Aviation Safety Information Processes: Useful in Health Care

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Aviation Safety Information Processes Useful in
Health Care?
Presentation to Pillsbury Winthrop Shaw Pittman
Health TechNet Name Christopher A. Hart Date
October 17, 2008
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Using Information Proactively in Health Care?

• Can Aviation Help Health Care Use Information
  Proactively to Reduce Mishaps?
• The Context
• Challenges and Solutions
• Similarities and Differences
• Aviation Successes and Failures
• Improving Safety and Productivity, Too
• The Role of Leadership

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The Context Increasing Complexity

• More System
• Interdependencies
• Large, complex, interactive system
• Often tightly coupled
• Hi-tech components
• Continuous innovation
• Ongoing evolution

PEOPLE
MATERIALS
PROCEDURES
The System
SOFTWARE
EQUIPMENT

• Safety Issues More
• Likely to Involve
• Interactions Between
• Parts of the System

FACILITIES
TOOLS
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Effects of Increasing Complexity

• Human Error More Likely Because
• System More Likely to be Error Prone

• Operators More Likely to Encounter
• Unanticipated Situations

• Operators More Likely to Encounter
• Situations in Which By the Book
• May Not Be Optimal (workarounds)

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The Result

• Front-Line Staff Who Are
• - Highly Trained
• - Competent
• - Experienced,
• Trying to Do the Right Thing, and
• Proud of Doing It Well

. . . Yet They Still Commit
Inadvertent Human Errors
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When Things Go Wrong
How It Is Now . . .
How It Should Be . . .
You are human
You are highly trained
and
and
Humans make mistakes
If you did as trained, you would not make mistakes
so
so
Lets also explore why the system allowed, or
failed to accommodate, your mistake
You werent careful enough
so
and
You should be PUNISHED!
Lets IMPROVE THE SYSTEM!
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Fix the Person or the System?
Is the Person Clumsy? Or Is the Problem . . .
The Step???
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Enhance Understanding of Person/System
Interactions By

• - Collecting,
• - Analyzing, and
• - Sharing

Information
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Major Source of Information Hands-On
Front-Line Employees
We Knew About That Problem
(and we also knew it might hurt someone)
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Objectives Make the System
(a) Less Error Prone
and
(b) More Error Tolerant
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The Health Care Industry
To Err Is Human Building a Safer Health
System The focus must shift from blaming
individuals for past errors to a focus on
preventing future errors by designing safety into
the system. Institute of Medicine, Committee
on Quality of Health Care in America, 1999
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Health Care and Aviation Working Together A
Significant Win-Win

• Similarities

• Stigma Associated With Errors
• Many Interacting Components Working Together
• Continuous Innovation, Rapid Introduction of
  Complex New Technologies
• Usually Several Links in Mishap Chains
• Typical Response to Errors is Punishment
• Safety vs. Production and/or Throughput
• Litigation Potential

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Win-Win (cont)

• Differences Aviation Has

• Inherent Reporting Incentive (e.g., Pilots)
• Less Operational Variability Thus, Activities
  Generally More Prescriptive, Less Judgmental
• Less of a Craftsmans Guild Environment
• Smaller, More Homogeneous Teams
• Workforce Consisting Mostly of Employees
• More Media, Political Attention Public Fear of
  Flying, Thus
• More robust data collection infrastructure
• Reporting, tracking, and trending of near misses
• Non-Adversarial Mishap Investigation (NTSB)
• Federal vs. State Law

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Current System Data Flow
Most Data Lost Forever
Currently Only a Minute Portion of Data
is Collected and Analyzed
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Heinrich Pyramid
ACCIDENTS
INCIDENTS
UNREPORTED OCCURRENCES
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Legal Concerns That Discourage Voluntary
Collection, Analysis, and Sharing

• Public Disclosure
• Job Sanctions and/or Enforcement
• Criminal Sanctions
• Civil Litigation

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Typical Cultural Barrier
THEN Consider Safety?
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Next Challenge
Improved Analytical Tools
Legal/Cultural Issues
As we get over the first hurdle, we must start
working on the second . . .
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Information Overload
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From Data to Information
Tools and processes to convert large quantities
of data into useful information
DATA

• Smart Decisions
• Identify
• issues
• Prioritize
• Develop
• solutions
• Evaluate
• interventions

Data Sources

Info from front line staff
USEFUL
INFORMATION
and other sources
Analysts
Processes
Tools
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Analytical Challenges

• Analytical Tools Must Support Development of --
• Interventions that address SYSTEM issues, not
  just OPERATOR issues, and

• System interventions that
• Are SYSTEM-WIDE in scope, and

• Focus more extensively on HUMAN FACTORS

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Aviation Success Story
65 Decrease in Commercial Aviation Fatal
Accident Rate Since 1997
largely because of Proactive Safety Information
Programs
plus System Think
P.S. Aviation was already considered VERY SAFE
in 1997!!
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Aviation System Think Success

• Engage All Participants In The Process of
  Identifying Problems and Developing Remedies
• Airlines
• Manufacturers
• With the systemwide effort
• With their own end users
• Air Traffic Organizations
• Labor
• Pilots
• Mechanics
• Air traffic controllers
• Regulator(s)

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Manufacturer System Think Success
Aircraft Manufacturers are Increasingly Seeking
Input, Throughout the Design Process, From
(User Friendly) (Maintenance Friendly)
(System Friendly)
- Pilots
- Mechanics
- Air Traffic Services
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Failure Inadequate System Think

• 1995 Cali, Colombia
• Risk Factors
• Night, Mountainous Terrain
• Airport in Valley
• No Ground Radar
• Airborne Terrain Alerting
• Limited to Look-Down
• Last Minute Change in Approach
• More rapid descent (throttles idle, spoilers
  deployed)
• Hurried reprogramming
• Navigation Radio Ambiguity
• Spoilers Do Not Retract With Power

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Recommended Remedies Include

• Operational
• Extra Vigilance re Last Minute Changes in an
  Approach!!!

• Aircraft/Avionics
• Enhanced Ground Proximity Warning System
• Spoilers That Retract With Maximum Power
• Require Confirmation of Non-Obvious Changes
• Unused or Passed Waypoints Remain In View

• Infrastructure
• Three-Letter Navigational Radio Identifiers
• Ground-Based Radar
• Improved Reporting of, and Acting Upon, Safety
  Issues

Note All but one of these eight remedies
address system issues
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Icing on the Cake avings

• Immediate
• - Significant

Significantly More Than Savings From Mishaps
Prevented
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Two Levels of Savings

• First level (immediate) savings
• Bottom-line benefits ancillary to safety
  improvements

• Second level (potentially much larger) savings
• Information pipeline contains more than safety

Ye Who Can Fix
Information about Safety,
Staff AND OTHER Sources
Efficiency, Reliability, and Other Productivity
Metrics
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Other Potential Benefits

• Better Labor Relations
• Transforms workforce from brunt of blame when
  things go wrong, to valuable source of
  information about potential problems and how to
  remedy them, i.e., converts labor and management
  from Adversaries to Partners in Improvement

• Reduced Legal Exposure
• Collecting, analyzing, and sharing will become
  industry standard for most, if not all,
  potentially hazardous endeavors woe to those who
  dont

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The Role of Leadership

• Demonstrate Safety Commitment . . .

But Acknowledge That Mistakes Will Happen
- Include Us (e.g., System) Issues, Not Just
You (e.g., Training) Issues
- Make Safety a Middle Management Metric
- Engage Labor Early
- Include the System -- Manufacturers,
Operators, Regulator(s), and Others
- Encourage and Facilitate Reporting - Provide
Feedback - Provide Adequate Resources - Follow
Through With Action
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Thank You!!!
Questions?