Many of you will have seen the recent BMJ article asking if there were any further lessons to be learnt from aviation for healthcare. My immediate response was that the question is less relevant than it first appears: the real issue is whether healthcare is ready to learn lessons from any safety critical industry, especially about safety and human factors.
Last year I spoke at a workshop with the Medical Protection Society. One of my fellow speakers, a softly spoken Australian doctor with an Irish family background made this observation: ‘In the old days in Ireland if you wanted to be closer to God there were three professions: a priest, a teacher or a doctor. And the healthcare system still thinks of itself as one of those ‘institutions’. It needs to shift its thinking… to think like nuclear, rail, aviation or other such safety critical industries.’
Pilots can offer a unique perspective on the development of safer systems. I believe this is currently especially valuable and relevant to areas such as revalidation and the increasing use of simulation (where the training of skilled ‘notechs’ – non technical skills – observers is particularly crucial to get the most from the simulation or any feedback opportunity). But I also think the time has come for the modern, safety and human factor aware clinician to take the lead.
Let me explain. It seems true that clinicians love hearing flying stories – they like the tales of disasters and how we’ve made flying safer. However, last year I met a pilot who strongly disagreed with this. He’d done a lot of work with clinicians in the US and his experience was opposite to mine.
It got me thinking and then I reached one of those eureka moments: the reason clinicians like hearing pilots speak is that while many can identify strong lessons with their work, it doesn’t threaten them. Pilots can inspire, but if they say ‘This is how you should do it’ then the audience can walk away at the end saying ‘Of course, it doesn’t work like that in my hospital!’
But if a fellow clinician stands up and says ‘This is how I’ve made my practice safer for me and my team’ then it’s very different. Suddenly some of the audience feel excited (if not a little concerned) and others feel threatened because it questions basic assumptions, training and practice. Often the more observant can sense a new way of doing things, but if only the old school would listen!
A nurse colleague of mine was teaching a group of Foundation stage doctors last week. She commented that they were really demoralised when she met them, because they’d learnt all about safer systems such as the WHO Safer Surgery Checklist (which, as we know, is used properly and consistently in every hospital in the land – yeah right!) and then, when they got into their work placements, they faced comments such as ‘We don’t do that here’.
So much for evidence-based medicine then.
When I first got involved in patient safety I massively underestimated the complexity of healthcare – I too thought it was just like aviation. If you want to make a change you just ‘regulate’ it and everybody, after a while, does it because life’s much easier with a job!
But I learnt there is one massive difference between healthcare in the UK and aviation. Pilots have grown up with a military-style command and control ethos. However, the inertia and complexity of healthcare have created an autonomy that makes it hard for simple policies and regulation to influence. I realised a while back that to make real, lasting change in healthcare requires the clinicians to want it, while at the same time the organisation creates regulations that target the managers to provide the fertile ground for safe practice to flourish.
I recently spoke at Whittington Hospital in London in a joint session with Mark, an orthopaedic surgeon from Leeds. He’s an example of what healthcare needs more than ever, someone who has learnt how to integrate safer practice and systems thinking into his lists – and it works.
I spoke first, about my late wife’s story and some lessons from aviation, and Mark followed straight on talking about his practice, the evidence, and challenging the audience to think about what professionalism really means in this age where we now understand what can make healthcare safer.
Normally, on any panel, the bulk of the questions at the end of the session come to me, but everyone wanted to ask Mark about what he’d said. And it felt good, really good, because at last here was an audience who felt someone who spoke their language had found a way to ‘do it better’ and they could learn from it. This was the best example I’ve ever witnessed of clinical engagement or clinical leadership in action.
You’re entering a new age of clinical practice, one in which safety is built into systems and ways of working that take account of human performance variability and human error. It’s probably going to be the best time in history to be a clinician because you’ll be making history.
Maybe the light at the end of the tunnel is you?
Martin is the founder and current Chair of the Clinical Human Factors Group.