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High Reliability Healthcare

Observations and Lessons Learned on the Journey to High Reliability Health Care.

Transferring Aviation Industry Improvements to Health Care


Chris Hart, former Chairman, National Transportation Safety Board

Followers in the high reliability space frequently tout the airline industry’s success in safety and speculate about rolling out the same principles to other industries.

Especially in the last decade, there’s been a great deal of discussion about applying concepts of high reliability to health care. It’s certainly worth our time exploring. In aviation, an industry considered “very safe” in 1997, there’s been an 83% decrease in fatal accidents from 1997-2007. This success is largely because system think was fueled by collaborative proactive safety information programs.

Similarities Between Health Care and Aviation
Health care and aviation have a lot of similarities. Staff are highly educated professionals who are trying to do the right thing, often under extremely stressful circumstances. Both are incredibly complex systems, comprised of several coupled subsystems.

It’s also interesting to note that both industries rely on several system interdependencies, especially:

  • pilots
  • controllers
  • doctors
  • lab workers
  • mechanics
  • manufacturers
  • regulators

Safety issues are likely to involve interactions between parts of a system, a concept familiar to those working in health care and aviation. Because of that, both industries work with redundancies to help prevent errors. This can cause tension between safety and productivity. Despite these tensions, there are opportunities to use safety data proactively.

One of the most significant and unanticipated outcomes of the collaborative process is that it also improves productivity while improving safety. This flies in the face of conventional wisdom that improved safety and improved productivity are mutually exclusive and compete against each other. The improved productivity is important because history has demonstrated that safety improvement programs that hurt the bottom line are not generally sustainable. The Commercial Aviation Safety Team (CAST) has been sustainable for more than two decades because it also helps the bottom line . Savings are realized not only in terms of funds not expended because accidents didn’t happen — which is obviously very difficult to measure — but in terms of immediate operations and maintenance savings due to more effective and efficient operations because the collaboration helps the subsystems work better together.

One real advantage of working within a complex system is the availability of training to staff at all levels. In aviation, this means we don’t just train the pilots. Maintenance and air traffic control staff also undergo routine training. This kind of operational feedback loop helps inform improved design and training. Our motto is aviation is very much alive in health care:  Anyone involved in the problem should be involved in the solution.

Industry Differences
Despite these similarities, there are differences between aviation and health care that could affect implementation of high reliability principles. For one, the high number of state regulatory agencies health care personnel must juggle is far greater than it is for their peers in aviation, which is regulated almost exclusively by the federal government.

There’s a far greater stigma on error in health care, which reduces the likelihood and viability of near-miss reporting programs.

In health care, there’s considerably greater variability—as there should be as patients’ conditions are more complex than ever before. Still, this reduces both the role of checklists and the precedential value of historical data.

Staff is also organized into larger teams in health care than what we’re used to in the airline industry. This typically equates to a greater authority gradient. On the plus side, larger teams are also more likely to engage in internal safety competitions.

A popular saying in among quality professionals is “there is no one-size-fits-all” approach. That’s true but the structural similarities in aviation and health care suggest that much of the collaborative action safety improvement work is largely transferable. 

Christopher A. Hart is the immediate past Chairman of the National Transportation Safety Board, the federal agency that investigates transportation accidents to determine what caused them and to make recommendations to prevent them from happening again. In that capacity, and before that as a senior official in the Federal Aviation Administration, he has seen how successful the collaborative Commercial Aviation Safety Team (CAST) has been at improving aviation safety, and he is seeking to transfer that success story to other industries that are involved in potentially hazardous endeavors, such as health care. Mr. Hart has a BSE and MSE in Aerospace Engineering from Princeton University and a JD from Harvard Law School.