We have been focusing the last several blog posts on what the health care industry can learn from other high reliability organizations, specifically U.S. Navy aircraft carrier flight operations, to improve the overall quality of care delivery. We have covered topics such as peer review, color-coding a specific functional team's uniforms, FOD walks, and the Officer of the Deck (OOD). Today, I want to go back to something I mentioned in an earlier post - specifically, the importance of leadership. In talking about the Solutions for Patient Safety network, I mentioned that one of the fundamental tenets of safety in this network of over 135 children's hospitals is the direct involvement of both the CEO and the Board in safety. The CEO and Board must adopt a "Buck Stops Here" mentality when it comes to safety. As it turns out, leadership definitely matters.
Other high reliability organizations recognize the importance of leadership too. High reliability leadership principles are fundamental to high reliability operations! That is certainly true for U.S. Navy aircraft carriers. There is something very unique, however, about the commanding officer (CO) of an aircraft carrier. The CO of an aircraft carrier always comes from the ranks of Navy pilots. Pilots can be easily recognized by the fact that they wear brown shoes (all other officers wear black shoes) and wear gold wings above their left shirt pocket. So, every CO of an aircraft carrier wears brown shoes and gold wings. They typically have between 20-25 years of flying experience with incrementally increased leadership responsibilities, including command of a carrier-based squadron. In addition, prior to becoming the CO, a pilot must complete training at Navy Nuclear Power School (a six month course with a heavy focus on physics, engineering, and mathematics), followed by six additional months of Navy Nuclear Power qualification. After serving a tour as the Executive Officer (XO) of an aircraft carrier, the successful candidate would then serve a tour as the commanding officer (CO) of a surface ship, usually a Marine transport ship, oiler, or supply ship.
Why does the Navy insist (it's actually legally proscribed) on having experienced pilots in command of its aircraft carriers? One word - culture. Only a pilot can truly appreciate the intense demands of flying and landing an aircraft on the deck of a pitching and rolling ship in the middle of the ocean. It's all about setting the right expectations and achieving operational excellence through a culture of high reliability. Navy pilots are unique individuals - having a fellow pilot serve as their leader brings that unique culture to the rest of the ship.
So, the next logical question. If hospitals are looking to learn from other high reliability organizations, such as U.S. Navy aircraft carriers, should hospitals require that their CEO (the civilian counterpart of the aircraft carrier CO) come from the clinical ranks? There are certainly a few excellent health care organizations that have this requirement (I am thinking, in particular, of the Mayo Clinic and the Cleveland Clinic, two health care organizations that are perennially listed at the top of the nation's best hospitals). I am not suggesting anything new - there are studies showing that hospitals that are run by either physician or nurse CEO's have better quality, better patient experience, and lower costs than those that are run by non-clinician CEO's. According to a study by Amanda Goodall, hospitals that are led by physician or nurse CEO's have quality metric scores as much as 25% higher than those led by non-clinician CEO's. Unfortunately, fewer hospitals today are led by clinician CEO's (according to a 2009 study published in the journal Academic Medicine, only 235 of nearly 6,500 hospitals across the United States were led by physician CEO's).
Most clinicians don't have the experience of managing a large organization or a big budget. However, more clinicians are taking graduate programs in health care administration or business administration than ever before. With gradually increasing experience, akin to the education, training, and experiences that pilots go through, there is absolutely no reason why clinicians can't get the requisite experience to run even large hospitals. With a similar training pathway, physicians and nurses can get just enough financial experience to work with an experienced Chief Financial Officer to lead a health care organization. After all, there is no way that an aircraft carrier CO will have as much experience driving a ship as a Naval Surface Warfare officer who became a CO after rising through the ranks of the surface Navy (destroyers, cruisers, frigates, amphibious assault ships, etc). However, that aircraft carrier CO has enough experience, especially when paired with a team of surface warfare operators, that he (as of today, there have been no female CO's of aircraft carriers, though that will likely change in the very near future) can do the job and perform to the standards of a high reliability organization!
It's a lot to think about. But the overall mission of health care is still focused on patient care. Who better to lead a hospital than someone who has dedicated their lives to direct patient care?
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