I first met Professor Trevor Burke in our local French restaurant, when we happened to be dining at adjacent tables. The conversation took off that evening, prompted, as I recall, by a natural interest in what each of us do for a living; pilot and dentist. There have been many equally lively and thought-provoking conversations over the past few years.
Trevor recently reminded me of another occasion at the same restaurant. We got into a conversation around whether any of the lessons aviation has learnt, regarding the management of safety and the development of training, could be read across to the world of dentistry. We even went so far as to make some notes of our thoughts on a napkin, aware of the fact that, like so many things, they might well evaporate unless written down. Having deciphered some of what we wrote that evening, Trevor has asked me to expand on some of the topics that we covered, with the intention of seeing whether there is value in looking deeper into some, or all, of these areas.
The intention of this article is not to answer specific questions, but rather to highlight where I believe there is common ground between these two professions. I've then suggested how these challenges might be grouped together and where there could be benefit in sharing more detail in the future, if there is an appetite for that.
Background
My experience in aviation includes being trained by the RAF and subsequently operating the Harrier on the front line. After leaving the RAF, I flew for two commercial airlines before joining British Airways in 1996. Within British Airways, I've flown as a line pilot, gained extensive experience as a training captain delivering training to flightcrew and have, in addition, for the past 14 years, held roles managing the delivery of training across many of British Airways' aircraft types. I presently fly and train on the Boeing 747 alongside my management role.
For the last 6 years I've held the position of Chief Training Pilot, responsible for all aspects of the delivery of British Airways' pilot training. That role also includes responsibility for the oversight and delivery of cabin crew training and for managing British Airways' simulator training facility at Heathrow.
My management roles have involved close co-operation with the Civil Aviation Authority and other regulatory bodies, as well as working closely with many other airlines to share experience of managing safety and training.
What similarities exist between aviation and dentistry?
It doesn't take long to identify a number of areas where there are significant similarities between the two professions.
Risk and regulation
Risk is inherent in both areas, both for those that practise the profession and for the passengers or patients that are our customers. It is accepted that the need for continuous improvement and the avoidance of complacency in order to reduce risk is vital.
Regulatory bodies oversee areas which set out requirements for professional and operational standards, risk management and training but also ongoing assessment of competence.
The responsibility for implementing the required standards is delegated to companies or practices that are approved by the regulatory bodies.
There is a requirement for the development and implementation of procedures, policies and practices within operating companies. They should not only comply with the regulators' demands, but are required to adapt to the changing needs of the operating and technical environment, the introduction of new technologies, the needs of the customer and the needs of the people on the front line.
Managing safety
In the airline industry, there is a need to create an open reporting culture and a method of capturing data when incidents or accidents happen, or when things might have happened. Data needs to be shared openly in a way that encourages honesty without fear of unfair reprimand and that data needs to be captured and shared, both within operating companies and more widely across the professions, to enable others to benefit from the lessons that are learnt.
There must be an aspiration to move to a world of proactive safety management. It is no longer acceptable to wait for incidents or accidents to happen, then identify the procedural, technical or human failings that contributed to them and put in place retrospective remedies. Potential risks must be identified and action needs to be taken to avoid incidents rather than wait to trap or mitigate after the event.
A feedback loop needs to be created which enables changes to be implemented, when necessary, as the result of identified failings in process, practice, performance or technology. The effectiveness of implemented change must also be assessed and reviewed within this feedback process.
I am not aware that these concepts have been adopted in dentistry: indeed, I am aware of the publicity surrounding the very substantial number of cases which, in the recent past, have been brought against dentists by the General Dental Council. This is rather different from the open reporting culture that is now central to the airline industry, so, perhaps there are lessons to be learnt here?
People
Both professions are tough to get into. Academic and financial commitment is required from those that wish to join either discipline and the initial training is arduous.
Once trained, dentists and pilots move into a world where they are required to demonstrate their professional competence day in and day out without supervision. They become a remote workforce in many ways. This should be acknowledged and considered when managing safety and standards.
Hopefully, much of the time carrying out the required tasks is a routine process. But, things do go wrong and members of both professions need to be equipped with the personal knowledge, skills and attitude to deal with time critical, stressful events which may well have an associated startle factor.
Training structure
The training that is delivered at the start of a career sets the standard and framework that can then be built on during postgraduate training.
Technical and non-technical skills are vital in both areas. There needs to be focus on not just ‘What’ is done, but ever more on ‘How’ it is done.
Lessons learnt in the areas of ‘Human Factors’, ‘Crew Resource Management’ and ‘Teamworking’ need to be a fundamental part of initial training in aviation and similarities can be identified in dentistry.
The levelling of authority gradients within the flightdeck in order to create an environment within which all members of the operating crew are both empowered, and indeed expected to share relevant information, has contributed greatly to safety. The need to speak up when things go wrong and to intervene where necessary is an inherent part of the job. Are their situations within dentistry where there could be improvements in this area?
Evolving strategies and tools for the trade
Appropriate use of Standard Operating Procedures (SOPs), checklists and the blending of the two, is fundamental throughout aviation and has delivered significant improvements in safety. Opportunities for the same disciplines to show benefits within dentistry could be envisaged.
Much work has been done to identify how simple but effective decision-making, teamworking, situational awareness and time management tools can be applied to aviation. Organizations such as the National Aeronautics and Space Administration (NASA) have developed tools that have now become embedded in how we train and manage the operation in aviation. These tools have further evolved to satisfy specific needs within the profession. Could similar developments deliver benefits to dentistry?
Technological advances in aviation have meant that the physical skills needed to operate modern high technology aircraft are less demanding than those required to operate earlier generations of aircraft. However, the challenge of the management task when operating in an ever more complex operational environment, with increasing commercial pressures and expectations from our customers, has increased. That means that ever more focus needs to be placed on developing core competencies that can adapt to the challenges. Similarities, I'm sure, exist in dentistry.
Developing and maintaining standards
There is a need to develop a recurrent training programme that not only satisfies the basic regulatory requirements, but also focuses training where it is needed. Training syllabi need to be adapted to address identified areas of risk across the industry, within specific areas of operation and amongst specific populations. Areas of training focus that were important in the past may no longer be as critical and training needs to adapt.
There needs to be a fair, transparent and robust means of continually assessing the competence of pilots and dentists in all relevant areas of their operation.
There needs to be an effective means of identifying underperformance, delivering appropriate remedial training support, but also recognizing the fact that, where standards cannot be maintained, appropriate action is taken.
Potential areas for further sharing of ideas
Considering the groupings of challenges listed above, which are, by no means, an exhaustive list, I've suggested below where there could be opportunities for more detailed sharing of ideas.
Risk and regulation
How airlines work with the regulators to identify and manage risk.
What risk assessment models and tools are routinely used in airline management?
How are policies and procedures developed and approved?
How are effective risk controls identified, implemented and improved?
Managing safety
How do you create a ‘Just Culture’ within which people feel comfortable to share reports of what went well and what didn't?
How do you capture data effectively and manage the sharing of it?
How do you move to a world of proactive safety and risk management?
How do you create an effective feedback loop to ensure that changes are reviewed and refined?
People
How do you engage with your people to make them part of the continuous improvements in safety and standards?
How do you ensure that your people are aware of the challenges they face, want to improve their own standards, and are engaged with recognizing the need to evolve?
Training structure
What lessons can be learnt from the content of initial and recurrent training?
How can we share the benefits of the human factors training that has been developed?
How can we create an operating environment which maximizes the contribution of all members of the team, to enhance overall effectiveness?
Evolving strategies and tools for the trade
What lessons can be learnt regarding the use of standard operating procedures and checklists?
What decision-making, teamworking, situational awareness and time management tools could be of benefit in dentistry?
How can the concept of developing core competencies to deal with complex problems benefit dentistry?
Developing and maintaining standards
What lessons can be learnt regarding the development of recurrent training programmes that fit the current and future needs of the dental profession?
What lessons can be learnt from the way in which competency standards are continually checked and monitored?
What lessons can be learnt from the processes of managing operational performance issues that are used in aviation?
Conclusion
The aim of this article has been to provoke some thoughts and ideas. A series of papers will look at these areas in more detail, and I will work with Trevor on how to achieve that.
