Summary: Both healthcare and aviation are system engineering problems. Healthcare does have things to learn from aviation, some simple and some very hard. One of the simple things is crew resource management techniques. The extremely hard is transitioning from a vengeance based quality system to a modern quality system.
There are three very different kinds of engineering problems:
- Complex part engineering problems, like mechanical design engineering: In this kind of problem there are a small number of different interacting parts, and each part is extraordinarily complex. A single camera housing part may reflect hundreds of man years of engineering, with stress analysis, temperature flow profiles, manufacturing plastic fluid flow simulations, etc.
- Huge number engineering problems, like financial software: In this kind of problem there is an extraordinarly huge number of interacting parts, but each part is fairly simple. Financial software and web commerce applications routinely deal with millions of transactions every hour. The rules for any one individual transaction are fairly simple.
- System engineering problems, like aerospace and medicine: In this kind of problem there are a large number of interacting parts and each part is complex.
It's unfortunate that many people see the recent successes solving huge number engineering problems and think that these huge number approaches will solve a system engineering problem.
Aerospace engineering and aviation problems are 99% hidden from the traveling public. Being a major traveler does not mean you understand aviation engineering. I was on the system engineering teams for several satellites and radars. This gives a different perspective. There are things that medicine can learn from avaiation.
One simple but difficult step that will have very large benefit is introducing the medical equivalent of crew resource management. There are some providers making progress here, but right now it's tiny little islands of effective management in a huge sea of mismanagement.
In the 1950's and 60's aviation was similar to medicine. In aviation the pilot was god, just as in medicine the doctor is god. Investigations of accidents showed that this was leading to major accidents and significant loss of life. Pilots were ignoring important information and making mistakes of judgement. There was serious human factors and psychological research into changing this. Simulations and practices from other industries were studied. Airlines forced a change in pilot and crew behaviors through training, explanation, practice, and supervision.
The first really big public success for crew resource management was the Sioux City DC-10 crash. After a mechanical failure that should have been unsurvivable and caused 296 deaths, an amazing ad-hoc crew managed a crash landing with only 111 deaths.
I've once seen a doctor listen respectfully to the advice from a transport orderly, take the advice, change patient treatment, and thank the orderly. Once, at one hospital. Most of medicine is still struggling with maintaining civil relationships between nurses and doctors. Only a few hospitals have reached the point where doctors will tolerate and participate on a working committee that is chaired by a grounds keeper.
Medicine and aviation are at a similar maturity level for equipment. My experience with making products for the aviation industry prepared me for medical equipment. The two are similar. Medicine can learn from aviation in this area, but it is a learning between equals. Both aviation and medicine have mature modern quality systems for their equipment. Each can learn some things from the other.
The really hard problem is switching the industry from a vengeance based quality system to a modern quality system. The vengeance based systems go back into pre-history. They also work. Rome grew to a major civilization that lasted for centuries with the simple vengeance quality system:
If the slave does low quality work, torture them.
It's sad that this works.
Modern quality systems date to Demming and Juran. They are presently entering medical practice under names like the Toyota Production System. The details evolve, but one principle is abandoning the vengeance based quality system.
One example of the difference between aviation and medicine is that there is an NTSB that examines all aviation accidents involving fatalities or major losses. The accidents are impartially investigated, causes analyzed, and mitigations evaluated. These reports provide input to other organizations. These provided a sound basis for things like the investment in crew resource management. There are islands of vengeance, but the sea is a modern quality system.
In contrast, public evaluation of medical errors is deeply feared and avoided because of fears of malpractice, retaliation, loss of status, and other harms. This fear is well justified. Any doctor who has been through a malpractice suit will agree that it is a form of torture. Similarly, when the government decided that something needed to be done about "never" events, there was no investigation of causes or evaluation of mitigations. There were threats by medicare and payment retaliation for failures. A medicare audit is another form of torture. There is a sea of vengeance based quality systems. You only find occasional small islands of modern quality systems.
The change from vengeance based to modern quality system is needed before large improvements can be made in patient safety. Other industries have made this transition. It has happened in aviation, electronics, and manufacturing.
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