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Importance of Checklists: What Healthcare Can Learn from Aviation

Dec 16 | 3:30 PM

The aviation and healthcare industry share obvious commonalities like the need for consumer safety and error minimization. A pilot is responsible for the safety and well-being of all the people aboard a flight; similarly, a doctor is responsible for their patients. In 2019, the global accident rate for the aviation industry was 3.0 per million scheduled departures. On the other hand, medical errors accounted for the third-highest cause of mortality. There are obvious distinctions between the two industries, but what makes the aviation industry safer than medicine? Join Col. Dr. K Nageshwar Rao, Chief Medical Officer of Indigo Airlines, to discuss areas where healthcare can learn from aviation.

[Music] welcome everyone uh to a very interesting and slightly offbeat kind of a session today on what can we learn from aviation in healthcare and we have a super distinguished guest with us to talk us through this we have colonel dr nageshwar rao he did his mbbs from afmc then went ahead and did his md from institute of aerospace medicine indian armed forces is had a long illustrious career with the armed forces and in government service set up multiple medical establishments across services and also independently led medical units across the armed forces so a great career in the forces and since 2016 he's been with indigo he's currently the chief medical officer at indigo airlines and we had the honor of having him as a guest on a previous session about a month back the session was on in-flight medical events uh by dr madhu desai and uh with dr rao and that was one of our um very well attended very well appreciated sessions it's available uh in the replay session replay section if if some of you missed it and want to watch it later so uh dr rao it's a it's a pleasure to have you thank you so much for uh sparing time and coming back uh on the show if if you want to say a couple of words and then i'll introduce the topic uh we have a couple of polls to start off with but before that if you want to say a couple of words please just thank us for having me here it's a very different topic from what doctors normally hear i won't be talking about too much about medical diagnosis and the intricacies of treatment and all but i hope all of you enjoy this and [Music] that's it thank you very very much for having me here so uh dr rao we we have a also for a different topic we have a slightly different uh kind of audience tonight so we have a fair number of hospital managers administrators professionals from quality students faculty and professionals from indian institute of hospital management and research so apart from clinicians uh postgraduate students uh and and specialists that we normally have for our sessions we also have many people who are from the industry today so it will be fun to hear about uh some of the insights which you'll share so uh let me actually run three polls uh which will set some context for this session so here's our first poll it it might seem fairly obvious but you can just tap on the option that you think is the right option uh i don't think many of uh i mean there might be close competition between two options the third option is fairly obvious yeah so uh road travel is the worst uh in terms of the number of fatal accidents for for i mean uh this is measured in different ways it could be measured per trip per per uh per vehicle per kilometer per passenger kilometer so there are different ways of defining this uh but on on all forms road travel is uh the most dangerous form of travel and air travel is by far the safest form of travel and this is very interesting because uh you people who are flying for the first time are always scared offline um so the whole idea of accelerating at that speed and going that high is very scary but it's remarkable that uh the industry has progressed so much and worked so much uh to make it the safest mode of long-distance travel so that was our first goal uh let's then look at this question um so how many people uh do you guess lost their lives in fatal air accidents worldwide uh between in the last 10 years and this is an approximate number but this is a worldwide estimate so what's the case the correct answer is thirty five hundred uh it's close to three thousand three hundred uh in the last 10 years there have been 3 300 deaths worldwide in commercial air travel this excludes military and training and other forms of travel and then i come to the last question how many deaths worldwide from medical errors annually approximately so the order of magnitude of options itself is very different a fair split between all options but unfortunately the right answer is 250 000 that's the estimated uh number of deaths annually this was based on a meta study uh in the first decade of this uh this century uh there was another study in 2013 which put this number at 440 000 um and the the thing is that these are in-hospital deaths uh there's another study which estimates an equal number of deaths outside hospitals from medical errors um so the number might reach about a million um it's it's i mean see this comparison between aviation and in healthcare is in a way artificial and uh arbitrary so they're very different industries and there's there's no comparing but the and the complexity of healthcare and the subjectivity so there's a lot of variability in healthcare every patient from the next patient is a different patient um so it's in that sense it's not really a fair comparison to do but this is just a matter of trivia and this is also a matter of learning from another industry so uh anesthesia for example so anesthesia used to be within healthcare the field where maximum fatalities or medical errors were happening 50 years back uh there were one in 5000 deaths uh due to anesthesia errors and that has uh they have worked extensively they have improved their protocols processes and that number has changed to 1 into 50 000 so there has been a significant uh improvement x significant x improvement in that field particularly and therefore i think there are lessons which are possible there is possible to reduce this deaths and that is what this session is about so uh drow with with that little context uh i'll hand over the session to you uh you may take this forward from here sure uh thank you for setting the context in such a beautiful and crisp manner and that makes it very easy to take it forward from there having said that a very good evening once again to all the listeners and across the country whoever is logged in i once again thank the organizers to for permitting and for choosing this topic i don't know whether it is by design or by coincidence that it is the eve of the first award flight in 17 december 1903 so today is 16 december so we are just talking about aviation and aviation medicine does owe a lot to powered flight so that that i suppose is a coincidence the topic as uh you said is not very new the topic of learning from aviation is not uh it has been talked about for a very very long time and it is also true that it is [Music] not completely fair to compare healthcare directly with aviation but there are certain aspects there are certain fundamental things that one can do in terms of certain small changes not major changes which will bring about very very good results even in healthcare so before i go a disclaimer that these are which is a very customary disclaimer these are personal views based on individual experience and open source research and not to be quoted as government abuse or regulatory bodies or or on behalf of individuals there is no known conflict of interest regarding the same so when we look at health care and aviation people have been talking about it from 1960s maybe before that they have a lot of similarities i have listed out the similarities in both the industries staff are highly educated and all are well trained professionals they are trying to do the right thing whether it is in aviation where he's taking the uh passengers safely from place a to place b or in terms of a doctor taking care of the patient's very to the best of his ability and they always always work under stressful circumstances every takeoff is very easy every landing is extremely extremely stressful similarly handling every patient is also very stressful depending on the complexity of the case both are extremely complex systems and if you go into an icu if you go into a aircraft cockpit both are so complex there are so many monitors so many people involved that it is crazily confusing there are 178 parameters which the nurses actually look at every single day similarly there are about i mean almost 100 plus parameters in the aircraft before the aircraft actually takes off and finally both are responsible for the lives of others the doctors in case of the patient and passengers in case of a pilot but before i compare healthcare to aviation i'll take this opportunity to also introduce you to the subject of aviation medicine which will set the context in terms of what an aviation medicine specialist brings to the aviation industry and how they have made a major influence in getting these systems right can i have the videos please the first video so the journey of aviation medicine when you look at an aircraft line so beautifully in your screen is in two parts now on the left is the su-35 magnificently doing all the maneuvers the right is a trainee pilot actually it is not the pilot of that aircraft if this person is sitting in that aircraft you will have a crash very soon so he is doing all the maneuvers it looks so majestic from outside but actually inside the pilot is actually fighting for his legs by pulling acceleration forces by fighting off hypoxia and by just ensuring survival while doing his entire activities to the requirement the acceleration forces are so high that the heart is unable to plum pump to the blood and that's when this thing happens he is losing his consciousness if you can see on on the monitor now and when he recovers his consciousness he will have only cloning seizures those tony cloning seasons now in a compact environment like the cockpit if such a thing happens regularly then you can understand how many things can go wrong he is actually fighting for his survival the aviation medicine specialist job is to ensure that this task that the pilot does is easier this is a military aircraft in civil aircraft such things are not available let me go back to the presentation such things may not be the challenge but there are different kinds of challenges we will see what those are it's not yeah so by definition aerospace medicine which is also called aviation uh which was earlier called aviation medicine and currently it is called aerospace medicine is a branch of medicine that is a preventive or occupational medicine in which the patient or the subjects are pilot air crew or astronauts indian astronaut program is also going strong now and all our aviation medicine specialists at the air force are very much involved in that program it is a unique study pathway that provides physicians with comprehensive theoretical and practical instructions in advanced aviation physiology psychology pathology clinical and operational aviation medicine as i said last time i don't know if somebody from the last times audience is here the aviation medicine specialist is the bridge between the engineers and the pilot when he is in the cockpit aviation medicine deals with if if you see the slide arm in the figure on the right aerospace medicine and classical medicine differ in one fundamental aspect in classical medicine the physiology has become abnormal the person is unwell he goes to the environment is normal he goes to the doctor he becomes well he gets treated he gets medicines and he gets treated whereas in aerospace these are supremely fit people of the population whether it is civil or military aviation they are extensively screened population they are selected for to become the pilots and they have an absolutely normal physiology but they are thrust into an environment which is absolutely abnormal not consumed conducive to human life and that is the essence of aerospace medicine the problems in aerospace medicine can be medical related like in the video we saw the blood is pulling down into the legs it is not able to the heart is not able to pump up against gravity up to just 30 30 centimeters which is the heart to brain distance but what are we doing we are giving them engineering solutions we are giving them anti-g suits we are giving them anti-gay valves so that blood doesn't cool down so those are in in aviation medicine the problems are medical the solutions are engineering let's look at the what why how and when of aviation medicine very very brief to understand aviation medicine we have to understand uh the standard atmosphere i may be it may not be blasphemous for me to say that man has evolved to an extent that he is not using any compensatory mechanisms up to two meters in height that's it anything above two meters is actually compensating by increase in heart rate by increasing respiratory rate whatever means you see a standard atmosphere the knowledge of our atmosphere becomes very very very important to understand the fundamentals of aerospace medicine the there is nothing called a standard atmosphere standard atmosphere is a definition like an ideal gas you know you it is a reference point against which all your gases are titrated similarly a standard atmosphere is a common reference for temperature and pressure variations as you go higher up in the atmosphere and there is a sea level pressure which is defined as 1 0 1 3 pascal or seven sixty millimeters of mercury and there is a certain composition of gases which is not expected to change up till eighty kilometers altitude there is uh the temperature lapse rate occurs up till tropopause which is taken as 11 kilometers nowhere on earth you will actually find this but this is the reference it is plus minus of this so if you see the temperatures normally the aircraft lies at about 40 000 feet what is the temperature there minus 56 can the human body survive no let's look at the pressures now i have put pressures on the left side pressure variations and the last vertical column is the oxygen content in our in the inspired air now at sea level which is 760 millimeters of mercury you have an oxygen content in the blood of 159.6 uh in the inspired area of 159.6 but at the alveolar level you are also having water vapor of 47 millimeters of mercury so that comes down at the alveolar level the oxygen content becomes now for all the systems for simply putting it for the mitochondria to work functionally the power powerhouse of the cell the oxygen requirement is three to five millimeters of mercury to provide three to five millimeter millimeters of mercury i need a oxygen concentration at the lungs of at least 60 millimeters of mercury now if you remove 109 minus 47 we are somewhere there so with all the extensive uh compensatory mechanisms of the human body you can barely make it till 10 000 feet anything beyond that the body needs to either acclimatize if you are walking up slowly or it needs to you know be assisted in terms of supplemental oxygen in terms of various other methods that are available in cabinet pressurization so in aviation it is the supplemental methods because a rapid ascent can never happen it always happens in aviation so with that what happens the slide is yeah so with the with the understanding of the knowledge the challenge that a pilots or pilot and space travelers face is starting with hypoxia forces of acceleration hypobaria spatial disorientation crm issues of survival noise fatigue drugs and alcohol human factors n number of medical problems the moment he is thrust into an atmosphere where he is not which is not conducive to human life now it is i'll just go back into a little bit of history of hypoxia is just absolute or relative deficiency of oxygen which is causing the physiology to get altered and become challenged hypoxia is not new if i say that hypoxia was actually described in 32 bc i may not be wrong the chinese mountain climbers actually mentioned that as we climb the higher reaches of the of the mountains the air becomes thin and we cannot actually survive let's leapfrog to the maximum oxygen research which happened after joseph priestley actually discovered oxygen and thereafter paul bird actually summarized his lab barometric history ties on barometric pressures and there was a guy called sandeer or spinelli and civil these three scientists they decided to go on balloon flights by now oxygen was discovered by now some balloon flights had taken place and uh there was a guy called derozier who actually flew up to 36 000 feet supposedly without supplemental oxygen that was the record uh till that time and they said now they could isolate oxygen and oxygen was used in leather bellows you know bellows which are leather bags and they said we are carrying oxygen we will create this record they went up in the hot air balloon and after a certain time of exposure beyond 10 000 to 12 000 feet they started losing consciousness the final altitude they kept losing their weight backs and balloon kept climbing up they kept having oxygen only supplemental oxygen which they were carrying they clogged the barometer on that clock about 8 600 meters that's about again 38 000 feet that's 6000 feet but they all three of them lost consciousness and when the aircraft ran out of fuel to have a hot air it came down the balloon and then only tissander survived this was the first air crash because of hypoxia subsequently there are many crashes recorded we have one of the golf greats who flew across a seven-seater aircraft they kept flying and nothing um nobody realized that there was hypoxia it kept flying into the pacific and crashed hypoxia is known as a silent killer it it uh does not have any symptoms the only symptom people have given is that you know uh i feel like i've had two pegs to drink that that's the kind of uh symptoms similarly acceleration forces what you have seen just now in the video the it is practically impossible for the fighter aircraft to do their maneuvers without engineering support and without oxygen support i will not go further into too much of detail because that will digress what else is looked at in aviation medicine is something called as human factors what we look at is human performance optimization which refers to the process of enabling each person to reach his or her potential optimal level of performance become part of a successful dream and accomplish the team's mission it has got various determinants various other components it could be as simple as the correct nutrition the kind of physical fitness the environment that he's working in the people that he's working with the operational factors is mental fitness and a major factor of family and relationships all these go into understanding the uh the human performance optimization and that is where in civil aviation we feature in a big way now now is the time to start comparing this with healthcare the first part it was a brief introduction to aerospace medicine from now on we will just look at how aviation has improved and what we can take away from aviation for health i'll take you back to 1977. there were two jumbo jets who which collided on 27 mark 1977. the history and the details are something like this there was they were to land at last palmas airport which is in canary islands of greece and uh there was a terrorist attack and terrorist threat at the airport or uh the los palmas airport and when they were all these aircraft international aircrafts coming in from amsterdam coming in from the united states they were asked to land at the nearby los rodeos airport now los rodeos airport is just a two lane to one airstrip and one taxiway it's a very small airport it became so congested that all the taxiways were also blocked by large aircraft which could not move when the terrorist threat passed away they decided to allow these aircraft to go again now if you see the runway all of them were stuck on the uh one side of the runway which is on the top of the runway there where equal to 1977 equivalent so the pan am aircraft moved first and he was asked to move out of the third uh my mistake the klm aircraft was asked to move first onto the main taxiway a main runway and go to the other end and start taking off immediately behind him because the space was less the pan am aircraft was also asked to taxi and move out from one of the links the third link from the main runway they both proceeded so the klm guy reached the other end and he turned back and he radioed the this one that i am ready for takeoff and i am about to take the pan am guy had still not crossed he had crossed the first link he has brought the second link he because of poor visibility on that day he could not cross the third link he could not uh actually spot the third link the runways did not have markings like they have till now these are this is an important accident because a lot a lot of things changed thereafter and lot of what we know today has actually come in because of this accident so they missed the third uh link third intersection and they started moving ahead just when the pan am aircraft radioed that we are ready to take off and the [Music] atc guy said okay there was radio interference where pan-am aircraft also was trying to speak the alm aircraft was also trying to speed so none of them heard the klm aircraft say that we have not cleared the aircraft we have not cleared the main runway and added to this the person sitting in the cockpit of pan am was the chief flying instructor of klm uh klm airways so the co-pilot did not have the authority or the or the confidence self-confidence to challenge him question him even though he was actually in doubt whether the pan am aircraft has cleared the main runway and he started throttling a full blast he throttled up and when they actually saw the pan am aircraft in front of them they were too uh fast and they would just barely lift off knocking off the tail of the pan am people died in this 583 people died including both the aircraft there were 61 survivors in the pan am but this was the biggest biggest aviation disaster which happened at that time the airport had to be closed for two days spanish military was called and to clear and everything was done accordingly let's leapfrog from that instance to hudson river 2009 which has been glorified in the movie sully also all of you most of you would have seen that the hudson river here sally sullenberger was the captain he takes off within three minutes three and a half minutes of takeoff both the engines suck in there uh have a lot of birds in and both the engines lose complete power he he radios back calmly the co-pilot was actually flying the take-off leg the moment this happens the captain takes on the takes over the controls he asked him to take out his checklist he asked him to check out the non-normal techniques engine engine shutdown indian real-life procedure checklist and thereafter he radios back and made a call that we have we cannot make it give us a nearby airport so even the nearby airport they said they cannot make it and he said we are going into the hudson now the atc immediately follows their sop alerts all the nearby vessels all the emergency rescue services that there is an aircraft going down in the hudson reach there immediately in this 156 people were there and not one had any major serious injury so what happened between these two how did one accident lead to so many errors how did the other accident have no casualties at all that is the success story of aviation and that is where we will be looking a slightly greater detail now in both the cases human error what uh said earlier is that human error is a major change in both aviation and the graph very clearly shows that 400 000 in excess of 400 000 per per year is the fatality rate because of medical errors if the same is extrapolated to aviation no aircraft will ever fly nobody will allow an aircraft to fly presently the the annual fatality rate is less than 200 in in aviation but human error forms a major chunk of these cases in both in both in aviation it is about sixty percent of the accidents uh 59 to 60 of the accidents are attributed to human error and so also in the medical cases but can the practices translate across industries some parts yes but not all parts as brought out earlier anesthesia has imbibed the aviation practices very well but can every department do it it's a bit of a challenge let us look at some of them i'll just compare what happens in aviation and whether we can actually look at the same thing being done in the medical field in india typically the the an airline is controlled by policies which come out from director general civil aviation there is a central regulator the central regulator is also answerable to the ministry of civil aviation international air transport authority indian civil aviation authority ministry of health indian air force who lay down the medical standards for aviation in the world and organization in the current circumstances there are so many governing bodies and they actually lay down every single rule as how the aircraft can fly how the what a person x can do or not do every single thing is laid out for the airline in the medical field do we have anything like that no we don't i may be [Music] stretching here and saying that some of the hospital change the larger hospital chains have actually started putting in certain procedures and policies in place to streamline this but we also have an unregulated system across where people are practicing individually does it apply there no it does not each individual practitioner there is no storage of records there is no analysis that is happening so that is the big difference this is something we can do in in terms of healthcare in a well established airline the policies and procedures are very crystal clear in terms of management the pilot in the flight two the employees and all under come under the gamut of flight safety flight safety is one of the strongest determinants of operations in aviation because you don't want to lose an aircraft you don't want to lose a passenger but similar thing is there a safety management system in medical line i'm not so sure not so sure at all is there a patient safety program no now there is something called a safety safety management system in all the airlines safety management system is an organizational function which ensures that all safety risks have been identified assessed and satisfactorily mitigated the objective is to prevent human injury or loss of life the major components of a safety management is a risk assessment and hazard identification i don't know how many of the doctors in this forum know the definition or the meaning of risk assessment and hazard identification this is something which we can do across every single speciality risk assessment with the usage of a certain x antibiotic on antibiotic resistance you can do that you can do the hazard identification in terms of what is going on in the icus you can do what is going on in the in the operation theaters but i am not sure whether any of us are qualified or is there a systematic method in this corporate hospital i won't say corporate certain hospital chains do have i am very happy that some of the safety managers and and patient safety representatives are a part of this conf this session and we would also like to hear them at the end of it but it is still a long way off when compared to aviation and this is something which you can do i am only talking about certain practices of aviation which we can translate we have a very robust in in medical medicare we have very robust quality management systems which looks at the customer satisfaction but we are not very clear on the safety satisfaction systems the next one is there is a safety culture in aviation a loader sitting at some corner airport he can pick up a thing which is wrong which is observed if he sees a bus park too close to the aircraft he can just dial up and tell me or tell anyone there's a operational hazard report he can raise anybody can do that this is a no blame no shame no punishment no punishment environment there is the organization is culture organizational culture is flexible enough and the organization culture is just enough just culture does not mean only no blame just culture means that wherever there is a chance of willful misconduct wherever there is a chance of willful misconduct those areas can be improved upon by reporting and learning it's a cycle it's a continuous cycle a just culture create helps create an environment where individuals feel free to report the errors without the fear of of being punished for that and all of us the entire organization can learn from the mistakes now unlike in a doctor's life a daily routine of a pilot is pretty well established he comes to the aircraft he prepares about his flight there is a breath alcohol test he does he checks his pre-flight papers he does his fuel calculations he calls on his other pilots and the cabin crew briefs them exactly what he is looking for does the preflight checks out outside and inside the aircraft goes through the normal checklist and there is a standardized communication which happens now post tenerife post tenerife i have to mention it here post tenerife accident certain things came to the fore one was standardized phraseology there is very specific phraseology that the pilots use the word takeoff cannot be used unless you are actually taking off unless you are cleared for takeoff it is all the other times preparing for departure moving for departure ready for departure but when the um atg says cleared for takeoff you take off that is one learning second learning was the crm which will come to crew resource management so he has standardized communication the sterile cockpit is sterile once the cockpit door is closed nobody can enter only one lead cabin crew can enter only on the express permission of the cap and also there is a system of post-flight checks a doctor's routine is generally not so well defined but can uh a planned surgery can you do this can you actually look at all the preparation and all yes maybe there is a there is a case in point there there's a lot of talk about checklist and checklist culture and what aviation has given the world checklist and this is where we'll be talking about this i'll again take you back to 100 1930s actually in the 1930s there was the aircraft you are seeing behind these these uh write-ups is a b-17 flying fortress at that time in 1930s it was called model 299. eventually in history as we see it now this was one of the most successful bombing aircraft this was the first aircraft which had four engines this was the first aircraft which was so complex to fly that when the demonstration of this aircraft was slated in 1935 in front of all people uh assembled to buy the on the manufacturing race going on between boeing and lockheed martin two test pilots major hill was the chief test pilot at that time of army aviation core u.s army aviation corps who could do nothing wrong he was on board this fire this aircraft along with another pilot it required two pilots they took off very smooth takeoff after about flying towards 700 meters height the aircraft stalled all is it lost its flying capability turned and crashed killing them there itself people could not understand what happened people could not understand that a person with the caliber of major hill could actually lose an aircraft there was nothing wrong the court of enquiry established that there was absolutely nothing wrong with this aircraft then what happened then test pilot after test pilot they sat and had meetings and meetings and then they decided that this aircraft is so complex and four engines have to be monitored simultaneously you cannot consign it only to memory you need something called as the checklist the the first origin of a first aviation checklist goes back to this aircraft and when they actually put the checklist in place and concise the checklist made the checklist precise that's when this aircraft became the most successful aircraft in the history of till such until that time till it was in service there are many such things what does a checklist do a checklist basically ensures that things that you are mundane things that are very habitual things that are very routine are likely to be skipped now i have come across a lot of pilots a lot of doctors who have said yeah this is not you can't directly translate it to medical science i disagree even in normal life we use checklist when i step out of the house i mean you see the mobile is there the wallet is there you are running a mental checklist you are carrying your keys mobile wallet and you're carrying it so there is a tendency to miss out small things and the routine things which are most likely to miss out a checklist ensures that such things are not messed up the biggest problem with checklist i saw somebody type surgical checklist by who fantastic the origin of a surgical checklist of surgical patient safe safety checklist in who has its origin in 2007 to 2009 there was a lot of lot of resistance to even to that they developed a 19-pointer checklist as to what is to be done pre-anaesthetic part was seven points during surgery was seven points post surgery was five points so 19 points at least they developed but it was an absolute failure they refined it again and again the person the researcher who was doing this checklist for the who he went back to the chief pilot of boeing and asked him how do you develop the checklist aviation has got this checklist concept of normal and non-normal so there are two sets of checklists the moment everything is going normal so they use the checklist non-normal checklist and none of the checklist you just have to identify the right point you make it exhaustive and long nobody is going to read it nobody is going to people get tired of it you have to be very precise and put in only the critical parts it has to be precise it has to be small and it has to ensure that the right thing is targeted only then the checklist will work and in 2009 when they actually re-established that patient safety checklist by who the fatalities came down by almost 47 percent the infection rates came down by 36 percent so it was a successful thing two departments which have actually established checklists in health care is the anesthesia department and the and the surgery depart the anesthesia department is very much like flying i always keep mentioning that because you know the pre induction of anesthesia is like takeoff the cruise time is the patient is unconscious and everything is happening comfortable the anesthetist is not too worried everything is running on that the most critical one is weaning the patient off the anesthesia it's very similar to landing they have developed their checklist whether it is checking the monitors whether it is checking the anesthesia equipment the anesthesia department has actually done wonders and ensured that patient safety has taken a major leap in terms of in healthcare we also have examples what is the tprbp chart it's a checklist we are all taught from from mbbs days as history of presenting illness i mean i'm presenting in complaints history of presenting complaints past history treatment history etc etc etc management dosage and i mean treatment and management all this is a checklist why why are these important because we should not miss out any single point and that's the reason uh the checklists are extremely important the next concept which is very important in aviation which we can imbibe is the crew resource management every pilot go undergoes this training it is basically if you see the diagram in yellow the central live where is the flight crew now his interactions have been identified he interacts with the environment he interacts that is the aircraft the airspace and which the clue operates he interacts with the other livewear that is humor humans that is the atc staff the ground staff and the cabin crew the engineers etc he interacts with the software the procedures checklist manual symbology and he interacts with the hardware that is the cockpit layout seating controls etc now this forms the basis for his situational awareness his decision making his communications and brings down his stress levels each of each pilot actually undergoes extensive initial and recurrent trainings in these aspects so that he understands where we can call out i i can there has the first tenerife accident is a failure because a post-tenary faction accident the screw resource management training came in because they realized that the first officer and the flight engineers both had identified the problem that they are going to crash but they did not bring it up to the senior captain who was very very senior to them and they felt that we should go by his decision the same culture is there in the in the medical community how many of us do have the have the courage of conviction to actually stop a senior doctor if something obvious is going wrong we don't we don't have that culture in us that is something which can develop with a proper crew resource management happening now accident causation the next one is every accident that happens is analyzed thread bare with not with the intent of pointing fingers with the in intent of fact finding there are various models the most accepted model is a reason swish tease model which has got different levels of causation of accidents whether it is the organizational fact starting with the unsafe acts what actually happened which triggered that accident what were the preconditions you identify in the environment whether there was any supervised supervisory lapses or whether there was any organizational factors which contributed to that so you are actually finding a fact and then going backwards and seeing at what level is the fault now there are agencies like the aircraft accident investigation bureau in india or the national transportation and safety bureau in u.s which investigate each such accident now it is not practical that 400 000 medical errors are investigated but do we at least do a percentage of that do we have an agency which actually does it again certain hospital chains do have this but not everybody not everybody has a proper morbidity mortality review meetings where you actually find the cause and go back and rectify that as a systemic response we don't have it that is something which we can do now the next one is recurrent training pilots undergo recurrent training at 6 months 9 months 12 months and believe me it is mandatory for them to pass they don't have a choice of you know paying for that conference or the training session and getting the certificate no sir they don't they undergo the training they give the exam and the exam is submitted to the regulatory authority we in do we have that do we have any supervisory training or any training such we have cms the the medical council or the nmc or whatever the authority is there they say that you know yes you have to earn so many credit points great points you know i know everybody knows we just apply for that conference and we get it so is there any actual recurrent training occurring it is not person practicing outside okay in in systematic hospitals there may be some training happening but if i am practicing outside individually it's up to me whether i want to individually train myself or not so this is one of the most important things which i stress upon that training is missing seriously in in healthcare set up the recurrent training part do we look at fatigue no sir we don't look at fitting fatigue this management system is one of the most important components in aircraft flying every fatigue report is analyzed pilots are open to you know uh describing their fatigue but they are also it can be predictive you actually can predict fatigue in certain sectors it can be we can take a wedding management proactively or it could be if somebody has actually undergone a fatigue episode there is nothing like that for doctors we are seeing in covid there is no nothing like fatigue management for doctors at all yeah i mean add to that something called as a flight duty time limitation a pilot cannot fly more than thousand hours in a year in a year so uh because fatigue regulation is coming because it is critical to the uh flight pattern so should we have a doctor's duty time limitation will hospitals function like that will individual economies function like that that's a matter of debate that's something which we need to look at which we can take from from our this one supervisory uh role there is something called a line oriented safety audit where the senior supervisors go on board the aircraft and actually check if somebody is making errors now the person being checked does not know that he is being checked they are checked for uh procedural errors they are checked for behavioral errors they all actually a report then it goes to the operations management and then corrective actions are taken on that it is not a finger pointing exercise it is a supervisory surveillance which ensures that if because of certain behaviors because of certain practices because of certain procedures there are certain threats emerging in the aircraft those can be controlled we can this is something which we can strongly take in health which we do not have next is the preventive care every pilot has to mandately undergo his annual medicals and they are very very stringent every year every cabin crew once in four years so the different sets and guidances are laid down and this is something which we can't even think of in medical science in medical field that is um that is for us to ponder now i may be i may be thrown out of most of the medical forum for saying this should we have a pre-flight medical check or pre-surgery medical check for doctors when when a pilot reports for duty the first thing he does is he takes a breath alcohol test so outside the ot or outside the icu or outside the hospital do we have a pre-surgery medical check i don't know how many will fail i don't know how many will pass but it has got it has got a great great capacity when users so uh the takeaways from what i have to say today is that true resource management if we handle our doctors correctly in terms of their their their fatigue management in terms of their physical fitness in terms of if we train them ensure their training with respect to soft skills with respect to interacting with the medical technology that is posed in front of them the software the hardware the livewear and if the protocols and briefings are more perfect if we bring in checklist culture very well thought or not everywhere random checklist is not to be done if we look at the fatigue levels of the of the doctors we we can actually make a there is a large area where aviation can contribute to health care patient safety in health care so with that i will just give you a can i have the video please i wouldn't like to leave you without a poser for the next time i have talked about aviation i have talked about aviation medicine how aviation healthcare can help each other but i have not talked about a large chunk of what aerospace medicine does is space medicine this video over the next two minutes please have a look at things that we take for granted on ground how they disappear the moment we move out of the earth's atmosphere it's very easy for us to say pick up this glass and drink it's not so i mean it's not so in space there are certain challenges which are tremendously pouring water having a bath is look at him having water now [Music] i mean he's a trained astronaut so he's actually having fun with it but that's how they have to drink it normal things that we learn normal things that we this is this is how he's sleeping there's no concept of down or up and to make these things work behind the behind the scenes toiling away on a daily basis researching a group of doctors along with the engineers of aviation medicine and aerospace medicine thank you thank you for your [Music] and please i would also recommend you to read as as the as the organizers pointed out the checklist manifesto by atul commander it's an eye opener it's a fantastic book which will give you small snippets i do repeat that all the principles of aviation can not be translated directly to healthcare but there is a lot of scope in many areas that we can actually make a difference by following the principles of aviation thank you thank you very much [Music] excellent sir uh i i don't have words uh it's been a incredible uh and the birth to bombay kind of a journey over the last one are beautifully started uh the journey was amazing and the landing was super soft and uh memorable uh so many stories uh so many amazing insights i mean uh when we when we conceptualize this topic i did not really know that there will be 10 clear concise things that we in healthcare could actually take away from aviation if i start to summarize the session i think i'll need 20 minutes uh which probably we don't have uh we should also take some questions uh from people but in the end i'll definitely summarize uh there are so many things i want to actually bring back to the four uh i i was reading a few comments there's uh multiple you know comments and questions around saying you know not really applicable to health care what do we do in emergency what do we do with myocardial infarction i think you know each question can be answered and i'll let her answer many questions but i just want to say this correcting something starts with acknowledgement and acceptance it's very easy to say we are different this is different it's harder to look inside see you look at things like fatigue who talks about fatigue in healthcare professionals nobody cares about fatigue who talks about limiting surgery surgery hours and i mean the whole expectation from society from the hospital owners managers uh governance is that doctors are super human uh you you make them do 100 procedures and the results will be the same it can't be the same right so i mean there's a lot of uh small medium big takeaways from this session we'll we'll actually write up a good summary of this whole talk circulate it with everyone uh but i think the fundamental thing is uh to me was the whole culture of cmd uh we we don't have that uh we don't focus on that uh in the last few years a lot has started happening in this there are patient safety conferences summits there are teams there are some very very uh well-known professionals here with us today uh we have i saw a comment from dr paragundani he he heads uh quality and he does a lot of work in qualities with workhead i would love for him to come on stage and share his views if he's still around so yeah things have started but i think the most important thing uh the most important reason why aviation has been able to bring about this remarkable heat is the whole focus on safety and reducing errors things we measure uh our average length of stay average revenue per patient every revenue per occupied bed i think those are important for sustaining any organization but at the same time the the safety has to be square in the middle of every institution's pursuit you may not disclose it you may keep it internal but it has to be there and where it all starts is with data as you pointed out rightly if we don't have data we can't analyze it if we can't analyze it we won't know what's going wrong uh and we won't be able to correct it so wonderful sir i mean uh extremely interesting session lots of things that can be learned here anyone who would want to come on stage have a have a direct conversation please uh raise your hand we will just upgrade you to the stage meanwhile i'm just going through questions which uh have been posted here uh dr rao first of all thank you very much so it will please you to know that over the last uh decade and a half indian health care is trying to live up to a very rich cousin uh av indian aviation and uh we probably learned more from you than you can ever imagine uh whenever i fly i make it a point to you know look at what's happening and i always make it a point to take home something in the learning sense uh the other important thing is you would be happy to know that uh over the last 15 years and in healthcare not only the corporate sector which you alluded to but also a private primary health centers in gujarat in tripura in madhya pradesh in tamil nadu and kerala primary health centers also setting up basics for looking at health care quality in terms of patient identification reducing return on mortality looking at not just the things that corporate hospitals would crave for but also looking at improving some of the indicators for which we as a country are always variated abroad you know i think there's a huge move the last two decades and i'm not going to say which government did all of that that's not part of the discussion so there has been a huge move uh is there more to do absolutely uh just today uh yesterday for example i i read about it that indian medical association has signed up with national accreditation board for hospitals and healthcare providers to have training for specialists and super specialists across the country i also believe that as of two years back uh medical safety and healthcare quality is being introduced as a subject and second mbps so we probably are the laggards uh you you're younger to be but we belong to a generation but it was not taught so we've got to learn it uh all hospitals today uh let's let me also tell you one more thing there is a financial linkage now to adhere to accreditation in case you want to get a premium on government business like cghs irda is now pushing that you cannot get certain insurances so i always believe that you don't have a danda in india people are not going to follow the rules so the irda the government agencies are all making it mandatory for indian healthcare to follow accreditation which is a pretty good benchmark of healthcare safety and health care quality the sad part is that still uh most of our focus remains on just doing it on the days of assessment uh as i also heard from your talk uh aviation is a 24 7 assessment thing uh you will not take the risk of flying off an airplane and be glad for that but in in health care today we are still governed and we're still coming out of the shadow of the gods and goddesses you know like surgeons used to be treated like that they still but we need to come out and we will yeah today's generation of healthcare administrators is definitely better trained it's definitely focused on patient safety uh the new generation of national accreditation also mandates that there should be something called a patient safety officer earlier it was just a facility safety officer so the structures processes that are required to set up healthcare safety are getting there and i'm sure that you know today the people who have trained under you who heard you out will definitely be more than happy to every time they enter an airplane i've stopped going to my mother-in-law's house because whenever i go to the house she always says you're looking for holes in the ceiling and loose wires so i think it's inherent to every accreditation specialist like us to look for all these potholes in fact sometimes i actually go up to an air horses and tell her you know there's a loose bulb in the in the toilet so you need to check it out uh we're grateful to aviation uh but healthcare is a long way to go so thank you very much for your time today and uh rohan fantastic topic uh only you can think of something like this okay thank you very much thank you so much yes yes dr rao thank you uh the biggest difference i mean it's very encouraging to hear that it is coming a long way in the sector and in the corporate sector we have to work towards building this happy culture right from our i mean only doctors nurses the paramedical staff every person who works in healthcare now if every person if we target everyone only then the change in culture will happen and that's that that's a big thing that's a big plus i'm sure it takes some time so i think so for those of our colleagues uh for those of you who are listening i'd just like to say that we always depend on u.s resources there's something called an ahrq agency for healthcare research and quality they've got a wonderful culture of quality a culture of safety survey which is downloadable free of cost and it makes sense we've been running it for the last four years and we've seen persistently that there is an increase in the perception of of sort of safety within the institution we swear by that culture of safety survey because it obviously gives us a very good dipstick about where as an institution we are moving despite attrition despite changes in management how we are moving so i think that's another cultural survey which which helps to monitor our problem dr now is that in india we love to talk we don't really monitor i think if we put our money where our mouth is we should be able to show the world yeah we should be able to show the world that this is where we are sir yes rohan thank you so much thank you dr i think you made a very good point on uh incentives i think uh there have to be incentives to put uh safety first and in the case of aviation what happens is uh every accident is a large accident and in the case of healthcare every error leads to one death uh generally unless it is an endothelius clustering doctor is kind of a situation but largely it is one error uh one which goes unnoticed it is very hard to attribute very hard to find and therefore i think uh as an organization there will never be a good enough incentive to actually spend money in training safety uh investing which is why incentives like this for certain audited reports for certain parameters cghs will give you higher rates nabs becoming mandatory so these are definitely things which uh will help organizations invest in safety another very interesting thing which i think dr rao brought out us quality is not safety uh quality uh this difference between the two i mean the context is important uh they could be the same but lastly quality is more for patient happiness and safety is more for uh just uh you're on stage probably if you can just turn on your mic and video you'll be able to speak uh good evening dr rao i'm a neurologist from indore i loved your talk and i've read the book the checklist manifesto and this is a lovely talk what i want to ask you is that if we had something similar that um thousand hours for a neurologist in a year what practice we would just be nowhere not practical so so how do you resolve it and so i think the aviation industry is built on so much of redundancy there's so much of excess everywhere whereas we are grossly understaffed we are grossly overworked we are the equipment is inadequate so how do you how do you reconcile how do you put these two things together so in my experience you are right i mean you can't compare uh as far as the redundancy levels are concerned you can't compare aviation and healthcare but i personally feel in my experience of last 30 years uh we don't use our paramedical staff and the nurses to the optimal level everything is doctor dependent every single thing is doctor dependent the patient is not happy because it's a culture the patient is not happy if the doctor doesn't take the bp if the bp is taken by the paramedic what's inside he's not happy true there is a systemic change which has to be brought about and as i said everything of aviation can't be directly translated certain aspects can be taken in a thousand dollars it's practically impossible with the kind of population we have and with the doctor patient ratio we have but if we utilize our nursing staff and our paramedical staff well i think we can reduce the workload of doctors to a large extent you know they will not take the nurse's word for it and neither we train our nurses nursing staff as per that we are not confident enough to say okay i am right we are not confident enough that is one also the regulatory milieu is not that the nurse can prescribe so that's another issue the doctor has to issue issue a prescription yeah so let me talk point about redundancy is very good sir uh so uh the redundancy is by design uh and uh you know we've recently read a case study on boeing and two very interesting stories from there i'd like to share so one is on redundancy so uh the audit team of boeing who actually audits the work which is done by the engineers is significantly more experienced than the team of engineers who actually builds it uh and therefore more expensive you will never see this in any process you'll never see an audit team which is more expensive than the actual team that is the redundancy they are building into the system and that is the you know cost they are willing to take to ensure that accidents don't happen so redundancy is true and i think you know unfortunately redundancy will come with a cost and the best institutions which will mean that richer people will be able to afford uh the kind of care which comes with that safety margin we can only hope that there are across the board systems and processes which bring in some of these at least in the grasp of every individual the second story uh was about the loader dr rao which you talked about so uh you know the loader uh has the ability to raise an alarm uh and inform everyone that something is wrong uh there is this concept of andon cord which i recently learned about so in a factory setup the anden cord is like this cord which runs across the factory um and any factory worker can actually pull the cord and bring everything to a halt whenever there is a small problem in the system uh now ending chords can be physical like in the case of a factory or logical like in the case of the loader i think hospitals would serve themselves well to have logical london gods built across the organization so everybody should have the ability to raise an alarm uh if you see a batch of vials where something is wrong so that that whole culture of no punishment no fear no shame no blame uh is a very very interesting uh insight which also you shared um again from the case of boeing the culture they established was you will be punished for disclosing for hiding not for coming out with your mistakes so you make a mistake you come out with it there is no punishment but you hide a mistake and you are done so i think that that whole importance of allowing people to come forward and disclose mistakes which they have made or someone else has made think a brilliant uh insight over them thank you dr pasil thank you dr raw good night excuse me can i can i ask a question sir question yeah please yeah it's this is uh open uh to the esteemed panel how do we address the gross mistrust towards medical health services today i mean nobody ever googles who's the captain of the flight what is his flight record but today for the smallest of procedures or even medication um i know there's no immediate answer to it but since you all are in the field of quality and dr raw himself being a doctor i'm sure you'll have better insights than you know the junior doctors like us has to how do we get back that trust in our profession i i mean i don't have a straightforward answer these are these are googly okay so so and and it has got nothing to do with patient safety also per se but having said that i can i can give you my perspective on this the biggest uh one of the most important things that we do in india is we [Music] put the doctors on a pedestal we put us i mean doctors are kept on a pedestal if something goes wrong the same pedestal i mean you are the is a brick bats are thrown on the same pedals it is a creation of the media i mean like we are seeing artichoke doctor scala is very similar to what cricketers converts he doesn't do well in one match his house is a target similarly a doctor it is a high profile thing because it is emotionally charged if we having said all this one thing which is missing from our curriculum and which i am told i am told is in the present day curriculums it is being stressed upon a lot the soft skill management most of these things have occurred are and are occurring where yes you will have animated people coming across you will have different types of people with the easy availability of mobiles and video recording if the soft skills are taken care of if the handling of care of the patient and care of the caregiver is taken care of i think some of these will come down but there is no quick fix answer so soft skills have to be focused understood and maybe sir as you said uh you know the limitation maybe if uh everybody agrees okay you have to put an upper limit on the number of patients you'll see in a day you know you cannot give quality care unless the patient is heard out so maybe i know it's too dramatic to achieve but it does make a huge difference so to a large extent this happens in in hospital but in individual practice if you see it is for the individual to design so there are people who are who are actually taking it way forward right but it was one of the most thought provoking webinars in a very very long time i can't express my gratitude in words uh how much you know as dr owen said internal reflection has been triggered of all the checklists to have and to just begin with aviation is thank you dr rao once again to see you and giving an excellent talk my point to do in relation to what dr nanda said is that we as doctors should stop playing god we should work like a professional we should not give any guarantee we should not then the question doesn't arise right if we start right from the beginning the moment we see the patient we say that we are professionals and we do what like any other professional do then that expectation will also be realistic and that will solve part of the problem but it was an excellent talk and i think there are so many takeaways from this that we would love to have you again again right on topics different topics so you're already put a teaser for the next topic so yeah so i think sir we've been stretched uh significantly over time just want to end with one interesting question i saw in the comment box it was a question i also had what can aviation learn from health care because what can aviation learn from healthcare is in terms of there is no interaction between the person actually flying the aircraft and the passenger and that connect is missing as as dr nanda pointed out a little while back nobody comes to knows flying the aircraft maybe that personal connect is the only thing that is that is different but otherwise i would rather have the current situation than have a big back being thrown at a pilot yeah i think if aviation was to face the kind of variability which which uh the hospital sector faces then there would probably be having said all those all that we have said because two very different organ because i have a fixed platform to work on so i can train people again and again and again but we all know one human body is different from the other yeah theoretically all are same but everybody behaves differently that much flexibility if we incorporate in our trainings and look at certain fundamental principles of fatigue management safety culture and crew resource management i think we would achieve a much more holistic reason wonderful sir thank you so much for taking time out and spending time till late in the night today to to everyone who attended we are also thankful to you for your continued presence

BEING ATTENDED BY

Dr. Brajamani Akoijam & 994 others

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dr. Nageshwar Rao

Dr. Nageshwar Rao

Chief Medical Officer - IndiGo Airlines

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dr. Nageshwar Rao

Dr. Nageshwar Rao

Chief Medical Officer - IndiGo Airlines

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