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Silverman began with a chuckle that rose to a full laugh as he shook his head. Will, those great procedural things from aviation are just the tip of the iceberg. CRM, for instance—crew resource management—is an incredibly effective way of getting leaders to employ and listen to subordinates as real team members. It revolutionized the airline cockpit by getting rid of the unresponsive, maverick captains who refused to listen to anyone, and it's a principle that's helped us considerably here.

But the real brilliance of what aerospace has discovered about human safety systems comes more from a subtle understanding of how to transform an imperfect, mistake-ridden, high-risk human culture into a culture of colleagues who actually can achieve near perfect safety. It means structuring a system that expects and safely deals with mistakes. That's the essence of a high reliability organization. The kicker is that even though they discovered it and pioneered the process of taking a dangerous enterprise to HRO status, few aviation leaders even today fully understand how they've achieved such incredible levels of safety.

By contrast, most major healthcare leaders do understand it, even though we have yet to achieve HRO status. There's an excellent paper out about that very point I've got for you in the packet. I had to do some very deep research of my own to learn how to crack the code. Once I realized that safety and quality depend on having unified teams of like-minded people willing to put all normal human and professional differences aside to achieve a common goal, the theory began to come together.

Applying that theory and actually changing us was a different story, of course. That was and is a matter of hard and sustained work built around the clearly stated common goal that everything we do here is done for the best interests of the patient. Now, Boeing understood it. There was real arrogance in the idea that aeronautical engineers were too good to dirty their hands by dealing directly with mere customers, or even with those who cut the metal to build the airplanes they designed.

John Nance at Medline's Prevention Above All 2010 PART 3 of 7

In many respects, those senior engineers were acting exactly the way we physicians act. But Boeing's leaders, and especially a gifted engineer and leader named Alan Mulally, crafted a new concept called "Working Together" to kickoff the design of a critical new jetliner that became the Boeing Now, Working Together is similar to a thousand phrases we've used in health care, but Mulally made it the battle cry of cultural change, and he went for no less than a cultural renaissance.

The whole approach was wildly opposite to the traditional way they'd done things, and it's wildly different from and almost assaultive to the way we've always done things in medicine. But I can tell you that it's the only method I've ever experienced that can take a gaggle of independent, ego-driven, mutually-suspicious professional humans and turn them into a real team truly dedicated to the same common purpose. For instance, Will, one of the things we do here is study every failure and near-miss to the point that all of us become truly eager to share our mistakes for the common good.

And, while none of us like to dwell on our failures, we constantly discuss the fact that we owe it to those we've injured or killed in the past to never forget that we have a duty to fix the system that failed them. I imagine as a former CEO you've got a few sad stories of your own. The memory of the disaster that had propelled Will here filled his mind for the briefest of moments, but it was enough to contract his stomach again. He pushed the feeling away and pulled out a small, silver object and gestured to it. I don't want to miss a word of this. Getting to his feet, Silverman nodded, well aware of his younger colleague's ashen expression and suspecting what had probably prompted it.

Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care

After all, he thought to himself, Jenkins had been far too relentless in getting this appointment to be driven by mere academic interest. You got the suggested schedule, right? First the ER, then some clinical settings. Jack Silverman's patented three-day course. Weeds out the insincere. Never mind that years had passed, it was still fresh and painful and mortifying. Never in his 16 years as a physician had Will Jenkins felt as helpless and depressed as he had on that terrible night in Of course, as a doctor, he'd lost patients before without knowing why, and as a CEO and administrator he'd presided over many more tragedies.

But this one was different, and he had mishandled virtually every aspect of it. For the three years immediately preceding that night—from the first day he'd been appointed CEO—he'd worked tirelessly and with growing confidence to build an entirely new era of quality and accountability into the suburban community hospital near Portland, Oregon.

The earthshaking report of the Institute of Medicine had shocked him profoundly. The title of the IOM's seminal work was To Err is Human, and its premise nothing less than bringing the previously shunned subject of medical error into the glaring light of public and professional scrutiny. But it was the part of the report that said American hospitals were killing just under , patients annually from avoidable medical mistakes that had moved Will to face down his board to get the necessary money to start changing things.

He had dived in fearlessly by hiring consultants, holding meetings, and even bringing in an energetic group of former fighter pilots to train his physicians in OR teamwork. He'd mandated the use of "time-outs" in the hospital's surgical suites although the rumors persisted that the surgeons were ignoring the directive , and threatened to pull privileges for physicians who failed to attend his training sessions.

He'd even weathered a furious lawsuit by one of the physician groups and forced a change in the medical bylaws to give him the unquestioned authority to throw out a physician who refused to comply, and he'd used much of his credibility with the board in the process. His staff members and even the charge nurses had been Six Sigmaed, Lean-Meaned, Studered, Joint Commissioned, trained in Toyota's methods, and lectured by a dizzying variety of experts.

Hard Lessons – “Why Hospitals Shoudl Fly” – The Journal of Healthcare Contracting

They'd filled notebooks with the six steps to this and the seven deadly problems to that, and his reports to the board of everyone's determination to "zero out" professional mistakes had been glowing and full of promise. It might be true, he'd told his board members, that up to 96, patients were being killed by mistakes in America's hospitals, but being killed by avoidable medical errors was no longer a probability at Memorial. And then the roof fell in, and despite all his efforts, yet another completely avoidable medical mistake in one terrible evening took the life of a young patient, garnered the undivided attention and excoriation of the media, and effectively canceled everything they'd accomplished.

After two years of public shame, litigation, and a ruinous verdict against his hospital, he could bear it no longer. Will's embarrassed resignation had followed. It seemed the only honorable course of action, but it hurt to have had it accepted so quickly by the panicked board.

Chastened and filled with self-doubt, he had packed up his wife and three kids and found a different state, doubting that he'd ever been competent to run a hospital again.


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For years after, it haunted him, as did the obvious inability of the medical community to put a substantial dent in the death rates from medical mistakes that were clearly caused by a combination of human errors and flawed systems. The thought was always with him that somehow he'd missed something in applying all the accepted solutions at his former hospital. Even as he resumed an uninteresting private practice, he found himself frequenting the nearest medical library, determined to figure out how he had failed. The research left him amazed at how many thousands of hospital leaders across the nation had apparently tried to handle the challenges of medical mistakes the same way he had, and with the same disheartening results.

Patient safety, he realized belatedly, had been treated like a specific disease for which a specific vaccine could be formulated. But by , two things had become painfully apparent. Despite six long years of sound and fury in health care about the emergency need to improve patient safety, just as many patients seemed to be dying as the result of medical mistakes. Equally disheartening, many uncounted others had lost significant quality of life to wrong-site disasters, unnecessary surgeries, and a horror-writer's laundry list of other heartrending human tragedies.


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He searched for but could never find the evidence that would suggest that the mass of American hospitals had changed for the better, though he heard rumors from time to time about various institutions that were taking maverick action and making significant inroads. The field was awash with hospital executives just as puzzled and frustrated as he, all of them wondering why the "fixes" they tried had barely made a dent in the unconscionable rate of accidental deaths and injuries.

Yet month after month physicians were still cutting on the wrong appendage or the wrong patient, good nurses were still grabbing lethal doses of the wrong medications, and across the nation many of the procedures, such as surgical "time-outs" and other double-checking procedures were failing from lack of standardization. If there were a "magic bullet" to use on the specter of medical error, Will had lost faith in its existence, until the small article about a tiny Denver area hospital caught his attention. It was a nondescript facility called St.

Michael's Memorial, the writer said, and it was being hailed as providing a true glimmer of light in an otherwise dark landscape of poor progress. Apparently, where others were failing wholesale across the nation, St. Michael's was succeeding by standing routine medical expectations on their head. It wasn't the only hospital to show patient safety improvement in the nation by any means, but St.

Strategies for Continuous Innovation. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: Qual Saf Health Care. The importance of leadership in preventing healthcare—associated infection: Infect Control Hosp Epidemiol. Learning accountability for patient outcomes. Responsibility for quality improvement and patient safety: Organizational culture and its implications for infection prevention and control in healthcare institutions.

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Creating a culture of safety. Physicians with multiple patient complaints: An organizational assessment of disruptive clinician behavior: Leadership and patient safety: Error, Guilt, Trauma, and Resilience. Facebook Twitter Linkedin Email. Introduction Disclaimer Book excerpt Disclaimer. Am J Infect Control.