five best practices to built “culturally united, team oriented employee base”.

  1. Establish an employee culture and hire based on fit:  It is relatively easy to articulate values and communicate among employees.  What is more important is believing in them and breathing them day-in and day-out.  Else, they’re mere slogans and rapidly fade away.  In same vain, there is no point in lecturing new hires during orientation, unless such a thing exists on ground.  Key is management is true belief it in, and then it propagates naturally.
  2. Encourage employee referrals: Yes, word of mouth publicity does help to propagate culture, but if done in excess it can be detrimental to work environment.  Care should be taken that referrals are not hired at the cost of best talent.  After all, there are other ways to communicate how current employee feel.  I’ve seen hospitals using their website quite effectively to convey positive statements from staff and patients.
  3. Developing profiles of successful employees:  Developing profile not only helps prospective employees, but also conveys the message to current one about what it takes to be successful and be recognized.  It is imperative that profiles are carefully selected, such that they convey the kind of values hospital wants to propagate.
  4. Engage current employee in the interview process:  This would be the next logical step once the hospitals values are clearly articulated, communicated and tested.  Once we have employees who truly believe in them, they can be asked to be part of the interview process.  That way they’ll be better able to hire those who can fit in.
  5. Keep culture as a priority past the hiring process:  Employee culture should not be restricted to interview process and orientation.  It rather be well past that, else new employee will become disillusioned.  That’s why it is all the more important to have the culture in place, well before we allow current employee to find their kind.

Random thoughts on patient safety & quality

Going about reading articles on patient safety and quality.  Here are few random thoughts

  • One of the articles states that organizations have patient safety officers who don’t have the vision to bring about change.  Was wondering what if organizations would ensure that such experts are clubbed together with leaders (managers/directors).  That will create an atmosphere where the technical stuff and ground situations are easily communicated between the experts and the frontline staff.
  • Was reading somewhere how a CEO created an atmosphere where hand-hygiene was part of the culture.  Not sure how that CEO implemented, but one of the things that needs to be done is that he/she should follow the same while visiting clinical areas.  It will convey a very positive message.  I know it is quite a daunting task considering the number of initiatives that need to be promoted.  But the management should at least follow those that are part of strategic focus. 

EMR: Pros and Cons

ref: Digital Records May Not Cut Health Costs, Study Cautions

Some silly study saying that digital records prompts physicians to order more tests, and hence does not help reduce costs.  Not going into why and how they’re wrong.  We all know that!

But one reader comment was indeed thought provoking and can be easily overlooked by big guys of the industry.  Here is how it goes

“All I know is that those with electronic spend all their time typing and looking at the computer and no time talking to or looking at me. I don’t know whether he has heard what I said or not. I now only go to doctors with old fashioned records.”

One more point highlighting the fact how healthcare is different from different industries.  Some non-healthcare consultant would have suggested that doctors type as they listen to their patients not realizing the nuances of the profession.  Doctors can pay full attention to their patient, and turn around and type as they do with paper.  It will take a few more minutes compared to type as you listen, but improves patient satisfaction/compliance many more times.  My only hope is the physicians in general don’t lose focus on this point.  I too will pay attention to this point the next time I visit my doctor. 

Integrated Healthcare Organizations–Part II

ref: Are Integrated Healthcare Organizations Right For Ontario?

A strong reason why IHOs are being suggested is because they are supposed to be more cost effective.  I’d go further and suggest that before we make them sit and talk, we should define how we would measure their success.  Specify the complete picture we would like to see, and in what way we would like it to be efficient. 

It has been argued that unlike LHINs one size fits all won’t work with IHOs.  Also, area such as GTA pose great problem in form of scale and complexity.  Apprehensions have been raised that the whole issue is very disruptive, and a more evolutionary approach needs to be taken.  The apprehensions are not unfounded as we have no major example to learn from.  I’d suggest that we should go along this route in a cautious manor and consolidating after each careful step.  Also, it should be left to organizations to join or not, or probably do at a later time.  In the sense, such integrated system should be allowed to evolve.  Also, with or without IHOs, a province wide EPR is a must to share info with everybody providing healthcare.  Once this is done, the providers will themselves have incentives to explore further avenues. 

I see no harm in IHOs being acute care hospital dominated, as hospitals are the natural choice.  And as has been rightly said, with right funding, measurement and accountability we will be able to achieve the kind of integration we want.  Further, they should try to integrate just the primary and home care.  A kind of working relationship can be worked out with LTC. 

Integrated Healthcare Organizations–Part I

Ref: Are Integrated Healthcare Organizations Right For Ontario?

Have just started reading that article, and there are a few things that come to mind.  The idea of integration is good, but so was LHIN.  The bottom line is no matter how good an idea is, it is of no use unless carefully brainstormed in detail.  I think in Ontario we have had enough of experience from our experiments to realize this thing.

It talks of combining acute care, primary care and home care into one organization.  First, will the organizations of this scale and complexity be really manageable?  In fact, we should first determine how to quantify success of these organizations.  We should first draw a complete picture, and then start planning backwards. 

Regarding integration itself, will there be an option where smaller organizations choose not to join a organization?  It is good to be part of a big system, but at the same time it will kill innovation.  Organizations who are doing well on their own will no longer have reason to excel.  In my opinion, there should be an option where small organizations keep a kind of working relationship with IHOs and other smaller organization.

Good part is that EMS will be part of this system, and municipal boundaries will no longer relevant.  Also, person availing the service don’t care which hospital they are sent to.  Regarding the number of IHOs, it would be a painstaking process to carve them out.  Each will be unique to its area, as further discussed in the article regarding GTA.