Mandating health care by creeps and jerks

Abstract

In the 1970s a famous stoush occurred amongst evolutionary theorists. Stephen Jay Gould and Niles Eldridge, giants of the field, proposed that evolution occurs in bursts after long periods of relative stability, which they labelled punctuated equilibrium . A critic humorously called this theory ‘evolution by jerks’ [1], which Gould bested by responding that gradualism was ‘evolution by creeps’ [2]. Whether or not scholars are as witty and acerbic as they once were is a moot point. But it reminds us of a serious puzzle in health policy: should regulation of patient safety continue on its path of gradual improvement or drive rapid change? Aviation is a case exemplar. It has taught other industries many lessons. Creating better teams through ‘crew resource management’ by institutionalizing team briefings before and after assignments, using checklists to confirm procedures have been done, practising graded assertiveness when problems arise, making efforts to be aware of one's surroundings and identifying, monitoring and reporting adverse events all come to mind [3, 4]. In short, aviation's knowledge is about how to run high reliability organizations [5], and it has created this through rapid step changes. Much of what has been achieved in aviation is through mandating behaviours [6]. Flying is controlled and regulated, and not just for briefings, checklisting of procedures, standardized language and dealing with incidents. No one can report for duty let alone fly if they are ill, fatigued or under the influence of alcohol or drugs, which are randomly tested. Even over the …