Lessons from the Runway: How Southwest’s System Crash Illuminates Healthcare’s Technical Debt Problem

When Southwest Airlines canceled system-wide flights during the 2022 winter holidays, stranded passengers sleeping in airport hallways made headlines. The scenes were eerily reminiscent of something even more serious yet less publicized — ones I encounter daily as an emergency physician — patients waiting in crowded hallways of U.S. Emergency Rooms. 

The common link between these crises is “technical debt” the cost — measured in time, effort, resources, and money — of maintaining outdated technology within a complex system. When ignored, technical debt precipitates a descent into inefficiency, culminating in system failure.

Southwest’s antiquated SkySolver scheduling system, when overwhelmed, resulted in more than 16,900 canceled flights, stranding over 2 million passengers, and losses surpassing $825 million over the 2022 holiday season into the New Year. 

The warning signs — previous software failures, small but cascading weather events, and employee callouts — were largely unheeded. In a spoofed promise of improvement, NBC’s Saturday Night Live announced a Southwest “upgrade” to 2008 Dell computers. 

Healthcare systems grapple with a similar form of technical debt, including 73% of medical equipment that is controlled by outdated operating systems, according to the 2021 HIMSS survey. Hospitals often prioritize short-term gains, read: profits, over averting preventable failures. 

The ER is the primary entry point for hospital-based care in the U.S. Technical debt that delays or prevents efficient communication, scheduling, and hospital management because of outdated software and archaic systems, e.g., fax machines and pagers, erect barriers to our essential purpose — making rapid diagnoses and starting treatment for critical illnesses and injuries. 

ER crowding doesn’t originate solely within the ER itself — it’s a systemic and solvable patient-flow challenge requiring a comprehensive hospital-wide solution. Regrettably, most hospitals have declined to adopt the technologies necessary to improve patient-flow. 

Reducing input — the number of patients arriving at the ER — and improving throughput — the efficiency of which patients move through the ER — could draw from technology in other industries that have successfully enhanced workflow efficiencies. 

Overhauling the systems used for check-ins, health record documentation, and care coordination could accelerate the transcription and summarization of crucial patient information, ensuring quick and efficient access for medical staff. 

However, the central problem is not input or throughput but enhancing output in EDs — ensuring the hospital has admission beds available. Financial constraints and overcrowded conditions result in hospitals operating at very high occupancy levels. However, when inpatient beds are fully occupied, ER patients may wait in hallways, sometimes for days, until beds become available in the inpatient wards. 

These barriers turn already busy EDs into holding areas where patients receive hallway-level care. To improve output, we need real-time bed census systems that provide an instant snapshot of occupancy and use crucial data to predict ER traffic, such as the volume of incoming ambulance calls. 

Enhanced outpatient scheduling may reduce the need to hold patients in the hospital for tests that can be done as easily as an outpatient, e.g. cardiac stress testing or MRI. Just as flight schedules are managed to prevent airport congestion, elective surgeries in hospitals should be predicted, outpatient testing can be scheduled, and coordinated in alignment with ER wait times to avoid crowding. 

Unfortunately, due to privacy laws, ER crowding can’t be publicized in the same way and this lack of transparency prevents the community scrutiny that might provoke hospitals to accountability — we don’t see photos of crowded ER hallways the way we do of airports. So, who can step in to provide the needed oversight?

The airline industry provides an apt model. Federal intervention created consequences for the airlines’ ethos of prioritizing short-term profit drivers and prizing compensation based on quarterly earnings, rather than investment to decrease technical debt. 

In his written testimony to the U.S. Senate Committee on Commerce, Science, & Transportation on February 9, 2023, Captain Casey Murray, President of the Southwest Airlines Pilots Association, detailed the avoidable “operational meltdown” occasioned by a pattern of increasingly disruptive failures, misallocation of resources, and poor management decisions. 

Southwest employees had previously flagged the company’s technical debt issues and had even gone on strike, to no avail. Had these concerns been addressed, the December 2022 crisis might have been averted. 

In December 2023, Department of Transportation Secretary Pete Buttigieg assessed fines of $140 million for violating consumer protection laws, $35 million going to the Treasury — value going back to customers, back to passengers. The penalty is in addition to the more than $600 million in refunds Southwest provided passengers who faced travel disruptions during the operational meltdown.

A decade ago, the Centers for Medicare and Medicaid Services introduced core metrics focused on ER operations that target the time it takes to see a healthcare provider, the rate of patients who leave without receiving care, and the overall length of stay for patients who are discharged and those who are admitted to the hospital, but these metrics missed the mark. Health and Human Services Secretary Javier Becerra could take a strong stance, beginning with initiatives to tackle the misaligned underlying economic causes of ER crowding and hospital occupancy. 

Regulatory bodies like The Joint Commission and CMS need to explicitly focus on how ER crowding compromises patient safety and affects staff well-being. Regulations should include concrete metrics for assessment and impose penalties, including fines, for non-compliance. Because crowding is predictable, well-crafted and actionable, surge plans should be mandated. 

Technical debt leading to a canceled flight can ruin someone’s day, but the consequences of a crowded ER can be fatal. Unaddressed technical debt in the ER serves a dual warning: (1) it signifies a looming need for essential reforms to avert worsening inefficiency in emergency care, and (2) it acts as a crucial alert, illustrating that the ER — and, by extension, the healthcare system — is teetering on the brink of widespread failure. 

Thus far, the holiday travel season has been largely fiasco-free — the new systems appear to be working. A lasting solution requires the political will to rethink how healthcare is financed, enabling hospitals to function without exceeding crucial occupancy thresholds.