Aviation and Health Care: Quality and Safety Systems

Aviation and health care have much in common. Both fields are extremely complex, requiring that highly trained personnel function ably under considerable stress. In both, human beings are entrusted with the safety of others, and the available literature is replete with evidence that human factors cause the vast majority of harmful mistakes.

As in aviation before the advent of CRM, the healthcare system is grappling with its own significant gap. Despite the best intentions and efforts of all concerned, and the staggering sums of money spent, an acknowledged quality gap — a "quality chasm" — persists.

For health care, the quality problem is compounded by spiraling costs. Healthcare decision-makers must somehow find a way to simultaneously improve quality and reduce costs in today’s volatile economy. See, for example:

1. Closing the Quality Gap: The Role and Importance of “True Benchmarking.” The MCM Group, February 2005, 1. www.themcmgroup.com/PDFs/Closing_the_Qualty_Gap.pdf (accessed January 14, 2009).
   
2. Agency for Healthcare Research and Quality (AHRQ). Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 1. Rockville, MD: U.S. Department of Health and Human Services; 2004. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/qualgap1/qualgap1.pdf.
   
3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

As a practical matter, the debate has ended about how to best attack health care’s quality/cost conundrum. According to the overwhelming consensus of authority, the ultimate solution lies in evidence-based practices—sustainable best practices that are backed by credible research.

Moreover, it is now recognized that evidence-based practices apply not only in the clinic, but also to the business of delivering health care. More pointedly, an expanding reservoir of evidence shows that continuously improving quality across an entire healthcare enterprise inherently saves money. Politics and geographic boundaries aside, this concept is a pillar of global healthcare reform initiatives. See, for example:

1. Office of Management and Budget. “President Obama’s Fiscal 2010 Budget: Transforming and Modernizing America’s Health Care System, FY 2010 Fact Sheet.” http://www.whitehouse.gov/omb/fy2010_key_healthcare

Noble Purpose, Human Limitations

People generally enter the health care profession for the noblest of reasons: to help others. But health care professionals, like all human beings, are imperfect, fallible, and susceptible to error. This simple, unassailable truth means that in health care—as in every domain of human endeavor—mistakes of commission and omission will be made, even by the most proficient and well-intentioned clinicians.

Most human mistakes are harmless. Car keys are misplaced, written numbers transposed, verbal messages garbled. But when made by people with life-or-death responsibility, small mistakes can lead to dire consequences: friendly fire on the battlefield; jetliners colliding on runways; wrong limbs amputated in operating rooms.

It took a landmark tragedy—the largest in aviation history—to indelibly imprint the lesson of human fallibility and rouse a revolution in aviation safety that is now spreading to health care. In 1977, a preventable error by a seasoned and respected pilot put two Boeing 747s on the same foggy runway in the Canary Islands, causing a collision that killed 582 people, including one of the most respected pilots in the world at that time.

That signal disaster, which followed a rash of deadly airline mishaps, led to industry-wide self examination. And soon, a startling revelation: human error was the primary cause of 60 to 80 percent of all aviation accidents. Acting with concerted resolve to close this pronounced safety gap, the aviation industry began to study the human factors that cause errors—why and how errors happen—and based on the research, to change systems and behaviors.

Patient Safety and Health Care

The fact that "patient safety" is a relatively recent initiative in health care is nothing short of shocking. Emphasizing the reporting, analysis and prevention of medical errors and adverse events should be inherent in the system that patients rely on for care. However, the frequency and magnitude of avoidable adverse events was not generally acknowledged or discussed until the late 1990s, when reports in several countries revealed a staggering number of patient injuries and deaths each year.

A decade later, patient safety initiatives and quality improvements abound. The problem is these are generally desperate attempts to place band-aids on systemic problems. These random acts of quality and safety can do more damage than good when applied haphazardly or piecemeal in an organization.

Patient safety and quality initiatives that are being adopted today include the application of lessons learned from business and industry, implementation of advancing technologies, education of providers and the public, and economic incentives for providers and facilities. While well intentioned, these programs must build on a common foundation that is often lacking in health care organization.

The foundation that is needed, regardless of initiative, is an effective strategy that embraces and hardwires effective teamwork and communication.

One of the best practices in creating teams that perform and communicate reliably in critical situations is Crew Resource Management (CRM). This training methodology used by the commercial aviation industry hard wires the skills and techniques needed to successfully build a culture of quality and safety on a platform of collaboration. CRM skill development, coupled with routine and frequent error and incident reporting, has helped transform commercial aviation into a model of high reliability operating well beyond a level of six sigma quality and safety.