High Reliability: What Healthcare Can Take From Aviation

By Matt Phillion

When it comes to safety, security, and compliance, many industries—healthcare included—look to aviation. Famously, the aviation industry learned a hard lesson during the Tenerife disaster of 1977.

In that incident, as dense fog rolled through a high-altitude airport, the captain of a Boeing 747 jet mistakenly thought he was cleared for takeoff and collided with another 747 that was still on the runway, resulting in a fiery explosion that destroyed both aircraft and killed nearly 600 passengers and crew. The catastrophe was a culmination of flawed assumptions, incorrect perceptions, and botched communications. It pushed the aviation industry to adopt better metrics, scorecards, and communication protocols in an effort to prevent such an event from ever happening again. Today, aviation is a high-reliability industry that others can look to as an example of eliminating risks.

Indiana-based Parkview Health, a soon-to-be nine-hospital system with over 160 physician offices scattered throughout Indiana and Ohio, has been using concepts from the aviation industry to build its own culture of compliance, safety, and security. After all, healthcare is no stranger to the same contributing factors that led to the Tenerife disaster.

Parkview’s efforts “stemmed from a book, Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care,” says Adam Tuttle, contracting and purchasing manager with Parkview Health. “[Its author] John Nance really stirred a lot of conversation around [the Tenerife] incident and the things that came from that.”

There’s much that can be taken away from the catastrophe, he notes: most significantly, the fact that such a devastating collision was still possible even though the captain and cockpit crew attempting takeoff were all highly experienced and competent. “I think aviation [today] does a lot of great things in terms of checks and balances,” Tuttle says. “They’re non-negotiables, and that’s made its way into healthcare.”

Such checks and balances in healthcare include things like timeouts in surgery, or checklists to ensure that nothing is started until everyone needed for a procedure is in the room. The non-negotiable culture of ensuring the proper steps are followed is pivotal.

“Even a decade ago, what we needed and noticed in healthcare systems was that healthcare needed to get its house in order, to have a culture and a mindset of safety and security,” says Dr. Jennifer Williams, director of market development and education and credentialing with GHX Vendormate. “In the Tenerife airport disaster, the pilot knew what he was doing, but he was in a hurry; he didn’t use his checklist, but he also did not understand what the copilot or the tower was saying. In healthcare, making sure we’re collectively communicating is key.”

To achieve high reliability, an organization needs to be forward-facing, Williams says.

“If you think about it this way, how many patients are hurt or injured every year?” she says. “It’s the equivalent of 1,400 747s crashing every five years. We don’t have those big incidents or crashes [with mass casualties], so we have to take the perspective that we have to do something every day.”

Organizations need to escalate their communication outward and formulate a plan to prepare their hospital for tomorrow. “We pride ourselves, and have woven it into our DNA within the system, that safety and communication is so important,” says Tuttle. “It really is a top-down investment building a culture of safety.”

Personnel, expectations, and who’s in the room

Although we look to airlines as a high-reliability industry, we’ve witnessed a rough patch in terms of delayed flights and other inefficiencies. In part, this has stemmed from the labor shortages that all industries have faced recently. “Everyone is struggling,” Tuttle says.

But even amid labor shortages, organizations must hew to the right tenets to maintain high reliability and patient safety. For Parkview, this means speaking up, ensuring safety for all, and maintaining a just culture. It goes back to valuing communication.

“One thing in Nance’s book that resonated with me was how it talks about barriers to communication,” says Tuttle. “I’ve talked to nurses about how they think Parkview sets itself apart in those areas, especially with all the things that have happened in the past year or so—do they feel like they can speak up? They do, and that’s part of our culture. There’s no pecking order; everyone is in the same room trying to help that patient in front of us.”

And that brings up the next point: Who is in that room? Knowing who comes and goes in the facility is a huge part of a safety culture.

“The parallel in aviation of crashes vs. non-crashes is how important it is to have access control in hospitals so people aren’t coming and going and getting hurt,” says Williams. “For visitors and family members, we need to highlight maintaining safety in the confines of the system.”

“Everyone is talking about value-based care,” says Tuttle, “and it’s something Parkview is getting into: the whole patient experience.” Safety-mindedness must extend beyond the confines of the facility and into the community, she notes. It also needs to encompass not just the patient, but also visitors and family members, which leads back to the topic of access control.

Parkview has been rallying around the access control concept, tracking vendors through GHX Vendormate. “We take a lot of pride from a security perspective, from the simplest thing like how you’re supposed to wear your badge—the little things matter,” Tuttle says. “It trickles down into expectations for your guests and your vendors.”

Compassion and education

Compassion is key, Tuttle says. “What I’ll say about healthcare workers as individuals, they’re all very compassionate—about their communities and about the people walking into their sites,” he adds. “But a big piece of this is making sure that compassion doesn’t fail us from a security standpoint.”

In the face of record-setting admissions and procedures, we cannot lose sight of the core tenets of access control and security, like badging in and out. The trick is to empower employees to use that compassion to reinforce good security practices. “It’s being able to speak up; to ask, ‘Can I help you? You don’t seem like you’re in the right place,’ ” Tuttle says. “That’s all training and understanding, and it’s vitally important.”

There’s a life cycle of education for access controls across a patient’s stay, says Williams. “Patient safety is the most contemporary topic we have today. The system is really fragmented, and we need to unify that,” she says.

That unification starts at the C-suite but extends all the way down. “They can know what’s going on in their system and also push down a code of conduct and culture, making sure the hospital is well secured,” Williams notes.

“The code of conduct is one of those things we’re getting out of aviation,” says Tuttle. “It’s setting expectations. However, it’s a bit different in healthcare in that [hospitals are] really people-driven. We can’t let people-driven compassion overcome safety.”

The data matters

Parkview does a great job with their event logs, tracking events like slips, trips, and falls that happen in every health system.

“Something healthcare can take from aviation in terms of what healthcare can do better is through resiliency efforts: noting a failure, performing a root cause analysis, using Six Sigma to work through those problems to be as proactive as possible,” says Tuttle. “For example, we get a lot of snow here. What is the right amount of salt on walkways? How do you prevent slips and falls in the parking lot?”

This involves the risk management, safety and quality control, and emergency management teams looking at the data and making the best decisions for the organization and its guests. “It’s really an effort around root cause analysis,” says Tuttle. “It’s making sure that we’re working toward zero harm.”

Whether it’s proper use of badges or avoiding slips and falls, expectations for quality of care are core to this philosophy. “How do we make sure before they ever walk into the facility, vendors are set up and credentialed? How can we make sure the people at the front desk are asking the right questions?” says Tuttle. “It’s turning that compassion into compassion and safety.”

And that safety starts with the staff, Williams explains. “As a healthcare worker myself, we become even more compassionate when we know someone cares enough about us to keep us safe in the healthcare setting,” she says. “If we don’t feel safe, we can’t act in accordance with best practices. Compassion is derived from compassion at the top: making sure our hospital, patients, employees, and visitors are all safe.”

“It really is a top-down investment,” says Tuttle. “But high reliability is barrierless. It doesn’t matter if you’re an [environmental services] worker, if you’re a nurse, a tech cleaning down equipment. Every role is a job that requires you to care and look out for others.”

As such, every role is charged with knowing how to act upon spotting something amiss. “If you see a puddle on the floor, don’t walk past it—but what are the protocols behind that? Who do you call, how do you escalate it from there?” says Tuttle. “Just try to make sure everyone understands they have a part in it.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.