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Analysis Quality Improvement

Can we import improvements from industry to healthcare?

BMJ 2019; 364 doi: (Published 21 March 2019) Cite this as: BMJ 2019;364:l1039

Differences between an airplane pilot and a doctor

.What is the difference between a brain surgeon and God? God doesn't think he's a brain surgeon!

To answer “how to import improvements from industry, including aviation, to healthcare?”, box 1 which summarized “What’s different in healthcare?” was most welcome, being a mandatory prerequisite.(1) Indeed, Fong, a consultant anaesthetist at University College London who has also worked at NASA, called for expert “translators” to work to bring lessons of safety across to healthcare” as “systems that look superficially similar can be fundamentally different”.(2) However, the box missed the wood from the trees.

First, poor quality and errors in aviation have same consequences for the pilot or the team as for the passengers.

Second, should healthcare be characterized with terms such as “cutting edge”, “ever changing”, “much more complex”, “highly specialised professionals”, “skilled activities”, “advanced technologies” …?(1) As a lay clinician I feel uncertainty and poor understanding of what can happen are main characteristics. In other words, more humility, pride may be the strongest barrier against improvement. In the 16th century a French surgeon, Paré claimed he “occasionally cured, often relieved, and always consoled.”

Third, healthcare is enduringly promoting heroes.(3) This overlooks that in 2000, the Journal wisely promoted Root Cause Analysis to analyse clinical incidents with the ALARM method, stressing the formal investigation of incidents in the aviation, oil, and nuclear industries.(4) This method rightly focuses less on individuals (the usual simplistic explanation with routine assignment of blame or fame) but more on organisational factors. Obviously, no implementation yet.(5) Our misconception can be deeper as when Sokol claimed that a late change of surgeon may invalidate a patient's consent.(6) Why should choosing the surgeon be an issue? Could some surgeons in the unit perform surgery they should not. Why no concern for choosing the anaesthetist or the nurse too? Every link in a chain is equally important. Further, when travelling by plane, are we concerned about who is the pilot?

In airplanes, one of the two pilots – regardless of rank – acts as “pilot flying”, the other acts as “pilot monitoring”.(7) Due to highly competitive training, team building and cross-checking are far from being our natural mindset. Competitions which begin during our training plus the setting of inadequate targets or models for achievements have adverse effects. “Checklists and cognitive aids” as proposed (1) are not the solution.

1 Macrae C, Stewart K. Can we import improvements from industry to healthcare? BMJ 2019;364:l1039.

2 Coombes R. Anaesthetist urges caution over adopting safety strategies from high risk industries. BMJ 2014;348:g5660.

3 D'Silva J. BMJ Awards South Asia 2015: judging South Asia's unsung healthcare heroes.BMJ 2015;351:h5911.

4 Vincent C, Taylor-Adams S, Chapman EJ et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ 2000;320:777-81.

BMJ. 2015 Oct 7;351:h5305.

5 Ross N. Second letter to the GMC chair regarding Hadiza Bawa-Garba.

BMJ. 2018 Feb 13;360:k667.

6 Sokol D. Who will operate on you? BMJ 2016;355:i5447.

7 Braillon A, Bewley S, Ross N. The Health care system flies in the face of airline security concepts. JAMA Intern Med 2018;178:1142-1143.

Competing interests: No competing interests

27 March 2019
alain braillon
senior consultant
University hospital. 80000 Amiens. France