1. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 0 0 Aviation Safety Information Processes: Useful in Health Care? Presentation to: Pillsbury Winthrop Shaw Pittman Health TechNet Name: Christopher A. Hart Date: October 17, 2008 Federal Aviation Administration

2. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 1 Can Aviation Help Health Care Use Information Proactively to Reduce Mishaps? The Context Challenges and Solutions Similarities and Differences Aviation Successes and Failures Improving Safety and Productivity, Too The Role of Leadership Using Information Proactively in Health Care?

3. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 2 More System Interdependencies – Large, complex, interactive system – Often tightly coupled – Hi-tech components – Continuous innovation – Ongoing evolution The Context: Increasing Complexity FACILITIES PEOPLE MATERIALS TOOLS PROCEDURES SOFTWAREEQUIPMENT The System Safety Issues More Likely to Involve Interactions Between Parts of the System

4. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 3 Effects of Increasing Complexity: Human Error More Likely Because System More Likely to be Error Prone Operators More Likely to Encounter Unanticipated Situations Operators More Likely to Encounter Situations in Which “By the Book” May Not Be Optimal (“workarounds”)

5. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 4 The Result: Front-Line Staff Who Are - Highly Trained - Competent - Experienced, -Trying to Do the Right Thing, and - Proud of Doing It Well... Yet They Still Commit Inadvertent Human Errors

6. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 5 When Things Go Wrong How It Is Now...How It Should Be... You are humanYou are highly trained and If you did as trained, you would not make mistakes Humans make mistakes so You weren’t careful enough Let’s also explore why the system allowed, or failed to accommodate, your mistake so You should be PUNISHED!Let’s IMPROVE THE SYSTEM! and so and

7. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 6 Fix the Person or the System? Is the Person Clumsy? Or Is the Problem... The Step???

8. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 7 Enhance Understanding of Person/System Interactions By: - Collecting, - Analyzing, and - Sharing Information

9. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 8 “We Knew About That Problem” Major Source of Information: Hands-On “Front-Line” Employees (and we also knew it might hurt someone)

10. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 9 Objectives: Make the System (a) Less Error Prone and (b) More Error Tolerant

11. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 10 To Err Is Human: Building a Safer Health System “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.” Institute of Medicine, Committee on Quality of Health Care in America, 1999 The Health Care Industry

12. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 11 –Stigma Associated With Errors –Many Interacting Components Working Together –Continuous Innovation, Rapid Introduction of Complex New Technologies –Usually Several Links in Mishap Chains –Typical Response to Errors is Punishment –Safety vs. Production and/or Throughput –Litigation Potential Health Care and Aviation Working Together: A Significant Win-Win Similarities:

13. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 12 Win-Win (con’t) –Inherent Reporting Incentive (e.g., Pilots) –Less Operational Variability; Thus, Activities Generally More Prescriptive, Less Judgmental –Less of a “Craftsman’s Guild” Environment –Smaller, More Homogeneous “Teams” –Workforce Consisting Mostly of Employees –More Media, Political Attention – Public Fear of Flying, Thus  More robust data collection infrastructure  Reporting, tracking, and trending of near misses –Non-Adversarial Mishap Investigation (NTSB) –Federal vs. State Law Differences – Aviation Has:

14. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 13 Most Data Lost Forever Current System Data Flow Currently Only a Minute Portion of Data is Collected and Analyzed

15. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 14 INCIDENTS ACCIDENTS UNREPORTED OCCURRENCES Heinrich Pyramid (NEAR MISSES) Mandatory Reporting Voluntary Reporting

16. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 15 Legal Concerns That Discourage Voluntary Collection, Analysis, and Sharing Public Disclosure Job Sanctions and/or Enforcement Criminal Sanctions Civil Litigation

17. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 16 Typical Cultural Barrier Middle Management “Production First” Front-Line Employees “Please the Boss First… THEN Consider Safety? ” CEO “Safety First”

18. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 17 Next Challenge Legal/Cultural Issues Improved Analytical Tools As we get over the first hurdle, we must start working on the second...

19. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 18 Information Overload

20. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 19 Tools and processes to convert large quantities of data into useful information Analysts DATA USEFUL INFORMATION Data Sources Info from front line staff and other sources Tools Processes Smart Decisions Identify issues Prioritize Develop solutions Evaluate interventions From Data to Information

21. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 20 Analytical Tools Must Support Development of -- Interventions that address SYSTEM issues, not just OPERATOR issues, and Analytical Challenges System interventions that – Are SYSTEM-WIDE in scope, and – Focus more extensively on HUMAN FACTORS

22. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 21 65% Decrease in Commercial Aviation Fatal Accident Rate Since 1997 Aviation Success Story largely because of Proactive Safety Information Programs P.S. Aviation was already considered VERY SAFE in 1997!! plus System Think

23. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 22 Aviation “System Think” Success Engage All Participants In The Process of Identifying Problems and Developing Remedies Airlines Manufacturers – With the systemwide effort – With their own end users Air Traffic Organizations Labor – Pilots – Mechanics – Air traffic controllers Regulator(s)

24. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 23 Aircraft Manufacturers are Increasingly Seeking Input, Throughout the Design Process, From Manufacturer “System Think” Success - Pilots - Mechanics - Air Traffic Services (User Friendly) (Maintenance Friendly) (System Friendly)

25. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 24 1995 – Cali, Colombia Risk Factors –Night, Mountainous Terrain –Airport in Valley –No Ground Radar –Airborne Terrain Alerting Limited to “Look-Down” –Last Minute Change in Approach  More rapid descent (throttles idle, spoilers deployed)  Hurried reprogramming Navigation Radio Ambiguity Spoilers Do Not Retract With Power Failure: Inadequate “System Think”

26. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 25 Operational –Extra Vigilance re Last Minute Changes in an Approach!!! Recommended Remedies Include: Aircraft/Avionics – Enhanced Ground Proximity Warning System – Spoilers That Retract With Maximum Power – Require Confirmation of Non-Obvious Changes – Unused or Passed Waypoints Remain In View Infrastructure – Three-Letter Navigational Radio Identifiers – Ground-Based Radar – Improved Reporting of, and Acting Upon, Safety Issues Note: All but one of these eight remedies address system issues

27. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 26 Icing on the Cake: $ avings* - Immediate - Significant *Significantly More Than Savings From Mishaps Prevented

28. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 27 Two Levels of Savings Ye Who Can Fix Staff AND OTHER Sources Information about Safety, Efficiency, Reliability, and Other Productivity Metrics First level (immediate) savings – Bottom-line benefits ancillary to safety improvements Second level (potentially much larger) savings – Information pipeline contains more than safety

29. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 28 Better Labor Relations - Transforms workforce from brunt of blame when things go wrong, to valuable source of information about potential problems and how to remedy them, i.e., converts labor and management from Adversaries to Partners in Improvement Other Potential Benefits: Reduced Legal Exposure - Collecting, analyzing, and sharing will become industry standard for most, if not all, potentially hazardous endeavors; woe to those who don’t

30. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 29 - Demonstrate Safety Commitment... The Role of Leadership - Include “Us” (e.g., System) Issues, Not Just “You” (e.g., Training) Issues - Make Safety a Middle Management Metric - Engage Labor Early - Include the System -- Manufacturers, Operators, Regulator(s), and Others - Encourage and Facilitate Reporting - Provide Feedback - Provide Adequate Resources - Follow Through With Action But Acknowledge That Mistakes Will Happen

31. Aviation Safety Information Processes Useful? October 17, 2008 Federal Aviation Administration 30 Thank You!!! Questions?