Innovation Blog

The Art of Aerial Combat and Quality Improvement

United States Air Force Colonel John Boyd, in trying to understand the human dynamics of aerial combat between fighter aircraft (or "dogfighting," as it's more commonly referred to) postulated the existence of a decision-making process called an OODA loop. Within this theory, he tried to explain how a pilot was able to Observe the situation facing him, Orient it to his previous knowledge and experiences, Decide on a course of action and Act on that decision (OODA). Colonel Boyd’s aim was to explain dogfighting in a way that allowed for study and training beyond the inherent and untrainable attributes an individual possesses that allows him or her to be a great fighter pilot.

A similar challenge faces those of us looking to understand how to deliver high-quality health care. The art of medicine remains a critical aspect of clinical practice, often seemingly outside the purview of traditional workflow-based approaches to quality improvement. However, I believe Colonel Boyd's OODA loop theory can be equally applied to our work.

Prior to medical school, my experience in EMS taught me to read situations before ever entering them. I would look at clothing, posture, body language, smells and even bystanders to begin piecing together the story of what really happened to the patient. However, as a medical student, my standardized patients (someone who is trained to consistently portray a patient in a medical situation) rarely provided opportunity for these observations to be made. Their stories told of symptoms or social challenges that their clothing, diction and attitudes denied. It took me quite a while to recognize these subconscious patient observations, which were often made in what Malcolm Gladwell would refer to as a blink. However, these blinks are the undocumented observations that physicians make dozens of times every day. Our challenge in improving the quality of health care is to recognize these observations or add additional ones that could be critical to the provider’s decision-making process.

The orientation of these observations becomes critical within both individual patient care and population health approaches. Two providers examining the same patient may approach the situation as an acute exacerbation in a chronically ill patient or an unrelated acute syndrome in a generally healthy person. These variances in framing describe the very different diagnostic and treatment approaches between physicians with training and backgrounds in emergency medicine versus primary care. How then do we take these different orientations into account when advocating for improved quality? Even further, should these orientations be a specific target of our efforts in terms of reframing how physicians see and interpret their patients?

Predominantly, quality improvement efforts have focused on the physician decision, without recognizing the earlier steps leading toward that decision. I have often heard the statement, "if we could just get the physician to make the RIGHT choice." Deferring discussion of the fallacy of a universally applicable "right choice" in something as diverse and customized as the care of individual patients, we must consider that our influence doesn't extend to this phase of the OODA loop. Decide and Act are beyond our control, though not our influence. Our greatest ability to influence these decisions lies at the observation and orientation stages in either making sure that providers are able to observe the information that might affect their decisions (such as lab results or screening needs) or help orient those observations into an effective decision (and know that the missing screenings or abnormal lab result are actually important). The heads-up displays of modern fighter aircraft are designed with these principles in mind. How can we orient our “displays” of clinical records and data dashboards in today’s practice to align with these principles as well?