Christopher (Chris) Hart will be joining us for a Casual Conversation on Sunday, August 25, at 3 pm Eastern Time on Zoom. Chris comes to us courtesy of his friend from Denver grade school and our Dartmouth ’69 classmate Jay (“Yogi”) Glaser.
This is Chris’s description of what he would like to speak to us about (lightly edited):
“How Aviation Safety Practices Can Improve Your Safety in the Hospital”
What I plan to discuss with your group is my efforts to apply proven aviation safety processes to improve healthcare safety. In 1999 the Institute of Medicine published a report, “To Err is Human,” which estimated that 44,000 to 98,000 people die every year in US hospitals due to medical error. That revelation stirred up considerable interest, and caused many very smart people to enter the safety improvement fray. Despite all those efforts by very smart people for 25 years, the current numbers, which are not easy to find, are more like 250,000 to 400,000 fatalities a year in US hospitals . . . more than 1,000 a day.
When I see an industry that is populated with proud, competent, highly trained professionals whose credo is to do no harm, yet they are still harming people despite the best of intent, I have to conclude that the industry’s improvement efforts are not addressing the appropriate targets: Making the systems safer in which well-intentioned passionate caregivers are providing their services.
One of the major examples of a process that is foundational to aviation safety but essentially unused in healthcare is reporting about, and learning from, errors and near misses. Errors and near misses almost always reveal issues of poor system design rather than bad people, and they are a major source of improvement in aviation. Why are they not reported in healthcare? Largely because of the threat of litigation, and the fear that such information will be ammunition for the litigation.
That is why I am recommending eliminating litigation from the process of compensating for healthcare injuries, and replacing it with no-fault compensation — loosely analogous to workers comp — because litigation not only does not improve healthcare safety, it undermines it by causing people to hide information about errors and near misses rather than learning from it.
As explained in greater detail in the my draft White Paper, [which Arthur will send to anyone who asks upon request to him] other examples of unaddressed system issues in healthcare include threat and error management, i.e., addressing errors (frequently with punishment) but not doing anything to fix the threats that can lead to those errors; failure to incorporate human factors principles into the design of equipment and procedures; failure to avoid potential single-point failures; failure to address fatigue adequately; and inadequate collaboration by and among those with a stake in these efforts.
Attempting to make the caregivers more perfect while not addressing the systemic issues is analogous to training pilots extensively but doing nothing to make the airplanes or their flying environments safer.
I am looking forward to a lively discussion about how to improve healthcare safety.
Narrative excerpts from Chris’s impressive cv:
From 2009 until 2018 Mr. Hart was Chairman, Vice Chairman, and a Member of the National Transportation Safety Board (NTSB), having been nominated by President Obama and confirmed by the Senate. The NTSB investigates major transportation accidents in all modes of transportation, determines the probable causes of the accidents, and makes recommendations to prevent recurrences. He was previously a Member of the NTSB in 1990, having been nominated by (the first) President Bush.
Mr. Hart is Chairman of the Washington Metrorail Safety Commission, a three-jurisdictional agency (MD, VA, DC) created in 2019 to oversee the safety of the Washington area subway system. In addition, in 2019 he was asked by the FAA to lead the Joint Authorities Technical Review created bring together the certification authorities of 10 countries, as well as NASA, to review the robustness of the FAA certification of the flight control systems of the Boeing 737 MAX and make recommendations to improve the certification process. Also, in 2021 he was asked to join the Board of the Joint Commission on Accreditation of Healthcare Organizations, the non-government organization that accredits hospitals, to help improve healthcare safety. He was also invited in 2021 to be on the FAA Management Advisory Council. After an Uber test vehicle struck and killed a pedestrian in Tempe, AZ, in 2018, and Uber terminated such tests on public streets, Mr. Hart was included in the team of experts that Uber engaged to recommend how to safely resume street testing, which it has done.
Mr. Hart has a law degree from Harvard Law School and a Master’s Degree and Bachelor’s Degree (magna cum laude) in Aerospace Engineering from Princeton University. He is a member of the District of Columbia Bar and the Lawyer-Pilots Bar Association, and he is a pilot with commercial, multi-engine, and instrument ratings as well as a Cessna Citation SIC Type Rating. In 2022 he was selected to be on the Patient Safety Working Group of the PCAST, the President’s Council of Advisors on Safety and Technology.
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Usual rules apply. If you want to be part of this discussion, please email me by the close of business on Friday, August 23, at arthur.fergenson@ansalaw.com . If you want a copy of the draft white paper mentioned above, send me a separate email and I will forward it to you.
Arthur Fergenson
N.B. #1 Sorrel King wrote a book about her daughter Josie’s death by medical misadventure at Johns Hopkins Hospital in Baltimore: Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe. As a result of the that tragedy, Hopkins and other institutions implemented reforms including the use of checklists, following in the footsteps of airline pilot pre-flight procedure. See https://www.hopkinsmedicine.org/news/articles/2016/01/no-room-for-error .
N.B. #2 During our senior year, I covered for WDCR the crash outside Lebanon Airport, and obtained my credentials from the NTSB which had set up offices in a WRJ motel. Physics Professor Arthur Luehrmann and his wife and Players actress Martha guided me to the site from their home which was near the top of the hill just on the other side. None of the other reporters bothered to go to the NTSB, but they were eventually admitted to the crash site.
N.B. #3 Chris will be at least the second pilot to speak with us, the first being Debbie Dye, R.N., classmate Bruce Alpert’s friend and co-conversant for our hospice care Casual Conversation.