Posts Tagged ‘aviation’

00621 K12 is Risky Business

October 8, 2010

ames Bagian – a NASA astronaut, engineer and currently a hospital patient safety expert engaged by the Veteran’s Administration at their National Center for Patient Safety – was recently interviewed by Kathryn Schultz in her series on “being wrong.” Their discussion focused was on health care safety vs. aviation safety.

Aviation is a highly hazardous industry, but it has so much safety designed into the system, there is very little risk of a bad event. The field has a systems perspective, and there is a huge investment in safety. They are not interested in punishing the individual but rather learning what led up to the event and how to change the system to prevent a repeat in the future.

In his current job with the VA, Bagian found the opposite. Health care is all about,”finding out who made the mistake and punishing them for being stupid.” The profession trains them “the right way” and then blames them for mistakes. But a systems analysis and transformation in one area, medication, can reduce the error rate from the current 7% to 10% (!!!) to less than one tenth of one percent.

Admonishments to double-check, be careful, be diligent, and to read the literature do not work. But reporting close calls in a non-blame environment can be highly effective. Developing a culture where breaking the law (rare) remains blameworthy but human errors are expected and capitalized on leads to both a better work environment and a safer work environment. Punishing errors is a terrible policy because it chokes off reporting the very data needed to change the system.

The most similar industry to health care is education. Each is an integration of public and private entities within a large and complex system. They deliver critical human to human service where errors can cause serious problems. Errors in medical systems usually cause immediate harm, where in K-12 education the accumulated harm is only evident after many years.

Many K-12 reform efforts produced a range of admonishments — such as more parent involvement, hire better teachers, more money in the classroom, fewer administrators, and students should work harder — but practical systemic K-12 solutions are rare.

eSATS was founded based on the use of systems analysis applied to education. We discovered a number of serious systemic issues. The isolated classrooms and schools hampered close-call and error reporting, that could support systemic changes to correct for errors. The focus on summative assessments of students, teachers and schools on a weekly to yearly basis were of little value for continuous systemic reduction of risk of student academic performance failure. This results in significant risk to the probability of student academic performance success. The labeling of schools and judging of teachers and principals on summative assessments has been framed as a solution instead of being recognized as part of the problem.

eSATS focuses on real time, data driven formative assessment within the teacher-student relationship as the most important means to assure each student performs, and rises to, their academic potential. The automated data warehouse and decision support systems in our State are being developed for legacy summative data which is a necessary step forward. But only with the application of eLearning systems that include real time student-teacher formative assessment capability, will Arizona have the capacity to remove risk of student failure from of our K-12 education system.