Holding the Captain of the Ship Responsible: Is this possible in health care?
I have a friend, Gene, who was once the Commanding Officer of a U.S. Navy aircraft carrier - the Captain of the ship. And what a ship an aircraft carrier is. The ship alone is as long as the Empire State building is tall, with a flight deck the size of several football fields. it takes over 5000 sailors to keep it operating. It’s a floating city capable of sailing the high seas at over 30 miles per hour. Not counting the 100 or so airplanes it carries, it is a billion dollar asset of the U.S. government. Throw in the value of the airplanes that operate from its deck and it becomes a priceless instrument of U.S. power projection and policy.
The command of such a ship is a coveted prize among officers in the Navy. There are fewer than 10 operational carriers so there are very few “Carrier Captain” slots available to the 65,000 officers in the U.S. Navy. For a Navy pilot, it is one of the few routes to becoming an Admiral. Miss out on being selected as the Captain of a carrier and your chances of wearing the stars of a general officer are slim.
My friend’s command of the carrier’s helm ended badly. One night, while he was fast asleep in his at-sea cabin just aft of the bridge of the ship, the Officer of the Deck, a lower ranking officer in charge of the ship during the Captain’s absence, violated the Captain’s standing orders and commanded the carrier to turn off the plotted and authorized course. The ill-advised turn put the carrier directly in the path of a freighter and caused an at-sea collision and millions of dollars of damage.
Despite being asleep and not on the bridge at the time, and despite the fact his junior officer directly violated his standing orders to make no turns without first awakening the Captain, Gene was immediately relieved of his command by the Navy brass. Another Captain assumed command the very next day. Gene’s career was derailed and he retired from the Navy shortly thereafter.
Unfair? Perhaps, but his sacking was perfectly consistent with the long standing Navy tradition of holding the Captain of the ship solely responsible for what happens to the ship under his command.
My profession, commercial aviation, has a similar and firmly established tradition. The Captain is solely responsible for what happens to an airplane under his or her command. (See FAR Part 91.3.) That tradition has even been codified in the Federal Air Regulations which govern how commercial airliners are operated. Your co-pilot, mechanic, or flight attendant may in fact be the one who makes a mistake putting your passengers in peril, but once the airplane backs away from the gate, the Captain is the one held responsible by the FAA.
There has been a lot of debate within healthcare whether such a tradition and policy is possible in health care. Is the surgeon, for example, to be held responsible for anything that happens to his or her patient in the OR - even if the mistake harming a patient was made by a nurse or surgical tech?
While aviation is not perfectly analogous to healthcare - the roles and chain of command are less distinct, and it is sometimes unclear just who is really in charge - the level of reliability and safety achieved by aircraft carriers and commercial airlines is in part a result of the concept of holding the Captain of the ship ultimately responsible for what happens on his watch.
After ten years of helping healthcare adopt the best practices of high reliability organizations (HROs), I believe healthcare institutions that strive to uphold this tradition have a better shot at creating a culture of safety. Holding the “Captain of the Ship” responsible is a best practice of HROs.
Whether it is the U.S. Navy, commercial airlines, or a hospital - one thing we know is this: the Captain can’t do it all by himself. There is just too much to monitor and cross check alone. He or she needs the efforts of a well trained team that communicates and collaborates well. If the Captain is going to be held responsible for all outcomes under his command, he will do well to work just as hard at being an effective team leader as he does at his technical skills. The willingness of the team to “have his back” in all situations is directly related to his ability to create and manage an effective team.
Captains, be forewarned. Scream, belittle, ignore, or micromanage at your own peril. Those behaviors leave the needed teamwork stranded at the dock and put your crew members, passengers and patients in peril.
Ultimately they may leave you relieved of your command.
�
