Michael Alkire
Nearly nine months have passed since I thought I might lose my only daughter, Natalie.
As she boarded a flight to Ontario, California, we exchanged texts: “I love you,” I said. “I love you, too,” she responded.
Fifteen minutes in, Natalie texted again. The oxygen masks had dropped. She saw a gaping hole in the plane’s side. Thin, frigid air rushed through the cabin. The pilot announced they needed to make an emergency landing.
Natalie was on the infamous Alaska Airlines Flight 1282, whose door plug blew out 16,000 feet in the air.
I gripped my phone and thought of how I held Natalie as a baby. Now, she felt far out of reach. Still, I tried to comfort her even as I was afraid to blink, worried I might miss something.
Sixteen minutes later, the plane landed. Some passengers had minor injuries, but Natalie was unharmed.
As a parent it was my worst nightmare. As a leader who has committed much of his career to improving healthcare — an industry that holds millions of people’s lives in its hands — I took from this terrifying incident a new guiding principle. Healthcare needs to pursue a zero-failure rate.
When I worked in manufacturing, we acknowledged that small, seemingly insignificant failures can cause devastating consequences. In some sectors, repercussions are repairable. In others, like aviation and healthcare, they aren’t.
That’s why I believe in leveraging data to create a framework that hospitals and health systems can use to work toward zero failures.
Some might say this objective is unreasonable. Why pursue something so ambitious that it may well be unattainable? But it’s the status quo that’s unreasonable.
We’ve known for decades that as many as 98,000 people die each year from medical errors. That’s nearly the equivalent of a 300-passenger jumbo jet crashing every day, for 365 days straight. This country would never accept a spate of daily plane crashes, but we’ve resigned ourselves to as much in healthcare.
There are also business reasons to strive for perfection. Just as I trust an airline to transport me and my children safely, patients trust healthcare providers when they require care. Natalie and I learned that four missing bolts are enough to break that trust. As consumerism grows, patients will choose organizations that, above all, send people home alive.
With stakes this high, the question isn’t whether to aim for zero failures, but how.
Technology has primed healthcare to realize tremendous improvements — just as the consequences of long-standing issues such as fragmentation, friction among different stakeholders and transactional relationships are snowballing. The dissonance becomes clear as dreams of technology- and data-driven care collide with the realities of widespread health disparities, clinician shortages, and, yes, medical errors.
But technology alone won’t prevent patients and their families from paying the price when we get it wrong. That was clear as I monitored the Find My app during Natalie’s flight, powerless to influence the outcome.
Healthcare must take a methodical approach to continuous performance improvement and unite behind leading practices in a shared pursuit of zero failures. That’s how, despite my daughter’s outlier experience, major airlines achieved a fatal accident rate of zero per 100,000 flight hours in 2022. Imagine if we did the same.
One problem is that too few of the leading practices are standard practices. In healthcare, it takes roughly 17 years for clinical innovations to become commonplace.
Another stumbling block is clinician burnout. Although the impact is difficult to quantify, literature has produced 14 studies linking burnout to medical errors. Mayo Clinic Proceedings published findings that suggested physician burnout and fatigue appeared to be just as responsible for medical errors as unsafe working conditions.
These challenges stem from systems, not individual people.
That means healthcare organizations must think systematically when striving for zero failures. I’ve seen firsthand the results we can achieve when we unite behind large-scale improvement efforts.
For example, just looking at Medicare performance data, if all acute care providers performed at the level of the nation’s 100 Top Hospitals, we could save an estimated 350,000 additional lives and $17.6 billion in inpatient costs could, all while more than 607,000 additional patients receive complication-free care. Digging deeper, we found that implementing just one performance improvement technology – clinical surveillance – in nursing homes resulted in a 92 percent reduction in adverse drug events among some of the nation’s most vulnerable patients.
You can read these as impressive numbers on a page, or you can look deeper and see the beloved grandmother who got another day with her family.
When I think of zero-failure rates in any industry, I think of my daughter, Natalie. I see her holding back tears as an oxygen mask covers her mouth, clutching an armrest with one hand and texting me with the other.
Every patient we lose to an avoidable medical error is someone’s Natalie. They’re someone’s mom, dad, or daughter. They’re worth our pursuit of a zero-failure rate.
Photo: Spooh, Getty Images
Michael J. Alkire is the President and CEO of Premier Inc., a leading healthcare improvement company, uniting an alliance of more than 4,100 U.S. hospitals and health systems and approximately 200,000 other providers and organizations to transform healthcare. With integrated data and analytics, collaboratives, supply chain solutions, and consulting and other services, Premier enables better care and outcomes at a lower cost.
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