But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Thursday, April 28, 2011

Sully inspires and presses for action

Captain Chesley "Sully" Sullenberger was the guest of honor at a "Patient Safety Leadership Roundtable" hosted at MIT by a great group of people* from the Boston area.

Many people know of Sully from the dramatic Hudson River emergency landing in January of 2009, but he also is an expert on quality and safety improvement in the air transport industry. He was here to discuss possible applications of lessons learned from that industry to the health care field.

A key one, of course, is the use of crew resource management techniques. He defined CRM as "a compact, with defined goals and responsibilities" among team members. He noted, "These are not soft skills. They are human skills. They have the more potential to save lives than new medical technologies."

Referring to the current interest in checklists, he reminded the group: "A checklist alone is not sufficient. What makes it effective are the attitude, behavior and teamwork that go along with the use of it."

When I suggested that, in health care, the implementation of CRM management also suggests inclusion of patients and families in the "crew," he concurred, saying, "We have to listen to expertise, wherever it comes from."

He called on the group to apply a sense of urgency to this problem. Citing several publications, including this article on the temporal pattern of harm by Landrigan, et al, in the November 25, 2010, issue of the New England Journal of Medicine, he noted that there had been a flat rate of improvement in this field (charts excerpted below).

"I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

He remarked on the scattered application of systemic approaches to safety in the health care industry: "We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

* Jody Hoffer Gittell (Relational Coordination Research Collaborative, Brandeis University, MIT Leadership Center); John Carroll (MIT Sloan School, Lean Advancement Initiative); Jon Chilingerian (Brandeis University); Amy Edmondson (Harvard Business School, MIT Leadership Center); Ed Schein (MIT Sloan School, MIT Leadership Center).

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