On Sunday evening, April 9, 2017, David A.D. Dao, a 69-year-old Kentucky physician, boarded United Express Flight 3411 bound for Louisville from Chicago’s O'Hare International Airport. He didn’t make the flight.

As most people know by now, the full flight was delayed as gate agents tried to convince four passengers to give up their seats after completing their boarding process in exchange for United vouchers to accommodate four crew members who wanted to board. There were three takers. After raising the ante to $800 induced no additional takers, the gate agent informed Dao that he had been “randomly” selected by the system to be removed from the aircraft to make room for crew members. He refused. The rest is now internet lore: Airport security dragged him from the plane, causing a concussion, cuts, a broken nose and the loss of two teeth.

United’s CEO Oscar Munoz apologized on behalf of the company, promising to change its operating policies and procedures to avoid future incidents, but only after making two statements characterizing the incident as a “system failure” and Dao as “disruptive and belligerent.”

By the following Wednesday, the Dao family had hired lawyers and filed a petition ordering documents about the incident to be secured. And the story had gone viral, wiping out $800 billion of the airline’s value to its shareholders. United, however, avoided a lawsuit and settled out of court for undisclosed terms.

In reviewing United’s operating policies and procedures and performance data for the U.S, airline, it’s clear that this incident was avoidable but not surprising. It turns out that United’s front-line personnel mishandled what could have been a manageable issue. The flight was not oversold as first reported, and the gate agents could have offered more than the $800 they announced to recruit their volunteers. Dao’s selection was far from “random”: Gate agents are instructed to consider what a passenger pays for his or her ticket, frequent flier status and fare class in choosing whom they plan to eject. Dao boarded the flight as a paying customer and was involuntarily removed, but in oversold situations, UA personnel are instructed to secure volunteers prior to boarding. And it’s ironic that nowhere in Rules 21, 24 and 25 is a United agent instructed to make room for airline employees by bumping paying passengers. Nowhere!

Among the 12 largest airlines, data show that United ‘gets it right’ (via flights that leave on time, arrive safely and without deplaning incidents or baggage mishaps) 76 percent of the time. That means one in four flights will have a disappointing result.

Some incidents, such as delays, involuntary deplaning of passengers, mechanical issues, crew scheduling, lost baggage et al. are due to an airline’s operational performance. And many are a direct result of aviation system issues — how airports accommodate flights, work rules, compliance with regulations, air traffic control and more. Ironically, the Big Four airlines — Delta, American, United and Southwest — actually do better than the regionals on most measures and United’s performance had actually improved in recent months. But passengers who are stranded in airports, delayed, inconvenienced, put on hold for hours when trying to reach a customer service representative or “selected” for ejection from a flight blame the airline, whether it’s their fault or a complication of how the aviation system operates.

There is uncanny comparability between the aviation and health care fields — especially the hospital sector. Both are highly visible segments whose largest players operate globally. Both are highly regulated. Both are high profile, and mistakes attract widespread media attention. Both cater to consumers, who are watchful of their performances. Both depend on hourly personnel for optimal user experiences and problem resolution (such as gate agents, customer service reps and ticket counter representatives for the airlines; and nurses, technicians, clerks and support staff in our hospitals, clinics and doctors’ offices). Both manage highly skilled talent who often work under pressure: pilots and physicians. Both depend on technologies and advanced analytics. And both play vital roles in our economy.

It seems to me that hospitals can learn the following from the United 3411 incident:

  1. Mistakes can’t be hidden: Mistakes should be anticipated and our responses stress-tested. Dao’s treatment was presumably an isolated event, but it sparked a reaction from the traveling public that is tired of being treated poorly. Just as the shortcomings of airlines receive attention in mainstream and social media outlets, so do miscues in the hospital field. Long waits in the emergency department, long hold times on the phone as patients try to get test results or schedule an appointment, and the numerous lab tests and procedures patients undergo mar the patient experience and get frequent media attention.
  2. Media attention to negative incidents is intense and sometimes misleading: Simply put, there’s always more to a story than what’s reported. Deft handling of bad news requires organizations to be forthcoming about their policies and procedures, especially when technically in the right but with an adverse result. There was nothing illegal about what United personnel did, though lawyers would have certainly pointed out that O’Hare’s airport security personnel carried out Dao’s ejection in an inhumane manner. But the fact is that United’s performance is essentially no better or worse than that of its competitors: It’s not an outlier. Media shine a light on hospitals as brightly as on the airlines: Getting the messaging right with accuracy and precision is the lesson.
  3. Reputation depends on how front-line personnel perform, especially in times of stress. The operating policies and procedures, and the organization’s underlying culture, are exposed in extreme circumstances. In most organizations, it’s our front-line teams that define user experiences. Front-line staff see gaps between performance and perception. They distinguish between leaders who are sincere in serving their customers and those who are more self-absorbed. They understand how they’re evaluated and rewarded, and the expectations of their superiors. They know how much latitude they have to solve problems and the repercussions if they fail. Had the front-line personnel managed the Dao incident differently, members of Congress would not be considering punitive action, and shares of United Continental Holdings Inc. would be worth 4 percent more. More than 90 percent of the hospital’s workforce is in front-line roles: They see everything. They talk. Understanding their views about the hospital, how they assess its culture and leadership are essential to managing a hospital’s reputation.
  4. Boards of directors are ultimately accountable for how policies and procedures are implemented. It’s customary that directors steer clear of day-to-day operations to focus on strategy and building shareholder value. But United 3411 exposed an operational flaw that hurt the entire organization. A board can ill afford to overlook how an organization executes its operating policies and procedures. The travails of Uber and Wells Fargo are widely reported alongside biomedical corporate names like Mylan, Theranos, Valeant, Turing Pharmaceuticals and others. They involve more than what the executives of these companies authorized. Hospital boards must have firsthand knowledge of how policies and procedures are implemented, how incentives are designed and how hospital leaders are perceived by staff members at all levels and throughout the organization. And they must be wary of scenarios that can lead to incidents like United 3411. The traveling public has grown to expect long lines, delays and front-line service staff who are more concerned about accommodating their co-workers than the paying customers. Against those expectations, customers truly appreciate quality service; whereas, procedures that cross a line, as Dao experienced, spark resentment and outrage. Hospitals need to maintain the trust of their communities, and that starts with good customer care.

A commitment by senior hospital managers and boards to policies and procedures that empower front-line personnel to fix problems and put patient care above all else will go a long way to creating a caring, consumer-centric culture.