Monday, May 20, 2013

The Limits of Airline Safety When It Comes to Healthcare Quality

Readers of the Disease Management Care Blog are probably familiar with its past references to the airline industry's multiple lessons for health care.

The modern jumbo jet has become an inspiring model of human-systems work-flow engineering and information technology that, in turn, has led to unparalleled flying safety. The narrative used by the DMCB - as well as by the New York Times and Agency Healthcare Research and Quality - has been that if providers would embrace cockpit science, the U.S. health care system wouldn't kill the equivalent of four jets' worth of people every week.

The DMCB still agrees with the peer review literature that tells us there is much to be gained by the adoption of aviation safety principles. With further research and experience, it will likely continue to improve patient safety and save lives.

But it also thinks the lessons from the airline industry are not a safety panacea.  There are limits.

As pointed out by economist William Baumol, many parts of health care are still dominated by "personal" or "handicraft" services that remain very labor intensive. Human beings are more complicated than jumbo jets, which means both diagnosis and treatment have to be tailored to each person's unique anatomy, genetics, metabolism, psychology, culture and social supports, one person at a time.

Instead of a jumbo jet, think about a quartet made up of musicians with violins, violas and cellos playing a complicated musical score.:

Unlike the check lists, information inputs and back-up systems of a modern cockpit, each note has to be executed just right in concert with others. The likelihood of one note being off key or out of sequence is considerable. Fortunately, for the musicians and their audience, all an error leads to is an unsatisfactory concert experience.

For a patient with diabetes and heart failure who has been discharged from the hospital who cannot afford his medicines, who is having drug side effects and relying on an overwhelmed family, the likelihood of one note being off-key is very high. Unfortunately for patients and insurers, a single error can lead to a cascading series of interdependent events that will lead back to the hospital.

For the patient with a new diagnosis of cancer who has a chance at cure with the approach of more radical surgery combined with multiple chemotherapy drugs plus radiation therapy who is a healthy 88 year old, the likelihood of one note being off-key and ending up in the ICU is very high.

For the patient with clinical depression who dislikes taking drugs and tells his physician that he will take his medicine and has no intention of doing so, the likelihood of one note being off-key is very high.

For much of health care, one-on-one care involving docs, non-physicians and other professionals with their patients sweating each and every individual detail will still be necessary for the foreseeable future.

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