40 Years of Learning Culture

This December marks 40 years since the 1978 crash of United Airlines Flight 173[1]. The scheduled flight from JFK International Airport in New York City was bound for a final destination of Portland, OR.

This tragic accident killed ten people while 175 survived. There were many stories about survivors, neighbors living near the crash site, and even a story of an escaped convict on the flight that aided victims until he disappeared into the night. However, the biggest story came months after the crash was thoroughly investigated.

While the immediate issue for the flight crew was dealing with landing gear malfunction and preparing the passengers for a possible emergency landing, the plane ultimately crashed due to low fuel.

According to the accident report adopted by the National Transportation Safety Board on June 7, 1979[2], the probable cause of the accident was stated as follows:

“The NTSB determined that the probable cause of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crew-member’s advisories regarding fuel state. This resulted in fuel exhaustion to all engines. His inattention resulted from preoccupation with a landing gear malfunction and preparations for a possible landing emergency. Contributing to the accident was the failure of the other two flight crewmembers either to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain.”

Initially the main focus after this crash was determining where to place blame and what the captain did wrong, resulting in a multi-year court case. Thankfully though the airline saw this as a wake-up call, realizing human factors were at the core of the problem and a culture change was needed to reduce fatalities.

Programs within the airline industry were established to ensure training allowed everyone to have a say in identifying problems and offering suggestions on how to solve them. They made the transformational switch from a blame culture to a learning culture. A blame culture fosters fear, leading to a lack of reporting and ineffective communication, and even worse can lead people to cover up mistakes. By shifting to a learning culture, human fallibility is acknowledged with communication at the forefront and every error seen as a teaching opportunity. With improved transparency, communication, and a desire to improve, safety issues are detected early, resolved quickly and decrease in frequency.

The road to high reliability for healthcare starts here. Healthcare leaders can learn from the strides made by the airline industry to consistently and visibly support and promote everyday safety measures. The Joint Commission’s Sentinel Event Database[3] reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events. Two of those being insufficient support of patient safety event reporting and lack of feedback or response to staff and others who report safety vulnerabilities. These two items are key to developing a strong learning culture – one preoccupied with failure[4] and understanding root causes to mitigate risk.

Safety Culture requires everyone within an organization to be transparent and act. The common goal is to provide safe, and consistent high-quality care while reducing risk to patients. Learning culture offers the next step in a cycle of continuous improvement, taking what’s been learned through events, near misses, and safety rounds and applying it through actionable steps.

To create a culture of learning, senior leaders must encourage open communication, proactive risk management and continuous learning. Most organizations are learning from their adverse events, but how is your organization expanding Near Miss and Unsafe Condition reporting or leveraging safety rounds to increase data to inform decisions? How is your organization leveraging data from the EMR to identify adverse events and near misses? Contact Verge Health to learn how clients continue to evolve from reactive to proactive along their journey to high reliability using the Converge Platform and Strategic Advisory Services.

Sources

[1] http://media.oregonlive.com/history/other/2014/12/28/NTSB%20investigation.pdf
[2] https://www.oregonlive.com/history/2014/12/portland_airliner_crash_in_197.html
[3] https://www.jointcommission.org/assets/1/18/SEA_57_Safety_Culture_Leadership_0317.pdf
[4] https://trainingindustry.com/articles/strategy-alignment-and-planning/creating-a-learning-culture-for-the-improvement-of-your-organization/?utm_content=cpdc