If you want to improve safety, take a FOD walk

I want to stay with our theme on High Reliability Organizations for just a little while longer.  There is another concept used in Navy flight operations that I think we can learn a lot from in health care.  Hopefully, I convinced you in my last post that the flight deck of a Navy aircraft carrier is a very dangerous place.  If you don't believe me still, check out this video of a member of the flight deck crew getting sucked up into the jet engine of an A-6 Intruder several years ago.  Remarkably, the sailor escaped with only minor non-life-threatening injuries.  He was lucky!  But it's not just humans that can get sucked up into an aircraft engine.  Any piece of debris can cause a lot of damage to an airplane's engine, potentially causing the airplane to crash.

An article in the Navy Times estimated that the engine of an F/A-18C Hornet costs around $1.5 million to replace if it is damaged by random debris on the flight deck.  Engine replacement costs for the more advanced fighter, the F/A-18F Super Hornet costs around $3.5 million to replace.  And that assumes that a spare engine is readily available (they usually are), which may not always be the case when an aircraft carrier is out in the middle of the ocean and far from home. 

Given the costs associated with the possible loss of an airplane, as well as the potential risk to the life of the pilot or other crew members on the flight deck if an airplane crashed due to so-called "Foreign Object Damage" (commonly abbreviated as FOD), before any airplane engine is started on the flight deck, the entire flight deck crew conducts what is known as a FOD walk.  FOD walks are considered "all-hands" evolutions - meaning almost everyone participates!

If a sailor finds an object on the flight deck, no matter how small, he or she will hold it up in the air and continue to look for more objects.  All objects are then brought before a quality assurance team (on some aircraft carriers, the Commanding Officer, Air Wing Commander, and various Department Heads comprise the quality assurance team) to review the list of objects that were found, as well as the location where they were found.  The information is then used to make improvements.

Can you imagine a hospital CEO (the equivalent of a Commanding Officer) getting involved in a safety exercise such as a FOD walk?  It actually does happen!  There is a large network of children's hospitals, called the Solutions for Patient Safety network (the network started with the 8 children's hospitals in the state of Ohio and now comprises over 135 children's hospitals in the U.S. and Canada) focused on eliminating patient harm, largely through many of the techniques borrowed from High Reliability Organizations, such as Navy aircraft carriers.  One of the fundamental tenets for improving patient safety has been to involve the hospital CEO and the Board of Trustees in patient safety.  These hospitals, and other High Reliability Organizations have found that leadership matters - executive level leadership and oversight of patient safety is critical to reducing the harm that occurs to patients in the hospital setting.  The CEO and Board of participating hospitals in the SPS network sign an agreement that they will take ownership of patient safety in their organization and that they will not compete on safety with other hospitals.  SPS estimates that more than 9,000 children have been spared harm since 2012, while avoiding over $148.5 million in health care spending at the same time!

What is our FOD walk in the health care setting?  Well, I can think of a couple.  The SPS Network has implemented a number of "bundles" directed at reducing, and in some cases, eliminating, hospital-acquired conditions, including pressure ulcers ("bed sores"), central line infections, ventilator-associated pneumonias, urinary tract infections, and medication errors.  Each bundle consists of a relatively small number of evidence-based practices that, when performed religiously every day, reduce the rate of these hospital-acquired conditions.  If a hospital wants to lower the rate of a specific hospital-acquired condition, all they have to do is increase the compliance with the relevant bundle (there is, of course, a little more to it than that, but you get the idea).  Maintaining bundle compliance is our version of the FOD walk!

If you don't believe me, check out an article by the folks in the Pediatric Intensive Care Unit (PICU) at C.S. Mott Children's Hospital.  Apparently, the PICU team there increased and maintained their unit's ventilator-associated pneumonia bundle compliance from <50% (in other words, less than half of the time, the specific elements to reduce the risk of pneumonia were actually followed) to well over 75% over the course of 12 months.  The increase in bundle compliance was associated with a dramatic reduction in ventilator-associated pneumonia.  The leaders of the PICU found out that the physicians, nurses, and allied health staff felt that the checklist used to monitor bundle compliance was overly burdensome, so they stopped monitoring it.  After all, they had nearly eliminated ventilator-associated pneumonia and were setting their sight on other improvement projects.  During the next 4 months after stopping the monitoring, the ventilator-associated pneumonia rate spiked back up and rose to their previous level.  So, they re-initiated bundle compliance monitoring and the rate returned to near zero.

What's going on here?  In my mind, this (bundle compliance monitoring) is our FOD walk!  No matter what we do, patients in the hospital will always be at risk of developing one or more of these hospital-acquired conditions.  That's a fact of life.  We can dramatically lower the risk, but we will never be able to completely eliminate that risk.  But we can eliminate the hospital-acquired conditions.  So, in order to maintain vigilance, as long as patients are at risk, we have to monitor bundle compliance.  How else will we know if we are doing the right thing? 

I guess it all comes to down to this.  If you want to improve safety, take a FOD walk!