"Don’t ever take a fence down until you know the reason why it was put up."

Health care often looks to the aviation industry for best practices to improve patient and employee safety.  Despite the recent "60 Minutes" CBS News report this past week on Allegiant Airlines that found more than 100 serious mechanical incidents, including mid-air engine failures and flight control malfunctions between January 1, 2016 and October 31, 2017 and yesterday's Southwest Airlines accident involving a mid-air engine failure resulting in 1 death, the safety record for commercial aviation has been exemplary.  Just this past year, the current President of the United States accepted full responsibility for the fact that calendar year 2017 was the safest year on record for commercial air travel.  The commercial aviation industry is certainly an exemplar when it comes to safety.


Health care has often copied best practices from other so-called High Reliability Organizations (organizations that maintain excellent safety records despite the fact that they operate in dangerous environments).  Military aviation (at least, U.S. Navy aviation) is frequently cited as one example of a High Reliability Organization (HRO) - in fact, the U.S. Navy aircraft carrier, USS Carl Vinson was one of the three original organizations that was investigated in the original paper defining HROs by Tom Mercer, Todd LaPorte, Gene Rochline, and Karlene Roberts (the Federal Aviation Administration's Air Traffic Control system and Pacific Gas and Electric's nuclear power plant at Diablo Canyon were the other two organizations).  So it is perhaps surprising (and somewhat concerning) that the U.S. Navy, Marine Corps, and Air Force have all reported an increase in the number of aviation accidents in the past couple of years.


What's going on here?  The Navy has reported that Class C mishaps (defined by the military as an accident resulting in $50,000 - $500,000 in aircraft damage or lost work days due to injury) have increased by over 80 percent during the past five years.  The Marine Corps has observed a similar increase in Class C mishaps over that same time period.  Finally, the Air Force reported that Class C mishaps this past year hit a seven-year high.  In all three cases, the frequency of more serious accidents (Class A and B mishaps, which result in more significant monetary damage or death) have either remained level or, in some cases, decreased over the same time period. 


What is the common thread across these three branches of the military (side note: I could not find similar reports for the Army and one report actually suggested that the number of helicopter accidents has actually declined)?  Notably, in all three cases, the increase in Class C mishaps traces back to the year 2013.  What happened in 2013?  One word.  Sequestration.  Historically, the military has been funded through continuing resolutions under the Budget Control Act - this stopped in 2013, the year that automatic budget cuts known as sequestration went into effect.  In order to meet the budget targets, the military cut back on purchases of spare parts, released (through both early mandatory retirement and attrition) aircraft maintenance personnel and their supervisors, and decreased the flight time for pilots (flying a military aircraft is notoriously expensive).  These budget cuts have occurred at a time when the military has been asked to do much more with less resources (while military operations in Afghanistan and Iraq have been scaled back significantly, they certainly have not ended completely).  In other words, the military has scaled back, in some cases rather significantly, on normal operations in areas such as training and maintenance so that they can continue to fund combat operations around the world. 


"Doing more with less" is a phrase that we hear a lot these days.  However, in regards to military aviation, "doing more with less" is strongly associated (note that a cause-and-effect relationship has not been demonstrated) with an increase in the number of accidents (albeit, not the most serious type of accident).  It would appear that "doing more with less" is not necessarily something that health care should copy from this HRO!


We have significant problems in health care today.  U.S. health care is way too expensive, and the amount of money spent in health care doesn't necessarily translate to better outcomes and better value for our patients.  Hospitals are going to be forced to cut costs - truthfully, the vast majority of hospitals have already been forced to do so.  The key here, I think, is to be very careful about what expenses get cut.  Perhaps that is the lesson we should take from the Navy, the Marine Corps, and the Air Force.  Trying to find savings through cuts in maintenance expenditures or by decreasing the number of experienced personnel (senior, experienced personnel cost more and often get replaced with younger, less experienced, but less expensive personnel) in operational positions is likely a fool's errand that will cost more in the long run.


I am reminded of a quote by the author G.K. Chesterton from 1929, which was actually used once by President John F. Kennedy in one of his speeches.  "Don't ever take a fence down until you know the reason why it was put up."  In other words, be careful how you try to find cost savings in military aviation operations and health care.