Surprise! Patient safety can learn from the trades as well as from aviation.
Over the last few months, I’ve had the privilege of getting to know one of the Coalition’s new individual members, Gary Fasso, and have been learning from what may seem an unlikely source of wisdom about patient safety: the trades. Gary is with the Pacific Northwest Council of Carpenters and trains the members in safe practices for when they are working in occupied healthcare buildings (e.g., remodeling hospitals or clinics). I’m learning so much from him about what is transferable from construction to healthcare. We have recently engaged in a lengthy email dialogue from which I’ve excerpted just a few points; it started with a question to him about the importance of culture: how people behave toward each other, what they believe, what the organizational and personal/professional values are.
Some very good lessons and methods (Crew Resource Management, communication, use of checklists) have been learned from aviation. While construction is heavy, immobile, and not particularly glamorous, it shares important features with both aviation and healthcare: all three are highly technical, safety conscious, and run by fallible humans.
Ego: The first thing a carpenter does after tripping and falling on a jobsite is to quickly pick himself up, look around, and see if anybody saw: ”Jeez, if I can’t make it across the jobsite without falling down, I doubt they will keep me till the end of the job.” Our pride should not make us a danger to others. Leadership should give examples of near misses or near disasters averted by a low-level operative, and can make it clear that we are all human and we will do human things (misunderstandings, miscommunication, mistakes), but that we will not be terminated or retaliated against for being human or pointing out an issue. It needs to be emphasized verbally and in print, reiterated at safety meetings, and posted. It needs to be part of the culture of the organization.
Empowerment: Someone who speaks up about a safety concern and is told, “You don’t get paid to think,” is unlikely to speak up again. The trades are training leaders to use every asset at their disposal and to be open to suggestions; this is an ongoing process, starting with Union management and the elected Union delegates, who are brought together in small groups several times a year.
Jobsite Safety Hazard Analysis (SHA): In the construction industry, every job is different and every task varies in some way, but if we have procedures to deal with known hazards, and to anticipate possible dangers, it takes a lot of ego out of it. The SHA is a form that tries to cover everything that could happen on a job, and is filled out before any work begins. This helps minimize on-the-spot decisions. Further, each phase or portion of the project needs an SHA due to the completely different issues encountered at the start and at the end of the project. Modifications are allowed and encouraged.
And an additional factor: A major problem in a male-dominated field is what Gary refers to as Testosterone Poisoning (TP). Having more women in the union really helps: a man is less likely to work unsafely if there are female workers on the crew, whether or not they are directly working together. He is also less likely to haze a woman if a female loved one (sister, daughter, or friend) has been hazed. Gary offers examples of hazing as it might appear in construction work: Assigning a female construction worker to a job that is unnecessarily difficult or unpleasant (tasks that require special training or experience, essentially setting her up to fail). Using language—directly or indirectly—that can be expected to offend. Pairing a female with a known misogynist or simply treating a woman as if she doesn’t belong.
Attitudes are changing, and TP is slowly declining. Unfortunately, Gary says that the only certain cure for TP is to suffer or witness a bad accident or–worst case–a fatality. He described Tony, a veteran carpenter who came into the Union Hall very upset. Tony said his crew was never much on safety, often ridiculing the safety-conscious workers until that day, when a good friend and crew member fell. The buddy was, as usual, not tied off on a safety line, and when the plywood deck gave way he fell three stories and was severely injured. The crew all felt like garbage, because they knew it was their fault. Tony became a Safety Officer.
Readers of this blog who work in healthcare can think of many examples and analogies. Perfection is expected of imperfect humans. Those of us who make mistakes or “near misses” often feel we cannot share them with anyone, thereby losing the opportunity for others to learn from and avoid the same thing. Many of us have witnessed, engaged in, or experienced what might be called ‘hazing,’ although in healthcare we tend not to call it that.
What really struck me was the concept of the Jobsite Safety Hazard Analysis, as I could not think of anything quite like it in healthcare. The closest may be the pre-procedure checklist, but I can imagine many other uses for it during a healthcare encounter: e.g., during the admission or discharge process.
I’m looking forward to more conversations with Gary and learning more lessons from the trades.
Thoughts for Gary (gfasso@nwcarpenters.org) or me (msmith@qualityhealth.org)?
Miriam Marcus-Smith is program director of the Washington Patient Safety Coalition. This essay first appeared on the Coalition’s Safety Blog.