Friday, January 11, 2013

Patient Safety Lessons Forged on the Flight Deck

Patrick Monaghan
JSPH Director of Communications

When John Nance talks about safety, people listen. An internationally recognized aviation safety expert, Nance was on the Jefferson campus this week, speaking to 3rd-year Jefferson Medical College students at the 10th Annual Interclerkship Day for Improving Patient Safety. Nance is one of the best speakers you’ll see.

He is a pioneer of Crew Resource Management, which revolutionized aviation safety, and a founding member of the National Patient Safety Foundation. Best known for his work as aviation analyst for ABC World News and Good Morning America, Nance is also a decorated Air Force officer and pilot, a lawyer, and the author of 19 books, including Why Hospitals Should Fly, which received the prestigious “Book of the Year” award for 2009 by the American College of Healthcare Executives.

His mission: to convince people that patient safety can be dramatically improved only when the hospital is run to directly support, and be extremely responsive to, the needs and limitations of the people who actually take care of the patient. It’s a message that he also brought, that same evening, to a special meeting of the JSPH Chapter of the IHI Open School.

In a small and intimate setting, Nance’s message is even more striking and clear. He spoke of the climate of fear that prevails in health care – fear of rocking the boat, fear of harming a patient – and how that climate must change. He posited that simple safety checks and checklists can reduce medical mistakes. “We make mistakes because we don’t see or hear what’s there,” he said. “We make mistakes because we’re human.”

Organizational excellence is a theory that has been wrongly built, especially in the U.S. health care system, on the notion that no one is going to make a mistake, Nance said. Medical schools and other health care training institutions must change their philosophy to prepare students to expect errors and to understand how to deal responsibly with to mitigate their impact. Physicians, Nance said, are still too often taught to be commanders rather than leaders. To put it in Star Trek terms, which Nance likes to do, physicians need to evolve from Captain Kirk – who pretended to be omnipotent and infallible – to Jean-Luc Picard – who understood the inherent fallibilities that come with being human. Interesting.

Nance applauded the bravery of institutions such as Cincinnati Children’s Hospital Medical Center for its commitment to transparency and high quality care. In December, Cincinnati Children’s was named one of just 12 children’s hospitals and 81 hospitals of any kind in the U.S. included in The Leapfrog Group’s annual class of top hospitals. There was plenty of back and forth between Nance and his IHI audience, leading to discussions on patient safety surveys, coordinated care, and applying his teachings to small practices.

Nance’s now annual visit to Jefferson never fails to shed light on our health care system’s patient safety shortcomings. He’s the first to point out that progress, system wide, is slow and results are nominal. While the culture shift required is seismic, I’m betting on the resolve of groups such as our own IHI chapter and 3rd-year medical students to help see it through.