Wednesday, June 20, 2012

It's been working on the railroads. Why not hospitals?

#TPSER8  I am not alone in mentioning that people in health care have a lot to learn from other high-stakes, high-risk professions, like airline pilots.  Chuck Denham, for example, has teamed up with Captain Sullenberger, Dennis Quaid, and John Nance to go so far as to suggest an NTSB for health care.  (Aside:  Let's hope that this idea is paired with the equivalent of the Commercial Aviation Safety Team if it starts to catch fire.  That would pair regulatory review of adverse events with real time process improvement related to near misses and other safety impediments.)

But I am here today to talk about railroads.  As we were doing a review of our recent class reunion, my committee co-chair Duncan Allen made casual mention of NORAC.  "What's that?" I asked.  Duncan, who works at IBI Group and is a whiz about this stuff, replied, "Northeast Operating Rules Advisory Committee, which sets the common framework for railways in the Northeast, and is heavily borrowed from in other portions of the country."  My antennae went up, and he sensed that, adding, "This is very different knowledge domain from hospitals, but perhaps you will find something interesting.  The high-level principles of the rules applying to employees of one railroad on the property of another might be a case in point."

Now remember that I just spent a week in Telluride with a group of residents talking about quality and safety, and especially reduction of variation in clinical practice.  In my hospital CEO days, I had often seen what happens to residents as their training program caused them to move from hospital to hospital.  The difference in approach to quality and safety matters was dramatic, and these young doctors often found themselves middled by changes in rules and expectations.  Now check out the railroads.  When I asked if the rules are enforced, Duncan explained:

Yes, and rather zealously at that.  Technically, each railroad enforces its own ‘home’ rulebook on its own geographic territory, through a military-like structure (see Sections ‘Dispatchers’ through ‘Foremen….’ in NORAC). Larger railroads are typically divided into geographic ‘divisions’, each with a Superintendent who has ultimate authority.   The NORAC rules are incorporated into each of the member railroads’ rulebooks (explicitly or by reference), so are binding along with a lot of local territory-specific detail contained in each railroad’s ‘employees’ timetable’ and/or special instructions (usually a separate publication).  Per the NORAC rules, an employee of NORAC road B operating on NORAC road A is subject to A’s rules, which are enforced by A’s enforcers.

I asked whether there is an overall governing agreement that is in force.  He replied,  "In the strict sense I think you mean, not so far as I know.  In addition to NORAC rules, there is a General Code of Operating Rules (attached), to which virtually all non-NORAC railroads adhere.  These are somewhat narrower in scope, and address non-block territory (block systems are typical of the Northeast), and don’t say that much about operating in ‘foreign’ territory.  If a railroad joins NORAC or subscribes to the GCOR, then it has effectively agreed to make the common rulesets part of its own rulebook."

Now, look at this, the first section of the GCOR:

I like this part:  Report by the first means of communication any accidents; personal injuries; defects in tracks, bridges, or signals; or any unusual condition that may affect the safe and efficient operation of the railroad. Where required, furnish a written report promptly after reporting the incident.

Does this sound familiar?  Think back to Dave Mayer's criterion for a high quality hospital.  No organization can succeed at continuous improvement without a mechanism for recognizing and reporting out where it is not doing well or well enough.

But back to the issue of different hospitals, er, railroads.  Duncan, noting the great detail in these rulebooks, states:

It may seem incredible that so much wordsmithing goes on, but this approach has been evolving for decades, and rail safety is continuing to improve.   It’s somewhat a matter of necessity, especially in the Northeast – for instance, the Acela Express between Boston and Washington operates over five distinct ‘railroads’:  MBTA from South Station to the RI state line; Amtrak in its own right between there and New Haven; Metro North Commuter Railroad from there to New Rochelle; Amtrak again to just outside Washington; and then the Washington Terminal Company into the station in DC.  Most situations where train crew operate on other roads requires that crew to be qualified both on the ‘territory’ (information in the employees’ timetable and special instructions) and equipment (e.g. train handling, if they are going to operate the other company’s trains).  NORAC addresses the different wayside signal displays in the northeast in some detail, because so many trains operate in differently signaled territories."

An then there is the requirement for ongoing training in matters related to safety. Here's a page from the rules:

Duncan points out one provision,  "Another fun RR tradition is the ‘safety rule of the day’ (see item A-S2).  Your superiors can quiz you, and not knowing the answer is not a Good Thing."

Think of what would happen if we applied similar standards across all hospitals and forced clinicians to engage in continuing and intense quality and safety reviews as part of their professional certification.


Anonymous said...

There is no question that there needs to be a common standard across all institutions, and I think we are, ever so slowly, moving in that direction. However, your post prompted another thought - will the movement toward hospital employment of physicians, through ACO's or similar arrangements, inadvertently enhance the silo effect and prevent the absorption of best practices which may be evident as physicians (currently) practice in more than one hospital system? I have sat at many a medical executive committee meeting where a clinician might say, 'Hospital X handles Y problem this way. I think we should take a look at doing it that way.'

nonlocal MD

Anonymous said...

I understand Anonymous' concern with enhancing the silo effect. It is hard for me to imagine a healthcare system with a bigger silo problem than we already have. However, if healthcare had a system like the railroads of the NE, we could create "rule book" of best practices. Then we may be able to share information more readily and erode the silos more quickly. We lack the infrastructure, but it would be worth the investment to build it.

Barbie Gatton, MD