4 Critical Lessons Healthcare Can Learn from the Crash in San Francisco According to LifeWings

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On July 6th, Asiana flight 214, a B-777, hit the sea wall on approach to San Francisco airport (SFO), causing the death of three passengers. The effort to stop patient harm due to preventable medical error in healthcare can be assisted by examining some of the factors in the loss of life in aviation.

Critical lessons for healthcare can be gleaned from what has leaked out from the investigation, and what is known about the training and culture that pervades the airlines in South Korea.

On July 6th, Asiana flight 214, a B-777, hit the sea wall on approach to San Francisco airport, causing the death of three passengers. While the accident investigation for flight 214, or the "root cause analysis", is not complete, much is already known about factors that contributed to the accident. Airline captain and CEO of LifeWings, Steve Harden, suggests "Critical lessons for healthcare can be gleaned from what has leaked out from the investigation, and what is known about the training and culture that pervades the airlines in South Korea."

In the organizational culture in Korean airlines, most of the pilot training for South Korean airlines is conducted by expats. Many of the flight instructors for KAL and Asiana are American pilots (with a sprinkling of Britons and Australians). Years ago, Korean airlines had a horrible safety record. As a result, American and western European aviation authorities approached the South Korean airlines and told them they needed to rethink their whole approach to training and competency checks or be banned from the skies over the western world. Subsequently, most of the Korean airline training was contracted to training companies operated by westerners.

After the accident in SFO, many of these expat instructors began sharing their experiences and insights with their aviation colleagues around the world.

Here are four lessons that healthcare can learn from the tragic accident.

1. Beware of over-reliance on technology.

The pilot in command of the flight that day had over 10,000 hours of flight experience. He was not a rookie. However few of those hours were logged while in actual physical control of the airplane - what pilots call "hand-flying." The Koreans have an unwavering faith in the autopilot and automated flight systems of the modern jetliner. Almost all of their flight time is accrued while the airplane is actually being "flown" by the computer. Typically, less than three minutes of each 8-hour flight are spent in hand-flying. As one American flight instructor said, "Requiring them to shoot a visual approach (without the autopilot) struck fear in their hearts." Over-reliance on technology causes several issues including degradation in basic flying skills, and a tendency for a "lack of engagement and mindfulness" in monitoring the computer and the computer generated flight path.

When the airplane was not doing what it was supposed to be doing on approach to SFO, the pilots didn't sense it in the "seat of their pants" (lack of basic flying skills) and the crew failed to monitor the computer generated flight path until it was too late (lack of mindfulness). The lesson for healthcare is clear. Electronic medical records, computerized physician order entry, and decision support tools will never replace "basic flying skills" in medicine.

2. Culture eats initiatives for lunch.

Just like airlines in the western world, Asiana has a CRM (TeamSTEPPS) program. CRM is a big part of their initiative to change their accident rate. CRM training is conducted. CRM concepts are embedded in policy and procedures. CRM skills are assessed during competency checks. CRM language is used. Yet CRM behaviors are rarely used. Why? Culture. Their culture is all about "face" and respect for seniors. Culturally, it is bad form to mention something that might reflect badly on the senior person of the group. Observing this overwhelming reluctance to speak up when needed, the expat flight instructors coined a phrase, "You can't overcome 3000 years of culture."

During the last two minutes of the accident flight, the descent path to the runway was obviously and clearly wrong, yet none of the other three crew members in the cockpit said anything to the Captain.

The lesson for healthcare? A TeamSTEPPS program and a great Lean process improvement program will not yield sustainable results if there is no culture change.

3. Protecting the powerful is counter-productive.

This culture work is primarily a function of leadership and administration. 3000 years of culture can be overcome, but it takes a concentrated effort by leadership to communicate the expectations, to reward the new behaviors, to celebrate the results, to personally model the new behaviors, and to eliminate those unwilling or incapable of change. There must be a willingness to impose consequences for those unwilling to act in a manner consistent with the organization's values for safe care.

Many expat instructors in Korea only work there for four or five years. Eventually, they will have to give a “fail” on a competency check for a senior pilot in a position of leadership in the airline. This is not acceptable in the Korean culture. The rest of the airline sees the "protection" offered the favored few as inherent, with detrimental effect on the organizational performance.

It is not uncommon to hear a leader in a hospital that is implementing TeamSTEPPS say, "We can't afford to require Dr. Smith to participate in TeamSTEPPS training. He brings a lot of revenue to the hospital and if we make him play, he'll leave and take his business across town." Or, "I know she is disruptive and hard to work with, but she is a big producer." Everyone else in the organization is watching how you respond in these situations.

4. Even one person who can speak up and be assertive can save a life.

Despite all the cultural barriers that might have prevented it, one of the Asiana flight attendants used a TeamSTEPPS behavior when it mattered most. After the crash and when the airplane had come to a stop, the Captain announced that the passengers should not evacuate. One of the flight attendants saw flames outside the window and called the Captain on the intercom to let him know they needed to evacuate. This willingness to speak up undoubtedly saved a lot of lives.

About LifeWings:

LifeWings Partners creates documented, sustainable improvements in cost reduction, efficiency, reliability, safety, and quality by combining the best of Lean and TeamSTEPPS. LifeWings has improved the financial bottom line and patient safety record of over 140 hospitals worldwide. The LifeWings coaching cadre of pilots, astronauts, physicians, nurses and Toyota-trained Lean experts train more than 13,000 administrators, physicians and staff per year. Measurable results are guaranteed in all LifeWings’ initiatives. Documented return on investment typically exceeds 300%. To find out more, please visit http://www.saferpatients.com or https://www.facebook.com/LifeWingsSaferPatients.

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Stephen Harden

Angela Myers
LifeWings Partners, LLC
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