Coauthored by Steve Kreiser, Partner, Press Ganey Strategic Consulting, and former U.S. Naval FA-18 pilot.
On February 15, there was significant media coverage of testimony from the acting FAA administrator, who appeared before the Senate Commerce Committee to address the software problem that halted flight departures nationwide last month, near misses between two planes in New York and Texas in the last two months, and other recent safety problems.
In the aviation industry, these near misses are not brushed off as isolated incidents or looked at with a sense of self-satisfaction or pride since nobody was harmed or “nothing really bad happened.” Instead, with a deep sense of preoccupation with failure, these types of events are looked at as early warning signs and symptoms of latent issues that, if not quickly and thoroughly addressed, can and will lead to more serious events in the future—up to and including death. These latent issues can be system related, like chronic understaffing, crew fatigue due to long hours and overtime, or maintenance or equipment failures. They can also be due to culture and human performance failures, where people are not working together effectively, leaders are not reinforcing behaviors and expectations, or teams are not treating one another with respect to create environments of psychological safety.
The healthcare industry can learn some important lessons from the aviation industry’s response to these near-miss events. When past patient safety data has been extrapolated, it has been likened to an airplane crashing every day. A very recent study in the January 2023 New England Journal of Medicine reported that preventable adverse events categorized as serious, life threatening, or fatal were identified in approximately 1% of hospital admissions. In 2022, there were 33 million hospital admissions. And 1% of that is 330,000, which is ~900 serious, life-threatening, or fatal events per day. If 1% of the 25,000 daily flights in the U.S. had serious, life-threatening, or fatal incidents, it would be a national catastrophe.
Furthermore, this data was prior to the COVID-19 pandemic, where we have seen a worsening of safety outcomes. It also does not include harms across the entire continuum of care, nor does it include harm beyond physical harm, such as emotional harm. However, despite this worrisome data on the harms in healthcare, the same media attention and certainly senate attention has been lacking. A 1% failure rate—in an era where the data exists to identify harm and the pathway towards zero harm is known—is no longer acceptable.
To be fair, HHS recently convened a small group of CEOs to discuss how to energize patient safety efforts and is launching an Action Alliance, and the President’s Council of Advisors on Science and Technology is looking at opportunities to improve patient safety. But in a recent ACHE poll of CEOs, CEOs reported that attention to safety is not the top priority—staffing and finance are top of their lists, and finance has been at the top of the list for the last 16 years! How can safety not be at the top? It actually falls fourth on the list. “First do no harm” must be our core value in healthcare, as our safety issues impact far more people than aviation—and importantly, delivering safe care drives workforce engagement and retention. Boards of directors need to fully support this core value, hire CEOs that put safety first, hold them accountable for safe outcomes for patients, families, and staff, and, importantly, ensure the necessary resources to enable this to happen.
As aviation leaders come together to implement the solutions to their safety issues, healthcare leaders must do the same—and with even more focus and commitment, given the impact to patients and staff when they are most vulnerable. We know what we need to do: We must implement high reliability principles and practices that have come to healthcare from aviation and other industries as a way to optimize safety. We know they work in healthcare to prevent harm.
The healthcare industry must act to eliminate preventable harm now, and not tolerate a 1% harm rate as business as usual, at a lower priority than staffing and finance. And the roadmap exists. Just like aviation industry leaders are taking the time to ensure safe practices and systems continue to be fully in place and have not drifted, healthcare leaders and boards need to ensure they are leading a culture of safety, continuously anticipating where the next patient or employee harm event will occur, relentlessly examining their near-miss and precursor safety events to drive prevention, learning from other industries and organizations, and ensuring safe practices and systems are implemented and sustained. We simply cannot continue to seriously injure or cause the death of 900 people or more per day.
Press Ganey helps healthcare organizations across the country accelerate their progress toward zero harm. Our High Reliability Platform (HRP) and Patient Safety Organization (PSO) provides the tools and technology needed to consistently raise the bar on safety culture and outcomes. And our safety and high reliability consultants work closely with healthcare leaders to stop patient and workforce harm before it happens, from strategy and design through execution and measurement of a robust safety program rooted in high reliability principles and practices. Reach out to a member of our team to see how we can help bring it all together.