By Cheryl Clark
HealthLeaders Media
July 23, 2010

Hospital leaders attending the American Hospital Association's Leadership Summit in San Diego Thursday got a stern lecture from Captain Chesley “Sully” Sullenberger, who advised them they should adopt the safety culture of the aviation industry. They must stop thinking of accidents “as inevitable and start thinking about them as unimaginable," he said. “We in aviation have learned a lot, and we’re anxious to share it with you.”

Sullenberger is the man acclaimed for the Jan. 15, 2009 “Miracle on the Hudson,” when a bird strike of his US Airways Flight 1549 forced him to land his plane with 155 passengers right into the Hudson River.

Sullenberger made his remarks to 1,000 hospital and healthcare officials who assembled for the first day of the 18th Annual American Hospital Association’s Leadership Summit in San Diego, a conference focusing on how to make front line changes to improve quality.

He said that what happened that day, his quick decision to avoid crashing into land in a heavily populated area, came only after more than 30 years of aviation improvements and safety training for him and his crew, a system often referred to as CRM or cockpit resource management.

The safety improvements involved standardization and adherence to checklists which enabled him to work seamlessly with his first officer in such a dire emergency. And it required a culture that allowed subordinate employees to ask questions when they perceived a lapse in protocol or judgment, without fear of recrimination or firing.

“We worked to build a culture a safety that allows us to face an unanticipated dire emergency, suddenly, one for which we had never specifically trained, and saved every life on board with only a few non life threatening injuries.”

CRM, he said, changed a culture in aviation much like the change that is needed in medicine. “Thirty plus years ago, before CRM, captains could be alternately Gods or cowboys, ruling their cockpits by preference or whim with insufficient consideration of best practices or procedural standardization.

“And first offers trying to do the right thing would never quite know what to expect.  Some captains didn’t bother with checklists,” and it was unclear whose responsibility it was to extend or retract flaps or landing gear.

He said that although air disasters are mass accidents shown with ghastly footage on CNN, they are relatively rare.

“But medical mishaps, on the other hand, happen one by one. But as every one in this room knows, all too well, the mortality in America’s hospitals from accidents and hospital acquired infections is nearly 200,000 people per year in the U.S., or 548 lives a day, the equivalent of two large passenger jets crashing daily with no survivors.”

If that happened in aviation, he said, “the airline industry would come to a screeching halt; airplanes would be grounded and airports shut down. There would be Congressional inquiries and companies would go out of business.”

He listed numerous improvements to airline safety that have reduced accidental death in an aircraft from one in two million between 1967 to 1976 to one in 10 million today.

But improvement still eludes acceptance among the healthcare profession, he continued.  A recent federal study said 48,000 people die a year in U.S. hospitals just from pneumonia and blood borne infections, many of which are preventable. That, he said, “shows that prevention has failed to become part of the (medical) culture.” Checklists are important in medicine, he said. “But I know many of you have been a surprised, as I have been, by the resistance of some physicians in adopting the use of checklists. (They) believe that relying too heavily on checklists will turn them into procedural robots or they equate it to cookbook medicine, but that is simply not true.”

In some quarters, checklists have resulted in dramatic reductions in infections, such as reduction of central line bloodstream infections at some hospitals down to zero.  “But how can it be sustained.  Aviation has done it, but medicine has not.  Why?”

He alluded to a variety of problems.

“Conventional wisdom often has it that if a nurse makes a mistake, he or she should be terminated, but the vast majority of harmful events are due to system failures not practitioner error.  The leaders are responsible for the maintenance of these support systems, not the caregivers. And the current punitive culture only drives problems underground where they can never be examined or solved.”

“Burying errors for fear of shame or retribution only sets a trip wire for the next practitioner who comes along. Blaming only individuals when there are systemic deficiencies not only doesn’t solve the problem. It doesn’t prevent it from happening again.”

Additionally, he said, providers have not done a good job quantifying the cost their errors. In fact, he said, research shows that those same 48,000 deaths cost hospitals $8.1 billion, which they may well have saved.

“In every organization we must know what our infection rates are and right now, that’s just not the case,” Sullenberger told the hospital officials. “Federal legislation is about to link health care payments to the quality of service.  I believe in 10 years, when this is integrated throughout the system, we’ll look back at where we are today and will know that we were flying blind.” The audience gave him a standing ovation.