HCLF: Medicine is 'islands of excellence in sea of failure'

CHICAGO—Captain Chesley “Sully” Sullenberger’s dramatic landing of his plane in the Hudson River in January 2009 was the result of lifelong preparation, he said, speaking at the Healthcare Leadership Forum on Nov. 14. His family instilled a love of learning and he realized one should “not stop investing in yourself personally or professionally. That has become a necessity now as the pace of change only accelerates. People can’t get through their entire professional life with one skillset. You must know how to innovate.”

Sullenberger said his favorite definition of innovation is change before you’re forced to by competition or circumstance. That allows change to become an advantage and people are more able to turn adversity into opportunity.

Through his military service, he learned the importance of teamwork, finding inner reserves of strength and realizing that a team can accomplish more than individuals. “Bad outcomes are almost never the result of a single incident but are the end result of a causal chain of events,” he said.

Aviation has a formal lessons learned process. The National Transportation Safety Board investigates all incidents and offers recommendations for preventing a reoccurrence. Most pilots can name every major accident of the last century because those important lessons were bought at a high price—life—“that we dare not forget.” Debriefing after fighter pilot missions is where real learning occurred--finding out what worked, what didn’t and what to do different the next time. Unfortunately, there is not a similar process in medicine.

Prior to the Hudson River flight, Sullenberger was most proud of his contributions to changing cockpit culture, he said. There used to be a terrible accident rate and a lot of that was due to the arrogance of pilots who didn’t build teams. “They were solo acts and the accident rate reflected that.” First officers kept their own notebooks detailing the personal preferences of each captain and speaking up about an unsafe practice put their job on the line.

After decades of technical improvements, “finally in the 1980s we began to attack the human component.” Sullenberger taught the very first class that aimed to teach people to be both better leaders and followers and flatten the hierarchy in aviation. “That’s critically important because we fly all the time with people we’ve never met before,” he said. He actually met his flight 1549 copilot—Jeff Skiles—for the very first time three days before the Hudson River landing. “But, had you watched us you would have thought we’d worked together for years. We knew intimately our roles and responsibilities. The workload and time pressure were so intense it precluded having even a single conversation about what had just happened. I had no time to direct Jeff’s actions. I had to rely on him to understand what he must do to help me.”

Sullenberger cited an incident several years ago when he landed a flight in Minneapolis. He was working on his flight plan in the cockpit as the plane was scheduled to go back up for another trip. A worker unloading bags came in to say that he saw oil dripping. A look into it revealed that at the previous stop a mechanic had put too much oil into the engine. The plane was pulled. Rather than summoning the baggage worker, Sullenberger went and sought him out to give him feedback on the situation. “I encouraged him to do the same thing or something similar in the future if he noticed something unusual. That feedback closed the loop and reinforced this concept of team. It helped create a shared sense of responsibility for the outcome. Nowhere in the baggage worker’s job description did it say anything about watching for safety issues but people in different roles all have an opportunity to contribute.”

Flight 1549 was traveling 318 feet per second when it collided with a flock of large geese. That led to loss of thrust. Sullenberger had never experienced the failure of a single engine. “Throughout my career, I reminded myself to strive for excellence. Good enough isn’t. I never knew on which 208 seconds my entire career would be judged. I avoided complacency in spite of how commonplace air travel has been. That Hudson River flight was completely routine and unremarkable for the first 100 seconds. Then it became our ultimate challenge and we knew it as it was happening.”

After the miracle landing, he began to hear from colleagues and others from well in his past and realized that “my reputation had been built one interaction, one person, one day at a time. That’s true in each of our lives. In every encounter, there is the opportunity for good, ill or indifference. We have to choose which it’s going to be.”

Healthcare can benefit from those individual encounters too, he said. “Medicine has islands of excellence in a sea of failure,” he said. Preventable deaths are seen as unintended consequences. There is more complexity in medicine than aviation but that doesn’t explain away all the negative outcomes, he said. Medication errors are really system errors. The 200,000 annual preventable deaths translates to three jetliners crashing every day. “I am an eternal optimist. I believe you will eventually find a way to reduce the number of preventable deaths. The question is when. In 20 years after four million more preventable deaths? My vote is no.”

The Healthcare Leadership Forum was sponsored by Clinical Key and presented by Clinical Innovation + Technology.