Things that we should not learn from airlines

The Event

Recently (Feb 2015) I was waiting at Stockholm to board BA781. It was scheduled to depart at 1850. The departure monitor showed a delayed expected departure time of 2010. Naturally, I was anxious and annoyed. I changed my arrangements in UK to suit a delayed arrival.

I then checked London Heathrow Terminal 5 arrival board which said the flight was on time (in contradiction to the Stockholm departure board). I then checked BA's website which also showed that the flight was on time.

Now my hopes raised slightly. Suddenly Stockholm departure board showed a new departure time reducing the delay and a little later the board at Stockholm stated that the flight will depart on time. We were allowed to board at the originally scheduled departure time without any delays.

I boarded the flight and then cancelled my changed arrangements in UK.

Once we were settled in our seats and the doors were locked the captain made an announcement.

The captain said that there was some equipment which was faulty. Replacement equipment was arriving soon by the next BA flight from London. The new equipment will be fitted in by the engineer and only then we will leave. There will be a delay expected to be around 50 minutes or so.

All these happened and the aircraft finally took off at about 1945 hours.

Of course the reasons were explained (apparently there was only one aerobridge for that kind of aircraft), BA staff were polite and courteous.

The Issues

However, the above episode means

That BA had information about the issue before asking customers to board the flight.

They withheld information from their customers before the customers boarded the flight.

The announcement on the ‘departure’ board about the flight time was wrong, deliberately wrong.

Customers were invited to board the aircraft under what seems like a false premise of a departure Customers had no say or choice in the situation, we were blissfully unaware.

I wonder if the event would have technically qualified to be counted as wrongful restraint or false imprisonment in case someone wanted to leave the aircraft or press charges.

That statement could have shocked you. But, just think about it, change the scenario away from an aircraft to another location. Just because it was air transport by private companies we are attuned to accepting many things to the point that we are no longer shocked by whatever they do. Never mind shocked, we are often not even mildly annoyed at the concept of locking you in a plane when they know it will not take off and fully accept their justification for doing so.

It also meant that I had to make yet more changes to my arrangements in UK.

At this point let me reiterate that it is not just BA, they happen to be the illustration for this blog because I personally experienced this. Every airline company does this, every airport does this, they are probably even allowed to do all these. I have already stated that the pilot and cabin crew were polite, it is not the staff behaviour that I am complaining about. It is about the underlying core attitudes which airlines do and perhaps allowed to do.

What NOT to learn

We in healthcare are asked to learn from airlines, especially scheduled airlines. In healthcare we are asked to co-create with patients. In health care we are patient centric and are asked to be even more patient centric, quite rightly.

If a doctor or nurse or other healthcare professional staff deliberately with held information from  or provided false information to patients, for the doctor's convenience or her organisations convenience that doctor, nurse or healthcare staff is at the risk of being investigated and reprimanded.

For pilots and airlines there seem to be no such issues.

Stop asking health care to learn from pilots and airlines as though it was a one-way street, especially about customer centeredness. In airlines it is often take it or leave it presented in a way that misleads you to thinking you have real choices.

In health care patient (customer) autonomy is a core value. There are numerous other fundamental values around honesty, choice, candour and others. These are at the risk of being changed so that the presentation of these values to the patient on how good  these look, feel or sound  rather than how good the values themselves are. If healthcare was persistent on this learning from commerce, we could one day convince the patients that the presentation was more important than the value being presented. We in healthcare will be lesser that day.

It is important to constantly look for what not to learn and make sure we do not learn it.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Note:

I have already blogged on learning (or not) from airlines, they can be found by clicking the following links:

Healthcare is not similar to aviation but lessons can be learned http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html

Scheduled airlines are safe, just like outpatient clinics

http://successinhealthcare.blogspot.co.uk/2012/09/scheduled-airlines-are-safe-just-like.html

Blondes, pilots and doctors: Who should learn from whom?

http://successinhealthcare.blogspot.co.uk/2014/03/blondes-pilots-and-doctors-who-should.html

Improving the morale of NHS Staff

Improving the morale of NHS Staff

The vital role of improving the frequency of positive emotions and using positive feedback as a source for improvement. Time for the public/patients to be a part of the action.

Bad news all around

Poor care, cover ups, whistle blowers, gagging orders, complaints, et al; we very often hear about all of them these days through profoundly sad media reports, social media (twitter, facebook, blogs) and reports of various organizations. If you are following the news recently its bad news everywhere with Mid Staffs, Francis, Tameside, Morecambe Bay, Keogh 14 at the extreme end and A&E crisis, GP OOH crisis, rationing of services etc at the moderate end. (It is a worrying state of affairs, isn't it when the GP and A&E crises are called moderate?)

Dealing with what is wrong

When things go wrong there are a number of mechanisms present to address them – the immediate boss, PALS, complaints, medical director, nursing director, chief executive and other directors. There is the healthcare ombudsman if your local systems cannot sort it out. There are national bosses, DoH, NHS employers, NHS confederations and others who are very willing to intervene when things go wrong. Medico legal specialist lawyers who are very willing to take up and chase anything from the trivia to the grievous. There are regulators CQC, GMC (for doctors), NMC (for nurses), Monitor (for foundation trusts, more recently for all trusts). There are plenty of important bodies all willing to tell us how to practice clinical care; the Royal Colleges, NICE, various specialty organizations and others. All of these people and organisations issue the euphemistic 'guidelines' which are basically rules/regulations which if not followed clinical staff will be in trouble.

The NHS tracks its complaints and publishes it – quite rightly so. NHS bad news is reported big time when there is a serious complication or death or when there is a serious let down of an individual’s expectations – quite rightly so. Openness when things do not go right is very comforting for the affected patient and families; it also helps organisations learn and improve.

The Impact of Constant Bad News

'Bad news' i.e. news about poor performance, negligence, criminality, never events, serious untoward events, harm, complications and bad behaviour of healthcare staff even after accepting that it is grossly under reported forms a small part of the overall picture of healthcare and NHS. Vitally important part, but small part.

Majority of healthcare staff are well performing, well behaved, caring and produce good clinical and social results for their patients. An overwhelming majority of patients get good results. This is of course no excuse or balance and cannot be used to justify avoidable problems or even to defend the impact of unavoidable problems.

Having set that out very clearly, let us look at the impact of negative feedback, negative experiences or negative behaviour that healthcare staff get constantly from their newspapers, from their managers and from their patients. 

Studies by psychologists have shown that the effect (value or impact) of negative emotion we feel is twice (2.25 times) as stronger than the effect of a positive emotion. Here we explore how this plays a part in the morale of NHS staff. Let us say the impact of praise (and we feel a positive emotion due to that) is +1 and the impact of non-constructive criticism (we feel negative emotion due to this) is -2. So if we praised a person once and criticised them once, the net effect on an employee's emotion is not 0 or neutral, the employee ends up with a mental state or mood or feeling of negative emotion which in our scale will be rated at -1. Let us assume we praise an employee four times in a day and have a go at them four times in a day the net impact is likely to feel negative emotion rated (+4 -8 =) -4 and if we repeated this for a whole week the employee will have a mental state which on this scale will be valued at -20 or full of negative emotions.

It is indeed no wonder that NHS staff suffer from a low morale. There is plenty of negative news in every media, constant pressure from government and managers. The complaints from patients have reached record levels. It is indeed a surprise that NHS employees have any morale at all.

What can patients (service users) do to improve morale?

We now know that poor morale and unhappy staff results in poor healthcare delivery. As patients we would want to prevent that. We know that majority of the times, majority of the patients get very good results. We know that negative emotion has double the impact on the mind than positive feedback. So as patients I think we want to be congratulating, thanking, praising NHS staff every time we get a good service and/or a good result so that positive emotion can flourish. We should try to do that at a ratio of positive to negative feedback of at least 3:1 (you see a positive:negative feedback ratio of 1:1 leads to low morale staff and 2:1 will lead to neutral morale staff). We know positive and happy staff often translates into good results for patients.

As a patient it is in our specific and direct self interest to increase positive emotion in healthcare staff when things are going right for us as it does most of the time for most of us.

As a manager that is what you want to be doing to your staff, being aware of the impact of positive and negative emotions and using the ratio to boost morale.

Let us take a hypothetical example of a treatment which has a 90% success rate and a 10% failure/complication rate (this will generally be high rate of complications); let us assume that all patients provided feedback with 90% thanking and praising the staff for the successful treatment we have had and 10% of patients complaining about their result. We may have staff in great mood feeling very positive about themselves and are likely to deal with complications/problems in a confident positive manner.

Positive feedback as a source of improvement

The NHS has no system of capturing congratulations and kudos. Complaints are logged, measured and acted upon. Congratulations are not formally logged, hence not measured and almost never acted upon. If a patient writes in with a complaint hospital looks not only for resolution but also to try and prevent it from happening again. If a patient writes in with a compliment it will be a very rare place to study it immediately learn the lesson and roll it out. We learn if at all, on how to avoid bad things, we do not seem to learn on how to improve on good things. My premise is learning to avoid problems puts healthcare providers in a neutral position; learning to improve on what is already working well puts healthcare staff in a strong position. Here is why we need to do it, if you slip from a neutral position you go into a negative situation; if you slip from a strong position you either become less strong or even (though there is a small chance of getting into neutral).

Well we know that it is not exactly very British to be loud, vocal and break into a song and dance to praise when things go right but if we knew what is good for us that is what we would do. It is very wrong not to complain when things have gone wrong, it is very wrong not to whistle blow, it is very wrong not put in extreme effort into getting care right and not remedying problems effectively when they occur. It seems to me now that it is also very wrong not to praise NHS staff when things go right. The silence of the majority could be a major reason for the low morale. It is time patients and managers made the effort to improve the morale of NHS staff, it seems a route to good care.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Notes: The strength of positive and negative emotions we feel and its impact is well described in N Taleb's Fooled by Randomness.

Servant Leaders in Healthcare - Stand up and make it count

Airline operational performance results for major carries in USA have come out and it shows that in general flying experience parameters are all getting better. The WSJ has a nice tabular column which explains it really well.

Southwest Airlines had the largest number of system wide emplanements (I take this to mean the highest number of passengers took Southwest flights) and they have the lowest rate of complaints per 100000 emplanements. Southwest had about 40% less complaints than the next best complained airline and the highest complained about airline had 14 times (1400%) more complaints than Southwest.

United had the highest complaints. The stats show that United had the highest rate of bumping (passengers denied boarding due to overbooking by airlines) and highest rate of lost baggage and understandably they had the highest complaints.

Then an interesting fact leaps out:

Out of 7 major USA airlines, Southwest had the second highest rate of bumping, third highest rate of late flights and was in the middle of the field for lost baggage but had the lowest rate of complaints. As I explained earlier it was not just lowest it was (at least for the month November 2011) had 14 times lower complaints than United.

There is nothing more that annoys passengers than bumping or flight delays or lost luggage. Why did Southwest have such a low rate of complaints? Why did Southwest customers not complain more? Looking at the data, one would expect many more complaints. How can we explain this?

Southwest Airlines practices Servant Leadership, which is pretty unusual at a whole organisation level. Servant Leadership seems to have led to employee empowerment which then leads to building ground level relationships with customers. All those lovely videos on youtube about Southwest are examples. Customers begin to see Southwest employees as 'friends' who are coping with difficulties that are common and typical of airlines; they do not want to add to the burden of their 'friends' by complaining.

Relationships trumps poor stats and bad stories. This is true of healthcare as well. Patients relationship with their doctors and their local hospitals are the ones that keep our NHS hospitals going; if that was not the case we would see a significant movement of patients away from high mortality hospitals every time the mortality results hit the press or a bad news story hit the press. That is not happening at a perceptible level.

However, some hospitals are finding an increase in complaints every time the mortality results are published and on the occasion when bad news stories are published. Complaints are a useful tool for feedback, problem detection and improvement but when an organisation is already on a well recognised path of validated development complaints on routine operational matters can also be a source of distraction, expense and negative publicity. Problems which were not or could not be prevented, as might happen in healthcare often, if identified, as soon as they happened and customer service methods were used to deal with them, could avoid complaints and its ill effects.

In an organisation that is clinically performing well, to ensure that the doctor-patient relationship and the hospital-patient relationship which clearly exists is translated into a low number of complaints would need empowered employees enabled by an organisation wide servant leadership approach.

Where are the servant leaders in healthcare? Which organisations follow servant leadership approach? I can recognise very few leaders but no organisation practising servant leadership.

The thoughts on servant leadership are quite old, ''Mark 9:35 Sitting down, Jesus called the Twelve and said, "If anyone wants to be first, he must be the very last, and the servant of all''; there are other religious and philosophical variations which are older and younger to that quote. However the management description of it was by Robert Greenleaf who wrote:

"The servant leader is servant first. It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead."
"The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priorities are being served. The best test, and difficult to administer is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servant? And what is the effect on the least privileged in society; will they benefit, or at least not be further deprived?"
Robert Greenleaf: The Servant as Leader 1970. (http://www.greenleaf.org.uk/about.php)


One would have thought that the medical profession with its high altruistic calling of serving the ill would abound with servant leaders; it seems that may not be the case. The time has come for any true servant leaders in the NHS to stand up and be counted as this seems a good model for leadership development for our caring and noble profession.

©M HEMADRI 

Follow me on twitter @HemadriTweets

References

http://online.wsj.com/article/SB10001424127887324081704578231553159491828.html
http://www.dot.gov/sites/dot.dev/files/docs/2013JanuaryATCR.pdf

This blog was originally written for and posted at Faculty of Medical Leadership and Management  https://www.fmlm.ac.uk/blog/makani-hemadri/servant-leaders-nhs-%E2%80%93-stand-and-be-counted
Re-posted here