Aviation history buffs (and those who have read Malcolm Gladwell’s Outliers) are familiar with the events that conspired to result in the deadliest airline accident in world history: the KLM-Pan Am crash of 1977 that took 583 lives in Tenerife, the Canary Islands. John Nance, pilot, attorney, ABC aviation commentator and author of thrillers and the non-fiction book Why Hospitals Should Fly, used the story to great effect during a riveting keynote address Monday morning, officially opening the AHRA annual meeting.
Nance related the events that lead up to the crash: a highly experienced pilot who was in a hurry because he was approaching his fly-time limit; a co-pilot who deferred to rank when he should have questioned a flagrant breech of protocol; and mistaken communications.
“I want to help give you some new tools,” he told the audience, after recognizing the critical role of the radiology administrator in the quest for patient safety. “You are the generals.”
No. 1: “Your most important role and our greatest challenge in health care is communications,” he believes.
No. 2: If you see it, you own it. Nance says that this was one of the cornerstones of the campaign to make flying safe. Just as the airline industry had to overturn a culture in which the captain was God, so does health care have to undo the habit of deifying physicians and executives. Staff needs to be empowered to speak and act when they see a safety breech.
No. 3: Nance says the most dangerous phrase in health care is: “This is the way we’ve always done it.”
Health care leaders must always be on the lookout for the three enemies of patient safety, Nance warns: perception, assumptions, and communications.
“We see things that are not there,” he says. “We have to operate on assumptions, but they are dangerous. And communication is our greatest dysfunctionality.”
Understand the 12.5% rule, he urges. “12.5% of the time, people who understand everything about their business do not understand what they are saying to each other,” he explains. “Its endemic to the process of human communication that we think we are better at it than we are. Add in fatigue and distraction, and we are up to 40% discordance.”
Nance emphasizes that as human systems, we can never achieve perfection. But he does believe that systems can get us there. “The KLM-Pan Am disaster… came about because of systemic elements that set everyone up. Mainly what we had was culture. It was a system that let assumptions run wild.”
Nance described the three tiers of a healthy safety system:
1. Minimize error through training procedures, adherence to checklists, evaluations and standardization.
2. Expect errors, nonetheless, and build a system to fully anticipate and absorb those errors that will still occur.
3 If somebody in an imaging room says something is wrong, listen. Always have no better than a 50% expectation of success all of the time. Perpetually maintain a systemic expectation that something will go wrong despite all of the training.
“When you create collegial interactive teams it is wrong to have a leader and follower,” he emphasizes. “Your team needs to speak freely. We have got to break down the barriers that separate us as people, because first and foremost, it is all about communication. Here’s what we cannot do: We can’t bully people into doing things that we shouldn’t do.
Same with financial people: we cannot replace this contrast with something that is cheaper.”
Nance left the audience with another flight anecdote, put this one had a happier ending than the KLM-Pan Am disaster. He was a C-1 pilot, lieutenant colonel in the reserves, about to depart on a training flight from Spokane to Anchorage. His crew included a brand new road master, 18 years old. “The flight suit still has all of the factory creases,” Nance recalled. “I walked into the room and shook everybody’s hand, and looked them in an eye, and that’s how I was trained to build a team. Then I said one more thing: ‘You have to be willing to tell me if you think, feel, or believe intuitively that something is wrong’.”
Nance was so worried about the young road master who wouldn’t look him in the eye that he brought him up to the flight deck and said, “I really need to know if you’re going to speak up.”
The road master replied: “I’m Generation X, if you give me permission I will.”
The plane lifted off and was at 14,000 feet headed to 17,000, when the new road master said, “I could have sworn