Collaborative Commissioning

May 18th, 2010 by Kenneth Cohn

It was a proud family moment when my son was commissioned as Ensign in the US Navy Friday, May 14, 2010.

The oath of office that he took reads:

I solemnly swear that I will support and defend the Constitution of the United States against all enemies foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the office upon which I am about to enter. So help me God.

My son is living his passion to become a naval aviator.

Well-meaning friends have asked me if I am concerned for his safety. They point to the hazards of an aircraft carrier, where approximately 65,000 pound fully armed aircraft accelerate from 0 to over 150 mph in 3 seconds, launched by catapults, whose controls are set by 20-somethings with an average of 2-3 years experience. And then, there are the landings on a slippery flight deck bobbing up and down, with only four arresting wires to halt the plane.

Knowing that arguing would be futile, I respond, “Sure, any parent would be concerned for his child’s safety. One never stops being a parent.”

But deep down, I feel secure because aircraft carriers embody the five principles of high reliability organizations:

Preoccupation with failure: focusing on predicting and eliminating catastrophes rather than reacting to them
Commitment to resilience: assuming that systems can fail in unanticipated ways and learning to contain errors quickly by discussing and practicing responses to systems failures and near misses
Deference to expertise: de-emphasizing hierarchy to gain input from people with the greatest knowledge relevant to the issue at hand
Reluctance to simplify: accepting that work is complex and that failures are multi-factorial
Sensitivity to operations: understanding how processes really work and paying attention to a broad range of factors, such as distractions, availability of needed supplies and personnel, and length of time people have been on duty

Why is healthcare generally not as reliable as aviation?

As Jack Barker and I discussed in Collaborate for Success!, aviation utilizes organizations such as the Federal Aviation Administration (FAA) to develop and enforce regulations and the National Transportation Safety Board (NTSB) to investigate accidents. Furthermore, aviation has a mechanism through the Aviation Safety Reporting System (ASRS) to report near misses and errors that impact safety. Widespread use of medical guidelines and a process for reporting all medical errors that is not subject to legal discovery are in their infancy. Healthcare professionals face difficult transitions changing their status from craftsmen to people that value safety and interchangeability. Distinguishing between iatrogenic injury and complications due to disease often is a judgment journey.

One hospital system journey that gives me hope is the Sentara Safety Initiative which began in 2002 when hospital leaders became frustrated with the pace of change. Dr. Yates, VP and medical director for clinical effectiveness, wrote that the missing piece was a stronger organizational culture focused on patient safety. A group of 14 physicians and 2 nurses developed 5 behavior-based expectations (BBEs):

Pay attention to detail: using the mnemonic SAFE (Stop, Analyze, Focus, Evaluate) to focus attention on the task at hand and decrease skill-based errors
Communicate clearly, using clarifying questions and repeating back orders
Have a questioning attitude, empowering healthcare professionals to stop actions when unsure about their safety
Handoff effectively, using the 5P checklist to ensure successful transfers (Patient/ Project, Plan, Purpose, Problems, Precautions)
Never leave your wingman, using peer checking and coaching when appropriate

To convert expectations into organizational habits, supervisors provide everyday feedback on BBEs which serve as core competencies on performance reviews. Managers use walk rounds to reinforce safety culture behaviors and make sure that shift-change reports, handoff reports, and pre-procedure briefings are handled appropriately. As in aviation, staff receive encouragement and recognition for reporting near misses and unsafe events. Meeting patient safety goals is a criterion for medical staff reappointment.

Hospital leaders use a system call Real-time Behavior Based Monitoring to monitor overall performance. One quarter of variable executive compensation is linked to achieving safety goals, as is one half of the annual employee gainsharing bonus.

In 2 ½ years, Sentara decreased ventilator-associated pneumonia 84% and device-associated bloodstream infections 63% (Yates GR et al. 2004. Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety. Joint Commission Journal on Quality and Safety 30: 434-542.). They experienced a 50% reduction in events of harm per 10,000 adjusted patient days system-wide (McCarthy D, Blumenthal D. Committed to Safety. Commonwealth Fund pub. no. 923; 2006:17:165-200).

Sentara has shown that they can enhance culture change by embedding tactical safety improvement projects in a larger organizational strategy. They have promoted a virtuous cycle of organizational culture driving behaviors which drive improved outcomes that reinforce the safety culture and improve reliability.

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Posted in WaterCooler Collaboration

Comments

Comment from Mario F. Romagnoli
Time: May 19, 2010, 1:09 pm

Great blog, Ken.

However, there are other factors that operate in the Navy which are critical in the complex functioning of that machine-man combination known as the aircraft carrier:

1. Discipline: adherence to protocols, checklists, procedures doesn’t cease as soon as the accrediting agency leaves or the clinical study is complete. The reduction of catheter-related infections in the ICU’s at Johns Hopkins during a well-publicized study returned to baseline soon after the study was completed.

2. Leadership: The Navy specifically trains to a goal of leadership at all levels, enlisted and commissioned, whereas, from the professional staff side, hospital administrative positions are filled by the time-tested Peter Principle, often by people who have not been terribly successful practicing medicine.
Contrast this to the Chief Petty Officer overseeing aircraft maintenance who started as a Seamen Recruit actually doing aircraft maintenance, and whose promotion through the ranks was the result of a series of advanced technical certifications combined with leadership training with a gradual increase in supervisory responsibility commensurate with increase in rate (or rank).

3. Accountability: There is an old saying in the Navy: “you can delegate authority, but not responsibility.” In my experience accountability in hospital and medical school administrations is largely non-existent. There is no such thing as a “career-ender” for hospital or medical school administrative jobs. The failed administrators just move to a different institution with higher pay where they can continue to do the same stupid things.

4. Honor: when given the choice between doing the right thing or acting in their self-interest, hospital administrators will, more often than not, choose to serve their self-interest.

That’s all for now.