Review: Air Safety Lessons Could Save Lives in Hospitals

Beyond the Checklist opens with a horrifying story of a very close brush with death, due to preventable medical errors.

In a recent New York Times op-ed, a physician described how, due to inadequate coordination and communication among staff during his hospital stay, he lost a leg.

These cases are all too typical. A landmark 1999 Institute of Medicine study found that almost 100,000 patients each year die from avoidable medical harm.

Such failures result in large part from the rigid, traditional hierarchies that separate health care workers from one another. Hierarchies with deadly consequences were once a feature of the airline industry, too—until high-fatality accidents prompted a radical overhaul of industry processes, beginning in the eighties.

In recent years, health care providers have been trying to apply lessons from that overhaul. The most commonly known are checklists: just as pilots and maintenance crews run through a list of tasks to make sure the craft is ready for flight, doctors—and sometimes also nurses—go through their own checklists before and after surgery.

But checklists are only the simplest element. At the heart of the success in aviation has been the introduction of teamwork.

Regular readers of Labor Notes may cringe, justifiably asking, “How do I know this ‘teamwork’ is not another management scheme to eliminate craft lines, combine jobs, and justify slashing wages and benefits?”

Fortunately, safety teamwork is not about speed-up and cost-cutting—at least not in its origins. But this is not to say that managers won’t try to twist safety teamwork projects to those ends, just as they have done in some institutions when new health care technologies were introduced.

As Charley Richardson warned Labor Notes readers in 2010, technologies like electronic medical records and tracking devices can be used to hurt workers and “tip power toward management.” Richardson urged health care workers to educate themselves about such changes and organize to prevent technology misuse and abuse. Beyond the Checklist examines the new safety initiatives in the same spirit.

Dysfunctional Culture

It has been more than ten years since the Institute of Medicine published its shocking findings, but despite hundreds of millions spent on new patient safety efforts, hospital harm is still common. The authors of Beyond the Checklist explain:

Many well-intentioned safety efforts have fallen short because doctors, administrators, and other staff resist necessary changes in the hierarchical and often dysfunctional culture of hospital work. Patients get hurt or become even sicker when doctors, nurses, and other hospital staff fail to share information, don’t work effectively in teams, or ignore mechanisms—like hand-washing to prevent infection—designed to minimize human error.

They compare these failures to the safety success story of Crew Resource Management protocols in aviation. CRM requires everyone with any role in a flight—whether in cockpit or passenger areas, on the runway, in the hangar, or in air traffic control—to solicit information and acknowledge that information has been heard. It also mandates new, safer processes for every step from preparation through to post-flight checks.

Those implementing CRM had to overcome resistance from captains who were used to having the last word—often the only word—in decisions, and from pilots who were uncomfortable with the “the ‘soft skills’ of better communication and respectful interaction with co-workers.” As in health care, there were obvious gender roles at play.

Yet by now, the authors report, the consensus among airline workers “is that our cockpit management decisions are far better when we have regular input and information from all members of our aviation team, in the air and on the ground.”

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Unfortunately, this is not yet the case in health care. Few hospitals have created an environment where staff members feel free to challenge a physician or complain to an administrator. In medical schools and on the job, doctors are not encouraged, much less required, to consult with skilled and experienced members of their health care team, who may have life-saving input.

Doctors, nurses, transporters, and other staff must share crucial information about the patient and feel free to challenge each other if a mistake appears imminent. This requires parallel training on “codes of mutual respect”—to be blunt, doctors must learn to listen to, and not insult or demean, nurses, med students, or anyone else who red-flags a potential misstep.

Spotty Success

Several chapters in Beyond the Checklist detail the application of CRM to health care: how various hospitals implemented it, the resistance they overcame, and the impact on patient outcomes.

Above all, the authors argue, changes must be continuous and self-reinforcing. In some hospitals, managers used one-off CRM pilot projects to win bragging rights, but didn’t sustain the necessary follow-up—whether because of inertia, competing priorities, or insufficient buy-in from leaders and staff.

The authors recommend collective training, rather than training specific to medical specialties. They further recommend taking safety training beyond hospital walls, into schools for health care workers. In my hospital and others, staff members are also trained to encourage patients and their families to ask questions of their physicians and nurses.

Inadequate staffing, the authors note, can be another barrier to team-based safety. Co-author Suzanne Gordon, who has written and edited numerous books about nurses and nursing, is a well-known advocate of improved nurse/patient ratios. She and her co-authors describe how overwork produces stress, which in turn affects learning and performance. “One wonders,” they write, “how anyone can talk about effective teamwork in health care without dealing with the kinds of workloads and schedules that keep people from getting enough sleep”—or even from having time to eat, in shifts of eight, 12, or more hours.

The authors also note how a market-based health care “industry” creates its own barriers. For instance, one hospital CEO was afraid safety process changes would cause his physicians to take their income-generating cases to another hospital. The authors view this as a reason government regulators should make such changes mandatory.

Even in aviation, workers worry that the pursuit of profit is hurting safety efforts. Famed pilot Chesley “Sully” Sullenberger (hero of a near-crash and author of the book’s foreword) has warned of job outsourcing and a growing “culture of intimidation and pressure.” The authors write:

Work intensification—the attempt to get more out of personnel with reduced resources—is a major trend that threatens both quality and safety... Regardless of their place in the hierarchy, people are pushed to attain an increasing variety of productivity measures... their work is subject to more and more distracting interruptions, and they are given less time for rest and respite.

Such economic pressures are only going to increase in health care, as politicians of both parties continue their attacks on Medicare and Medicaid, slashing hospital reimbursement while providing ever-greater subsidies to the makers of high-tech medical devices and patient records software.

Yet government funding can also be a positive force. Beyond the Checklist gives a telling example: A government-funded teamwork program, called TeamSTEPPS, focuses on leadership, situation monitoring, mutual support, and communications. Because it’s a government program, hospitals wanting to adopt the program receive free materials and training.

My own favorite example is the VistA software used throughout the Veterans’ Affairs hospital system: a free, adaptable, cooperatively-developed and -improved program. It stands in stark contrast to the huge number of proprietary, for-profit systems peddled by competing vendors—which can make teamwork harder, and cross-institution information-sharing damned near impossible, as we saw during Superstorm Sandy.

Working to implement the cross-occupation, cross-institution safety practices recommended in Beyond the Checklist can be a small but important step to better equip workers for the bigger battles we need to tackle in the fallout of the economic crisis. A workforce more conscious of—and empowered to do something about—life-saving changes at work is a workforce poised to take on these bigger issues, such as government funding and policies.

Those Labor Notes readers who want additional context can’t do better than the recent volume co-edited by Suzanne Gordon, First Do Less Harm, which describes workplace and industry-wide barriers to pro-safety, pro-worker change. And don’t miss her previous books on nursing!

Andrew Pollack is a senior data and health policy analyst at Maimonides Medical Center.