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 

Scheduled airlines are safe, just like out patient clinics

There are constant comparisons between aviation and healthcare especially in terms of how safe aviation is.  There is no doubt that aviation in general has a low mortality rate for passengers. I have already written about the need to learn from how aviation achieved it, I have also pointed out to the limitations of the comparisons (http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html). The term aviation or air transport in my view, includes many things, which starts from the booking process, airport formalities, baggage, catering, flying, etc. It also includes transportation of animals and goods.

In general, the whole of aviation is considered arguably to be better than healthcare. What is not arguable is that commercial scheduled airlines have a very low mortality rate for passengers. Here is my problem, death is not one of the eventual natural outcomes of transportation when transporting essentially healthy persons from one place to another; quite rightly in aviation is mortality is unacceptable. Hospitals on the other hand are not in the business of transporting passengers, people come in with illnesses and diseases many of which are really serious; mortality is one of the eventual outcomes of serious illness and disease. In other words healthcare routinely battles against death and sometimes death wins.

To compare error rates could be valid as error is often a measurable part of process failure but to compare the impact of those errors is probably a false comparison. In aviation all mortality is avoidable mortality, in healthcare it is not. So to put it in context the comparison if we must is between all mortality in aviation and avoidable mortality in healthcare (i.e. the result of process failure). That is what I mean by impact. The impact of errors that result 'morbidity' is of course hugely different like losing a bag vs losing a leg. Hence let us not compare impacts of errors such as mortality morbidity between aviation and healthcare which skews the public discourse. Let us look at error rates and see what we can learn.

Variation the enemy of quality

People talk about variation of care across hospitals and locations; it is true that there is wide variation and reducing the variation will improve outcomes.

Aviation which is often looked upon as a beacon of safety also has variation. Looking at 2004 accident rates for North American airlines Delta scored 0.30 and Value Jet/Air Tran scored 5.88 – well, you work out the how wide the variation is even in an ultra safe industry. If you start looking at international comparisons the variations are of course much worse. (http://www.airdisaster.com/statistics/) There is also a five times variation of fatalilties per million flight hours with scheduled airlines being lowest compared with general aviation.

When there is human to machine interaction as in aviation, there is such a large degree of variation. Healthcare is human to human interaction so it is hardly surprising that variation exists and could be expected to be more than other industries. Looks like variation in performance is not a problem exclusive to healthcare industry; variation is a human problem or to put it better, variation is a function of human performance.

That does not mean we must accept variation especially when it causes harm, we should work very hard to reduce it to ensure safe healthcare.

Fatalities in Aviation

The human fatality rate is very low indeed in the scheduled airlines part of the aviation industry. The air transport of animals, however has suffered bad press. Airlines are apparently not even required to report animal deaths. The mortality rate of animals in air transport is thought to be 0.2%.(http://www.dailymail.co.uk/news/article-2102733/More-HALF-pets-died-airline-travel-year-flew-Delta.html)

The post surgical 30 day mortality for day case surgery in humans which is about 0.01%. In-hospital mortality for day cases is probably as low as the scheduled commercial aviation segment.

CRM and Simulation are of course extremely valuable tools and has a lot to teach us in healthcare. The number of air accidents and the number of fatal air accidents have remarkably decreased over the past few decades. That is truly fantastic. What is interesting though, is that the pilot error rate has been at about 50% since the 1950s to the 2000s, percentage of accidents attributed to pilot errors has not shown a significant decrease. The proportions of various reasons for crashes have also remained more or less the same. This is in a way a tribute to the aviation industry, since the planes have become technologically very superior it would not be surprising if pilot/human error played a bigger part and it has not, that is creditable. However, I wonder if it would be valid to argue that if CRM and simulation were indeed really powerful should the pilot error rates be falling?

Survival rates of passengers in aircrafts involved in fatal accidents has not improved (and averages about 25% since the 1930s to 2000s) (http://planecrashinfo.com/cause.htm) Military aircraft, fighter planes, aircraft engaged in warfare and private planes are thought to have much higher accident and fatality rate.

Some Aspects of Aviation are Safer than Others; Some Aspects of Healthcare are Safer than Others

I suppose in clinical healthcare delivery terms, scheduled airlines are possibly the equivalent of out patient care – not many patients die in out patient clinics. The risk to life is also very low for elective investigations, day case surgery and obviously the risk increases with emergencies and trauma.

In healthcare we talk about morbidity as well. Airlines perhaps should take into consideration DVTs, respiratory illnesses, musculo-skeletal problems and other health issues that happen after a flight. Non-health related morbidity for aviation perhaps include lost baggage, wrong meals............... no let me stop there before it gets silly. Hold on, why not, non-flying errors are also errors and results in 'airline industry morbidity' to passengers, perhaps not that silly.

What has to be said is in healthcare there is clearly much avoidable mortality - that is unacceptable. In healthcare the error rates in day to day activities are simply too high, that is again unacceptable. That is where learning meaningfully from other industries will help.

There is a fundamental problem with my writing here. I am not comparing like for like, I am comparing apples to pears. In my defense, I did not start that comparison. Comparing aviation to healthcare was not my original idea. There is a second problem with this manner of writing, it may sound like I am being defensive of healthcare and its practices, I am certainly not defending any poor healthcare practice or result. I acknowledge the superior results that aviation has had as a result of dedicated persistent efforts in the field of human transportation in scheduled airlines. I recognise the need for healthcare to learn from every source possible including commercial scheduled airlines. All I am saying is, let us stop comparisons and let us focus on learning. Let us look for clinical adaptations of these techniques rather than attempted direct transfer of airline techniques. Let us recognise the uniqueness and the intimacy of human to human interaction that healthcare involves.

A word of warning: This is not a 'hate aviation' piece of writing, this is not aviation versus healthcare writing. This is a plea to learn the lessons in a way that is appropriate to healthcare - clinicians and patients.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Healthcare not similar to aviation but lessons can still be learnt

Healthcare learning from other industries needs a much higher degree of sophistication

When are you in control and when are your patients in control?

When a plane is flying the passengers are not in control. It is the pilot who is in full control. The pilot also has controls on him/her but that control is not exercised by the passengers. Well, when there are 50 to 500 passengers in the cabin it will obviously be a problem to let individual passengers be in control of the flight itself. The passengers do get some control over their pre-made choices such as seats and meals; the passengers also get some control over when they use the toilets and when they can walk about as long as they are prepared to sit down and belt up as soon as they are instructed to do so. It is actually against the law to disregard pilot or cabin crews instructions; you do not have to harm yourself or others as a result, just not following the pilots orders is an offence.

Healthcare has made big noises about learning from aviation. We can argue that there are some similarities and some differences in the way passengers are treated and patients are treated. Just within the context of this short write up, can a chief exec of a small healthcare organisation or a chief clinician of a large unit say ‘we have a large number of patients to treat and hence we cannot accommodate individual patient choices’? Can clinicians tell patients ‘you have a choice over meals but for the rest of your healthcare you will do as you are told when you are in the hospital’? Will it ever become law that if patients’ disregarded their doctor’s instruction in a hospital they will be prosecuted (for potentially adversely affecting other patients care as a result)? Clinicians 'orders' are not orders at all. Of course it is an entirely different debate on whether the patients will get good results even if they followed their doctor's instructions completely.

The similarities between healthcare and aviation or any other industry for that matter are quite limited. This is for the simple basic reason that healthcare is direct and personal to the recipient – as direct and personal as a professional poking fingers and instruments into various orifices with consent in an attempt to make the lay patient better. That directness and ‘personalness’ does not happen in the often quoted ‘ultra-safe’ industries such as nuclear power plants, scheduled airlines, European railways and so on. It is a totally different empathetic human to human interaction where the 'relationship' is the main driver/lever. The synthetic 'have a nice day' with an artificial smile will not work in healthcare. Its a kind of relationship that a pilot or crew might have when the plane has crash landed and they are trying to rescue frightened and traumatised passengers; not something that they would wish to do everyday and that is something that many in healthcare do every day.


That does not mean healthcare cannot be safer than what it is now. It also does not mean that the ultra-safe industries have nothing to share with clinicians; of course we need to learn more from crew resource management methods, etc. It only means that the lessons and methods can only indirectly be applied; the principles have to be adapted and only then adopted. We are really poor in translating the lessons from other industries into healthcare.

I am very passionate about patient safety and quality enhancement. I have learned a lot from other industries including aviation. Healthcare is a risky business. If we attempt a direct application of the principles from other industries, healthcare will continue to remain a risky business. The translation and transfer has to be much more sophisticated than what it is right now. It is possible.


HEMADRI