John Nance: Culture Change in Healthcare Starts By Facing Reality

John Nance BooksA pilot in Vietnam and Desert Storm, John Nance has been working to share the wisdom and results of culture change experienced by the aviation industry with those of us in healthcare for 22 years. His book, Why Hospitals Should Fly, was pre-reading for our Telluride Patient Safety Summer Camp students, residents and faculty this year because it tells the story of a fictitious hospital, St. Michael’s, that has made the cultural transformation necessary to truly put the patient at the focal point of care.

I was fortunate to hear Nance speak live this past Tuesday night, as MedStar Franklin Square Medical Center invited him to share his experience with a packed auditorium of associates and outside guests. Using humor interspersed with hard facts and stories from his fieldwork in healthcare and as a Lieutenant Colonel in the Air Force, Nance was masterful in capturing the hearts of many in the room. Throughout his talk, he continually asked the audience to raise the sense of urgency around this culture change. The cultural transformation he experienced while in aviation lasted a quarter of a century, but he emphasized healthcare doesn’t have that amount of time. There is an urgency to this challenging journey. Paraphrasing from Nance’s talk:

Cultural change is so profoundly difficult if you think one inoculation is enough you are doomed to fail…the journey is not complete until there is no one left who remembers what it used to be like. 

Not everyone can make this journey—you have to look for skills that nurture human nature of people on the frontlines. Too often we make excuses for colleagues and say “they’re very good at what they do” but the human connections just aren’t there.

So much of our training, as Nance pointed out, has been based on the fallacy that we are infallible. As Will Smith said in the movie Men In Black, we are supposed to be “the best of the best of the best”. Our failure, according to Nance, has been our inability to accept the reality of our humanness–our capacity for error–and build functional systems to mitigate that reality. The culture new caregivers have entered into has dictated that a single individual be given all the power in a patient care interaction. He often referenced the Star Trek Captain Kirk “commander” model cited in his book where one person knows everything, sees everything and seldom if ever makes a mistake – a concept totally impossible in healthcare today. Physicians need to lead people, not be commanders who bark out orders and make others feel subservient and disrespected. For some, this is second nature. Leaders like Lucian Leape, Don Berwick, Gary Kaplan, Harlan Krumholz and many others across the country have been talking about, and modeling, patient-centered care for many, many years. We now need to get to that tipping point. Healthcare is requiring newer leadership skills be developed by all of us, asking the we learn:

  • To be team players
  • To be good communicators with all colleagues and patients
  • To listen with respect and value the input of all team members
  • And to invite patients and families into shared decisions about their care.

Many who have started this journey understand it takes courage and fortitude. For students and residents who have been bullied because they were honest in admitting they didn’t know something and called their attending for help,  for nurses and support staff who have watched in silent horror as those “leading” acted in an unprofessional and disrespectful manner–it’s time to raise the volume of our collective voice, drown out the last of the naysayers and the “narcissists” who have taken healthcare down a self-serving and dangerous path, and help lead the change John Nance is urging us toward.


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