Dealing with Culture Shock: The Aviation and Health Care Industries

One of my favorite things to do is travel. Traveling provides me with an unmatched exhilarating sense of adventure. Whenever I casually walk down an unknown bustling street, my sense are overloaded with new sights and smells. This kind of excitement is unbelievably addicting. My mind just races with comments. What is that brilliant green dress she’s wearing made of? Can you really eat that? Whoa, where did all of those chickens come from? Did those kids just point and laugh at me? Is his cell phone really that tiny? Why is everyone so tall?

Do I ever experience culture shock? Sure. Every new environment will take some time to adjust to, but the challenges of getting around and living outside of my comfortable apartment in Michigan is all part of the fun of traveling.

What about the culture shock of transitioning from one industry of work into another? The University of Michigan IHI Open School Chapter’s Monthly Speaker Series guest, Gary Sculli, probably does not have many positive feelings associated with his move from the airline industry into health care. Gary Sculli is currently a Program Manager at the National Center for Patient Safety in Ann Arbor, MI. He has both extensive experience as an airline pilot and is a registered nurse.

As Sculli starkly contrasted the two industries, it was clear that the airline industry and health care were two very different beasts. While it may have been difficult for me to adjust to taking cold showers while I was in Ghana, “traumatic” would be the word I’d choose to describe a move into health care from the airline industry. Here are some differences at a quick glance.

Airlines	Health Care
Team training	Hierarchical barriers
Human Factor awareness	Human Factors NOT emphasized
Standardization	Varying degrees of standardization
Checklists discipline	Expectation to complete outside functions
Formalized recurrent training	Haphazard recurrent training
FAA mandated performance checking	Absence of mandatory performance checking

Not only are there differences in work environment between the two fields, but health care is associated with higher error rates—rates that make up the harrowing statistic of up to 98,000 deaths a year due to medical errors, published in the IOM Report, To Err is Human in 1999. A recent study evaluating quality improvement in health care’s progress since the publication of To Err is Human reports the sobering fact that not much has changed. Just as many people become victims of medical error today. While a lot of improvements have been made, we still have a long way to go. According to the Joint Commission, at the root of many of the errors we see in health care are communication and organizational culture. So, what health care needs is a cultural transformation. With the likes of Gary Sculli, we are well on our way on the journey towards safer health care.

Being flexible and keeping an open mind are two important items to pack when traveling to ensure a positive experience. Gary Sculli surely did not forget to pack these on his move. He took the lemons he found in health care and made lemonade by applying effective communication and leadership strategies practiced in the airline industry to health care in order to make health care more effective and reliable. In his discussion, Sculli outlined the concept of crew resource management as a team building effort to not just strive towards eliminating error, but more importantly, how to manage error when it does occur. He also discussed different leadership styles, being a dictator or facilitator, and the health care consequences associated with each. What else is needed to make health care more reliable? Sculli illustrated the need to redesign health care to support “situational awareness,” being able to perceive, comprehend, project, make decisions, and perform actions on variation in one’s environment. Check out the University of Michigan IHI Open School website for more information on topics discussed at the Monthly Speaker Series event.

The application of many of these airline tools have been able to make some great changes in health care. With the use of checklists, many hospitals have been able to effectively standardize procedures and eliminate hospital acquired infections. Through communication training among the staff of the operating room, physicians have been shown to be more adept at soliciting feedback and taking appropriate actions, while nurses and other members of the OR team have moved away from the “hinting and hoping” strategy of declaring an error to providing feedback in a direct, concise, and specific manner.

Perhaps what I love most about traveling is that once you move past the initial jolt of shock that the differences of a new location can give you, people are really all the same. I’ve learned so much from the cultures and people I have interacted with on my travels and have adopted some of these practices into my daily life. Personally, these adopted practices have made my life better. Is health care really so different from the airline industry? They are both fields that include teams of individuals performing highly specialized skills with extreme risk and small margins of acceptable error. With the help of inspiring leaders like Gary Sculli, health care is adopting the best practices from other industries. If we keep moving in this direction, I’m sure the next culture shock health care will give is one of success that we can all be proud of.

News Flash!

U-M hospitals win award for being one of the nation's safest by Leapfrog! Click here to read more!

Gut Check: University of Michigan's Medical Error Disclosure Program

We're all familiar with the story of George Washington and the cherry tree that gave rise to the famous line, "I cannot tell a lie, father, you know I cannot tell a lie!"

What motivated him to tell the truth? Was it some sort of rumbling gut feeling that told him that it was the right thing to do? Probably the same motivating forces that led the University of Michigan Health System (UMHS) to transition to a medical error disclosure program that is fully integrated with the hospital's quality improvement and patient safety efforts in 2001.

Unfortunately, our health care world today is one in which we don't follow George Washington's leadership. Medical malpractice is guided by a "deny and defend" approach. Insurers and counsels often urge secrecy, dispute fault, deflect responsibility, and make it as slow and expensive as possible for patients to continue the already unfavorable process. As a result of this approach, it's not uncommon for medical lawsuits to take five or more years to resolve. Information about the cause of injuries is also denied to patients and families for long periods of time, compensation is unavailable to those who most need it. Worst of all, there is little meaningful quality feedback for providers. Patients and providers are placed in adversarial positions, allowing fear to fester in between.

Turning the current, "deny and defend" approach to medical liability on its head, the current system at UMHS emphasizes full honesty and transparency between staff and patients and encourages the participation of risk management, regardless if a medical error is involved. At UMHS Medical errors are identified and collected by all staff, patients, and family members. Experienced risk managers with a clinical background investigate the claims, and care quality is evaluated. The system's three guiding principles are:

1. Compensate quickly and fairly when unreasonable medical care causes injury.

2. Defend medically reasonable care vigorously.

3. Reduce patient injuries (and therefore claims) by learning from patient's experiences

Most importantly, conclusions of the investigation are shared.



We were fortunate to have Rick Boothman, UMHS Chief Risk Officer, join the University of Michigan's IHI Open School for our first Monthly Speaker Series event of the year to discuss UMHS's medical error disclosure program. Boothman's presentation was focused on the underlying principles of quality improvement that help inform the disclosure program.

Boothman's extensive experience as a trial lawyer has given him a strong and almost intuitive sense about cases that he can almost accurately predict if he can win a case. But, he does what he refers to as a "gut check." Would he accept this kind of care for his own mother?

The undercurrent of quality improvement has led to some great results. As reported in the Annals of Internal Medicine in a paper written by Allen Kachalia et. al., with implementation of UMHS's disclosure-with-offer program, the average monthly rate of new claims decreased from 7.03 to 4.52 per 100,000 patient encounters. The average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100,000 patient encounters. The median time from claim reporting to resolution decreased from 1.36 to 0.95 years. Average monthly cost rates decreased for total liability, patient compensation, and non-compensation-related legal costs.

A system that makes patients and physicians happier...and saves money at the same time? My gut is telling me that this is a system that we should take a look at.

Patient Centered Medical Home: An Anchor in the Ocean of Health Care?

The health care system is a ruthless and turbulent ocean. For many patients, even a regular visit to the doctor can be quite unforgiving. With patient safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity concerns, health care visits can feel like navigating the ocean on a flimsy fishing boat. Now that we are transitioning into the phase of implementing and executing health reform, we must push patient-centeredness to the forefront of all our efforts to inform us on how to improve the quality of our health care system.

For example, the concept of the medical home that many say will transform health care into a more coordinated and comprehensive system isn’t just implementing electronic medical records, restructuring care teams that group physicians, nurses, physician assistants and other allied health workers together, redefining scheduling, or figuring out how to pay for these new services. The medical home needs to be a patient-centered medical home—one that actively engages the patient’s needs and concerns. Our system’s struggles with achieving patient-centered care is most evident in how health care providers deliver bad news to patients...

Read the full post at the IHI Open School Blog

Lunch with Dr. Dean Gruner

The IHI Open School is a great resource for learning from the leaders in the health care field. As the first educational event of the year, five IHI members had a causal lunch with Dr. Dean Gruner, the president and CEO of ThedaCare. He described the lean processes his Wisconsin-based health system put in place to dramatically improve patient care. We learned about the beginnings of the program, his leadership style, and his thoughts on quality improvement. It was a wonderful opportunity to get a personal look at how the initiatives IHI promotes work on the ground. At the end of the hour, we joined him in a larger lecture where he talked in more detail about the cultural changes associated with quality improvement.

Dr. Jack Billi, the Associate Vice President of Medical Affairs at UMHS, joined us for lunch to add his perspective on lean process. Dr. Billi will come to the Open School in October to lead a lean training session. Watch this space for more information about these sessions and more opportunities to meet leaders in our field!

Steve Brown
Ross School of Business

The Gift of Stories

...My first year of medical school was defined by the time I spent in anatomy. I spent hours probing through various anatomical structure and yet I feel like I only scratched the surface in my pursuit of medical scholarship. But what I did larn during those hours in anatomy lab, as I slowly built an intimate rapport with my first patient, was the invaluable lesson of the joy and fulfillment gained through listening to the stories of every bump, kink, and scar. It is the magnetic draw for these patient narratives that led me to inevitably mature from the dangerous narratives of attempting surgical procedures on myself to attending medical school and working towards becoming a doctor. Your special gift, my first patient narrative, is one that will always stay with me as I continue to learn and never stop listening...

Delivered at the University of Michigan Medical School Anatomical Donations Memorial Service (Sept. 15, 2010)

Click here to read more on the IHI Open School Blog.

Preparing for the Future

This summer, while I was traveling around Ghana conducting clinical quality and management research focusing specifically on the changes posting an OB/GYN specialist in district hospitals has on the hospital and the immediate community, my classmate Charlotte was busy administering a laparoscopic surgery training module to bring the technology of laparoscopy to Komfo Anokye Teaching Hospital in Kumasi, Ghana. Laparoscopic surgery, especially for gynecological surgeries, has been available to developed countries for at least 20 years, but this minimally invasive form of surgery has yet to become standard practice in Ghana. The benefits of laparoscopic surgery are many. It is cosmetically favored by patients and medically, reduces complications like hemorrhaging and has shorter recovery times. It is no exaggeration to say that Charlotte's work is ushering Ghana into a new surgical future that will bring a tremendous amount of public health benefit.

In 1910, Abraham Flexner's report titled, "Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching" ushered and shaped medical education into it's current form. The Flexner Report called for standardization of medical education that was rooted in sound and rigorous biomedical and clinical science challenging the American and Canadian medical education systems to train the highest quality of physicians. Flexner, not a physician himself, wrote a book-length report that was framed with the greater society in mind. He wrote, "The public interest is then paramount, and when public interest, professional ideals, and sound educational procedure concur in the recommendation of the same policy, the time is surely ripe for decisive action."

It has been 100 years since the publication of the Flexner Report and with 100 years of experience of modern medical education, we are due for some reflection on the alignment of the medical education system and the public interest. In an article published in Academic Medicine, Drs. Don Berwick and Jon Finkelstein write and discuss a, let's call it "Flexner Report 2.0", shaping a medical education system that will better prepare physicians to meet the needs of a today's world of health care. Read the article here.

In the article Berwick and Finkelstein outline new values that should complement the current emphasis on biomedical science we receive in medical school. These values include "patient-centeredness, transparency, and stewardship of limited societal resources for health care." There is no time in the current curriculum to add on training in these new skills, many educators would argue. Berwick and Finkelstein also review the innovative programs, including the IHI Open School, that attempt to provide medical students and residents with a foundation in these new skills, as well as outlining a new frame of reference for medical curriculum change that will incorporate these invaluable skills. I certainly can't reproduce Berwick and Finkelstein's eloquence, so I will leave the explanation of the fine details to the article. Definitely a must-read!

In the 100 years since the publication of the Flexner Report, the medical education system has trained millions of physicians who have dramatically transformed health care. It was this cohort of physicians that popularized laparoscopic surgery! Looking just at performance outcomes, we have made incredible gains in both the length and quality of life for our patients. However, there is much more we can do. If we adopt Berwick and Finkelstein's recommendations, we will be poised to create a new physician workforce adept at navigating and continually improving the complexities of health care to consistently meet patient needs. We all need to collectively reflect on and brainstorm innovative interventions to fold the skills of systems thinking into our current medical education system. If we can develop the technology of laparoscopic surgery, I'm confident that we too can succeed in reinventing ourselves to better treat our patients with the tools of quality improvement. In 100 years, the world will surely look very different. I'm imagining a modern metropolis not unlike the life of the Jetsons. But, what will medicine look like? What kinds of public health accomplishments can we celebrate in the next 100 years? Let's work together to reshape medical education so that we will have plenty to celebrate in the future!

What do you think of the Berwick and Finkelstein paper? Leave a comment!

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