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As many of you know, I've been a professional speaker for well over two and half decades and, for the last 18 of those years, my primary audience has been healthcare - ranging from individual physician groups through hospitals to most major medical associations. That experience, coupled with my long-time advocacy of patient safety and service quality (as well as governance and improvement of intra-staff relations) meant that it was no surprise on release of Why Hospitals Should Fly that an increasing number of hospitals would want these concepts presented in person by the author.  Each such request presents a wonderful opportunity, since a dynamic verbal presentation provides not only a clear picture of the solutions and recommendations in the book, but goes beyond the text by bringing some of the book's major stories to life (such as the accident at Tenerife in 1977). It this case, a major keynote based on Why Hospitals Should Fly is a chance to breathe form and, quite frankly, excitement into the realization that a St. Michaels environment can be created in almost any medical facility by changing the culture and the focus of the people who are that facility.

Speaking, of course, is a performance art, no matter how important and useful and serious the information presented. But whether a major keynote speech or a seminar, it can deliver depth and understanding that even a dynamic manuscript can't achieve.

Yet, the structure of this message - the keel beam - is vital, which is what this post is all about.

Just this last week I was asked to prepare a summary of one such upcoming keynote presentation centered around the Lessons from St. Michael's, and in writing it, I decided that perhaps it might also be a useful addendum to this blog.  I know, I know, this is anything but the traditional blog, whether the stream-of-consciousnes version or the mini-essay type. But since the birthright of this version is to support the ideas brought together in the book, you might just find this amalgam interesting:

This talk will dive headlong into a set of disturbing realities that block the path between where we are and where we must go in terms of the safety and quality of American healthcare delivery.

For instance:

For at least the last ten years, leaders in all facets of American healthcare have grappled with the terrifying reality that somewhere between 48-thousand to perhaps several hundred thousand patients lose their lives each year unnecessarily to medical practice mistakes in the hospital setting alone. (The death figures do not even touch the staggering assumed number of patients who are injured but survive - patients such as the two women in the past six years who underwent double mastectomies only to find that their records had been mixed up and neither had cancer.) That journey of recognition and initial reaction has led to - among other seminal realizations - acceptance of the heretofore unspoken reality that safety and quality in medical practice are NOT the same thing. Though safety and quality are inextricably intertwined (i.e. You can''t have safety without quality and vice versa), healthcare leaders had to begin looking for entirely new ways of reducing the carnage. That search has led to the following recognitions:

1. The traditional methods of performance improvement (more training, more rules, more effort) seem strangely unable to significantly improve overall system safety.

2. The CULTURE of medicine in America supports the current rate of deaths, survivable mistakes, and near-misses, and the inertia of that CULTURE resists change (recall Dr. Don Berwick's quote that "Every system is perfectly designed to get the results it consistently achieves").

3. Almost all, if not virtually all, medical tragedies and near-misses involve failures in one or more of three basic areas: Communication, Assumption, and Perception.

4. Improving patient safety and service quality requires significant improvements in (1) The rate of successful Communications in medical practice, (2) Decreasing the number of dangerously flawed Assumptions (IE "I thought someone had added the warning in his chart about that allergy"); and, (3) Decreasing the number of dangerous mis-Perceptions (IE "I read that as a 1.0, not a point one!").

5. The functional ability of any medical unit or department to decrease failures potentially leading to adverse patient impact rises in direct proportion to the level of collegiality, human caring, and human interaction among the medical staff.

6. The traditional Physician-Nurse communication relationship is, by definition, dysfunctional and dangerous and must be radically improved.

7. As the Joint Commission has now agreed, disruptive conduct by medical professionals toward each other cannot be tolerated a day longer because it has a direct negative impact on quality of care and medical outcomes, as well as increasing the possibility of medical mistakes reaching patients.

8. Safe and quality patient care, especially in hospital and clinical setting, directly depends on the quality and engagement and attitude of the nurses, yet the state of the nursing profession is one of abject crisis. (Too few nurses, an aging population, massive downward pressure on resources and upward demands for productivity along with an institutionalized rejection of nursing as having a legitimate voice in the governance of hospitals has fueled a cultural epidemic of horizontal hostility directly linked to low quality care and patient injuries and deaths).

The aerospace industry and nuclear power industries have blazed the path to massive cultural change by showing us how to take high-risk enterprises and make them high-reliability and low-risk.  Now medicine must understand and incorporate, on an emergency basis, the same basic human lessons. As for the book, Why Hospitals Should Fly is a compilation of most of the remedies we now know are needed to address these (and other) dysfunctionalities placed in one fictional hospital. If we can't envision such a place, we can't build it.

 John J. Nance

     In Hollywood, the acronym "POV" is universally understood to mean "point of view," and when characters speak through the medium of a script, the "POV" of not only the character, but the scene itself, has to be clearly understood - lest the message or the effect of the scene be confused and essentially squandered.

     The concept of POV can be more than useful to us in healthcare. In fact, when we're responding to the joint emergencies of patient safety and evidence-based best practices, we have a huge problem with the concept of POV: Precisely whose point-of-view are we discussing on any given issue?

     When it's physicians grappling with accommodating best practices versus maintaining extreme physician autonomy, the POV involved is obviously that of the physician's best interests. (Of course, healthcare has traditionally signed off on the idea that the doctor's best interests and the patient's best interests are identical).

     When it's a hospital or major health system's management searching for the balance point between the extremes of ignoring emerging best practice knowledge (at great legal risk) and risking a war with the medical staff by imposing what the "C" suite determines to be best practices, the POV is clearly through the eyes of governance, economics, and managerial prowess.

     And when it's the beleaguered nursing staff facing the Hobson's choice of truly caring for their patients versus doing more with less and less, the POV is clearly one of professional frustration and helplessness, leading to burnout and disconnection.

    "What we have here," said the wonderful Southern actor Strother Martin in the movie Cool Hand Luke (after backhanding Paul Neuman's Luke into the ditch with a shotgun) "...is a failure to communicate!" I've been hammering away for nearly two decades to medical audiences about the inescapable role of miscommunication in every aspect of patient safety and service quality. But the reality is that the type of miscommunication that has done the most damage in holding back a unified view of what is needed in each and every medical facility is essentially a modern version of the Buddhist parable of the blind men and the elephant.

     If you'll recall, each blind man was feeling a different part of the elephant and while accurately relating his own experience and interpretation, was mis-communicating the reality of the pachyderm's overall nature to his fellows - who were simultaneously turning in the same dysfunctional performance. Five or six blind men equaled five or six entirely different Points-of-View, and correspondingly, no possible consensus on the nature of the beast.

     We not only need a common and unified POV to effectively handle the problems we're facing in American healthcare, we need that consensus immediately. In fact, the myriad individual POV's of what ails healthcare are perpetuating the very dysfunctionalities we're trying to cure!

     If, for instance, we get so bogged down in dealing with the necessary but very parochial POV of finance and solvency that all other POV's are eclipsed, the true emergency need to take healthcare from high-risk and low-reliability to the opposite ends of both scales will continue to be held hostage. In that case, the demands for cost-accountability will continue to reign supreme, and we'll end up eventually as embarrassed as the Federal Aviation Administration was a few decades back when the public learned that their FAA had assigned a dollar cost to a human life in order to know when it was cheaper to accept more passenger deaths than require new safety measures. Stop and ask yourself, just how far are we in healthcare from that same point?

     Of course, this is not to flail at the C suite in any way, since there is a clear axiom: Ignore the dollars and the doors close. But aligning the POV's of finance, service quality, patient safety, and practice autonomy with the ultimate POV - that of the patient's best welfare - has clearly become an overriding and immediate Prime Directive (yes, I know, another Star Trek reference).

     Here's the main point I want to get across: Finding a common POV is as easy and effective as making a common pact that first, last, and always the patient's best interests override virtually every other consideration. With that one agreement we can restore sight to the blind and align our focus in the same moment.

     If, for instance, it's the patient's POV that governs, why would anyone advocate for less than a full and robust program in each medical facility to discover and immediately implement the best practices? If we have the patient's POV, why would anyone refuse the nurses a voice in how many hours of care are really needed, undermining their efforts to spend time with their patients and administer the human and humane care that only nurses can provide? If it's the patient's POV that drives us, imagine what else we could accomplish?  Maybe even designing a system in which healthcare professionals and institutions are compensated in direct inverse proportion to the decreasing need for their services.   

     The entire ethos of the St.Michael's Hospital model in Why Hospitals Should Fly is based on the patient's POV, and in my view, it's high time we started openly discussing this as one of the first changes needed in any institution.

     Welcome to the kickoff of my "Flying Hospitals" Blog! The philosophy is simple, but needs to be stated up front:

     WHY HOSPITALS SHOULD FLY presents a model of what a safe, well-run medical facility would look like and feel like if all the great ideas being discussed out there were incorporated into one facility. But this "ideal" is anything but a static target. Instead, St. Michael's (and any good institution that seeks the same level of excellence) is a moving model - a work in progress - and that's where this Website and this Blog come in.

     What I hope to provide over the next few years is a growing body of discussion about how to effect such seismic cultural changes as are presented in the book, as well as provide a growing resource of citations to those institutions that are already incorporating the principles of St. Michael's into their culture. In addition, I want this site to host a healthy running discussion of how to improve the model, change it, and add to it, whether in terms of various components (nursing, administration, ICU setup, etc.), or in terms of overall philosophy, and I know that this information can only come from you who labor daily on the front lines.

     Hearing from you that something Jack (in the book) claimed as a new idea is, in fact, actually up and running in your hospital is precisely what I want, especially if we can send others to your doorstep with questions on how to be equally effective. New papers, studies, and theories are welcome as well, but the most valuable contribution of all from those of you who take the time to communicate is what aspects of the St. Michael's Model are already working - especially "radical" ideas such as turning staffing control over to nursing and reorganizing the physical layout of a hospital floor.

     Remember, though, that the underlying strength of the St. Michael's Model (or that of ANY good medical delivery model) is the human relationship matrix that prevails there. A staff that has yet to learn and embrace the invaluable principles of collegiality, or one that can't focus on and openly discuss the common goal of helping the patient while incorporating deep, mutual respect for each other, can never reach minimally acceptable patient safety or service quality levels. And yes, that's both a pejorative and a proffered axiom, but it is absolutely vital. Hospitals are, after all, human institutions, and the majority of the problems leading to patient safety disasters, staff dissatisfaction, and quality crashes are directly traceable to dysfunctional human interactions in these principal areas: Communication, Perception, Assumption, and Mutual Respect.

      Remember, too, that there are at least 7 massive areas of dysfunctionality in American healthcare, and it's vital we clearly understand those different categories if we're to effectively solve the prodigious problems inherent in each. By my estimation, they are:

1. External Insurance (the 'universal coverage' debate that most Americans erroneously think is the only healthcare challenge);

2. The ongoing Internal Insurance crisis for practitioners and medical institutions;

3. Physicians in crisis, especially in terms of the daunting challenges to a happy practice and the degree to which our medical schools must change their training (and are loath to do so);

4. The near-meltdown of the Nursing Profession and the urgent need to recognize how perhaps the most vital lynchpin in the hospital-patient safety equation is teetering on the brink;

5. The Medical-Legal disaster, in which I can tell you as an attorney with special expertise in this area that the Tort system will never be able to serve the interests of the American taxpayer and absolutely must be disconnected from what is in fact medical MIS-practice in probably 90% of the cases;

6. Patient Safety, and the ongoing challenge of changing a high-risk human endeavor to a low-risk, high-reliability operation;

7. The overall philosophy of American healthcare, and the need for us as a people to debate and decide whether it is, legitimately, an "industry," or something else entirely.

So, again, welcome to the kickoff of what I trust will be a lively and growing forum of dedicated professionals equally concerned with overhauling "The Way We've Always Done It!"

John J. Nance

Seattle, May 21, 2008