Resistance to standard work preventing better, safer care from taking flight

Resistance to standard work preventing better, safer care from taking flight

I flew home the other day in a small commuter jet, after a long day of meetings in Regina. I love this flight: 35 minutes of flying over our patchwork prairie.  I was seated in the front row aisle seat, so instead of looking out the window, I had the the opportunity to watch the pilot and copilot fly us home.  You don’t often get to do this anymore. Commercial airline pilots used to invite you in to the cockpit all the time, to watch and learn. But the additional security measures instituted after 9/11 have pretty much stopped this practice.

I had a clear line of sight and this is what I saw: teamwork, vigilance, and a commitment to executing a well thought-out plan.  Working as a team, the pilot and copilot shared the responsibilities and tasks.  They worked together so closely that at one point it looked like both pilots had their hands on the throttle as we accelerated down the runway.

We love to make comparisons between healthcare and aviation.  But from where I sit, healthcare has a long way to go before we can say that we are “just like” the aviation industry when it comes to safety and teamwork.  Many in healthcare protest when the idea of “standard work” in medicine is even raised. Physicians fear that our autonomy is threatened when we are asked to manage medical problems or provide care using a clinical pathway — even when we, the doctors, are given the opportunity to create the pathway for our patients.

Dr. Philip Fourie, family physician and past president of the Saskatchewan Medical Association, told me a story that helps him understand and explain to physicians why we need to be more thoughtful about professional autonomy.   At the Canadian Conference on Physician Leadership ,  Dr. Fourie had the opportunity to hear Jeff Skiles speak on the importance of professionalism in healthcare. Skiles was copilot on US Airways Flight 1549, the plane that was masterfully landed in the Hudson River after developing a complete engine failure minutes after take off.

He described how the airline industry used to tolerate pilot autonomy: “I’ll do the preflight check the way I choose to. I’ll lower the landing gear when I judge it necessary.  I’m an expert. Your checks and processes lessen me as a professional.”

But planes would fall from the sky, lowering the landing gear would be forgotten, and pilots — along with their passengers — would die. As Dr Fourie said to me, “As a passenger, I would not get on a plane flown by a pilot who held onto these beliefs.  Why do we tolerate this in healthcare?”

Does anyone think less of pilots because they, as a profession, came together with their industry partners, to set standards and processes to improve the safety of flying?  We need to adopt the same behaviours and practices in healthcare.

What did you think of this post? Did it affirm your view on the topic? Change your thinking? Let us know, using the Inspire-o-meter below.

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6 Responses to “Resistance to standard work preventing better, safer care from taking flight”

  1. Paul Levy
    October 25, 2012 at 8:10 pm #

    I’m not sure I have the whole answer, Susan, but I do believe the impetus for standard approaches must come from the clinicians themselves, as opposed to administrative leadership. We need to engage their intellectual curiosity and training as scientists and show that reduction of variation is essential for quality improvement. We found that our doctors found this to be engaging and consistent with their professional values.

    Brent James offers the best description of this process that I have seen. Look here:

  2. Paul Levy
    October 24, 2012 at 7:48 am #

    There’s the old joke about the difference between a pig and a chicken, when thinking about a breakfast of bacon and eggs. The pig is committed, the chicken involved.

    Are pilots more committed because they are also passengers in the airplane? Are doctors only involved? Is that why it is harder to get their attention?

    • Dr. Susan Shaw
      Dr. Susan Shaw
      October 24, 2012 at 9:50 pm #

      Hi Paul. Yes, you are right, the pilot has a lot more at risk than the doctor if a key step is omitted or an error is made.

      Many clinicians see standardization as a threat rather than the opportunity that it truly can be. Any tips on how to shift this mindset? I’m sure you have had successes (and perhaps the occasional failure) from which we all can learn.

  3. Lisa Alspach
    October 23, 2012 at 12:55 pm #

    Excellent post Dr. Shaw. Often I have heard resistance to implementing best practice voiced in the form of, “that may work there…but it won’t work here. We’re different”. I believe we need to remind ourselves that in health care, we share more similarities than differences when it comes to the applicability of best practices.

    Your post also reminds me of a quote I’ve made note of regarding standard work. Dr. Atul Gawande wrote about an orthopedic surgeon at his Boston hospital who has sought to standardize joint-replacement surgery. “Customization should be 5 percent, not 95 percent, of what we do,” the surgeon told Dr. Gawande.

    • Dr. Susan Shaw
      Dr. Susan Shaw
      October 24, 2012 at 9:18 am #

      Thanks, Lisa, for your comments and for further highlighting the reality that much of what we, in healthcare, do can be standardized. Physicians aren’t the only professions who resist the idea of standard work. But perhaps, by virtue of our position, we can be the greatest advocates or resistors for the creation and use of standards.


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