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Journal List > Health Serv Res > v.41(4 Pt 2); 2006 Aug > PMC1955339

Health Serv Res. 2006 Aug; 41(4 Pt 2): 1690–1709.doi: 10.1111/j.1475-6773.2006.00572.x

PMCID: PMC1955339PMID: 16898986

Fair and Just Culture, Team Behavior, and Leadership Engagement: TheTools to Achieve High Reliability

Allan S Frankel, Michael W Leonard, and Charles R Denham

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Disparate health care provider attitudes about autonomy, teamwork, and administrativeoperations have added to the complexity of health care delivery and are a central factorin medicine's unacceptably high rate of errors. Other industries have improved theirreliability by applying innovative concepts to interpersonal relationships andadministrative hierarchical structures (Chandler 1962). In the last 10 years the scienceof patient safety has become more sophisticated, with practical concepts identified andtested to improve the safety and reliability of care.


Three initiatives stand out as worthy regarding interpersonal relationships and theapplication of provider concerns to shape operational change: The development andimplementation of Fair and Just Culture principles, the broad use of TeamworkTraining and Communication, and tools like WalkRounds that promote the alignmentof leadership and frontline provider perspectives through effective use of adverse eventdata and provider comments.


Fair and Just Culture, Teamwork Training, and WalkRounds are described, andimplementation examples provided. The argument is made that they must besystematically and consistently implemented in an integrated fashion.


There are excellent examples of institutions applying Just Culture principles,Teamwork Training, and Leadership WalkRounds—but to date, they have not beencomprehensively instituted in health care organizations in a cohesive andinterdependent manner. To achieve reliability, organizations need to begin thinkingabout the relationship between these efforts and linking them conceptually.

Keywords: Safety, teamwork, leadership, walkrounds, reliability, culture

In health care we excel in defining projects and tackling them with zeal, yet the endresult, particularly in the safety-based ones, is that most do not achieve the desiredoutcomes. Instead, projects suffer from inadequate design, and we harvest, at best,modest results. Five years after the IOM report “To Err Is Human” there is generalconsensus that we have not accomplished our goal to appreciably decrease harm, andhave little solid evidence that the delivery of health care is safer and more reliable(Kohn, Corrigan, and Donaldson 2000;Leape and Berwick 2005). Other industries,those labeled “highly reliable,” have a more systematic approach to achieve greatersuccess.

Highly reliable industries foster “mindfulness” in their workers. Mindfulness isdefined by Roberts, Weick, and Sutcliffe as being comprised of five components: Aconstant concern about the possibility of failure even in the most successful endeavors,deference to expertise regardless of rank or status, an ability to adapt when theunexpected occurs (commitment to resilience), an ability to both concentrate on aspecific task while having a sense of the bigger picture (sensitivity to operations), andan ability to alter and flatten hierarchy as best fits the situation (Weick and Sutcliffe2001). These common characteristics together appear to generate reliably dependableprocesses with minimal and manageable errors. Health care aspires to high reliabilitybut has not, to date, clearly framed the steps necessary to achieve such. Our historicalapproach mimics early steps in other industries as evidenced by a preoccupation withfancy technology and outcome-based initiatives, but without the systematic effort tobuild the mindfulness necessary to make all other initiatives successful. As the scienceof patient safety deepens, health care's path to mindfulness and high reliability isbecoming clearer. This article's goal is to fully relate three initiatives that are underwayin many hospitals and health care systems, and to argue that the three togethercomprise a cornerstone necessary for any comprehensive patient safety plan. Thesethree initiatives are critical and must be pursued with and integrated into all otheroperations. They are (1) the development of a Fair and Just Culture (Marx 2001), (2)leadership intelligently engaged in WalkRounds safety by using frontline providerinsights to directly influence operational decisions (Frankel et al. 2003), and (3)systematic and reinforced training in teamwork and effective communication(Helmreich, Musson 2000; Gaba 2001; Cooper and Gaba 2002; Leonard and Graham,and Bonacum 2004; Baker et al. 2005). The success of these pursuits isinterdependent, and hospitals interested in transforming care must spend equal efforton them. That effort must be substantial and equal to what is currently spent oninformation technology and outcome-based initiatives (see Figure 1), such as IHI's100,000 lives campaign (Davis 2005), NQF's Patient Safety Practices (Kizer 2001),and the Leapfrog initiatives (Milstein 2002). If pursued in this manner, the likelihoodis that outcome-based initiatives will reach their goals more frequently and faster,failure to do so is likely to ensure that safe and effective care remains an elusive goal.The tools work synergistically, are reasonably simple in concept but less easilyimplemented, and are difficult to measure. Ultimately they are essential for all otherefforts. This article relates the components of Just Culture, Engaged Leadership, andTeamwork and Communication and suggests a framework for action in each, includingspecific tools.

Figure 1

Determinants of high reliability in health care


Define Fair and Just Culture

A Fair and Just Culture is one that learns and improves by openly identifying andexamining its own weaknesses. Organizations with a Just Culture are as willing toexpose areas of weakness as they are to display areas of excellence. Of criticalimportance is that caregivers feel that they are supported and safe when voicingconcerns (Marx 2001). Individuals know, and are able to articulate, that they mayspeak safely on issues regarding their own actions or those in the environment aroundthem. They feel safe and emotionally comfortable while busily occupied in a workenvironment, able and expected to perform at peak capacity, but able at any moment toadmit weakness, concern, or inability, and able to seek assistance when concerned thatthe quality and safety of the care being delivered is threatened. These workers arecomfortable monitoring others working with them, detecting excessive workload andredistributing the work when appropriate to maintain safety and reliability.

Each individual feels as accountable for maintaining this environment as they do fordelivering outstanding care. They know that they are accountable for their actions, butwill not be blamed for system faults in their work environment beyond their control.They are accountable for developing and maintaining an environment that feelspsychologically safe. They will not be penalized for underreporting when it feelsunsafe to voice concerns.

This is not utopian; it boils down to the comment, “I feel respected by everyone ineach work interaction I have.” This state is achievable when outstanding leadershipensures that every employee clearly understands his own accountability and modelssuch.

Defining Accountability

Accountability—being held to account—is based on a relationship between two ormore parties in which the product of one party—individual or group—is evaluated byanother party. This process can be contractually formalized or molded over time bysocial pressures and historical norms.

The components of accountability include the individual's understanding that they areto perform an action, a clear expectation what that action is, and the means by whichthey will be evaluated. Consider a surgeon performing an operation. She isaccountable to other members of the “team,” to the hospital as a whole, to statelicensing and accrediting bodies, to the patient. She may have to account for thenumber of surgeries performed, or perhaps only account for those surgeries that areproblematic, or only those that go awry so badly that a patient is hurt. What becomesimmediately apparent in this simple description of an operation is that accountabilityin health care encompasses multiple expectations about actions and the reporting ofthem; each group's expectations differ based on social mores, regulation, law, andhistorical precedent. The tenets of a Fair and Just Culture should help organizationsdevelop a framework for consistent accountability, and begin to repair the currentenvironment, where accountability is poorly defined and individuals are unclear whatthe rules are or whether the rules are constantly changing.

Today, adding up the surgeon's various accountabilities, she is accountable forincreased risk, regardless whether knowingly or not; for not following rules, regardlesswhether to increase or decrease risk; and for outcomes based on the outcome severity,not the causative activity. In a Fair and Just Culture, the surgeon will be heldaccountable for knowingly unnecessarily increasing risk. The severity of the outcomeand the breaking of rules will be subject to that principle. To be absolutely clear,health care organizations, and occasionally individual providers, are ethicallyresponsible, through insurance mechanisms and otherwise, for aiding and possiblycompensating a harmed patient. However, from the perspective of systemsimprovement, learning and positive change are more likely to occur whencompensation is uncoupled from the evaluation of an adverse event. A Fair and JustCulture can be cultivated in health care organizations regardless whether this aspect ofadverse events is fully reconciled; in fact a Fair and Just environment is likely a viablemechanism for diminishing the sting of the current malpractice tort process. Opendiscussion and transparency are characteristics that lead to mediation and resolution,not litigation.

Industries Outside of Health Care

The environment described, while rare in health care, is embedded and evident inother industries we perceive as reliable and safe. In aviation, for example, insightsabout human behavior 45 years ago led to the science of human factors, which helpedshape the industry through the adoption of standardization and simplification rules toproduce greater reliability and safety. The importance of acknowledging employeeconcerns and hazards is evident. For over a quarter century an error reporting systempaid for by the federal government through the Federal Aviation Administration andmanaged by NASA has been extensively used (McGreevy and Ames Research Center2001). It has evolved to open reporting systems administered within specific airlines.Pilots have been trained for the past 30 years to understand and admit their fallibility,and the industry they work in promotes a discussion, on a regular basis, of individualfailing. Pilots are regularly evaluated for both their technical skill and their ability topromote effective teamwork. The application of human factors is uniformly manifest(GABA 2001). The result is an extraordinary safety record.

Relationship to Teamwork and Leadership Involvement

In contrast, as surgeons and anesthesiologists walk into hospital operating theatres,they do so with the underlying expectation, based on training and habit, that everyonein the room is “expertly” trained and will manage their specific job without error. Noreal briefing of the team consistently occurs before each procedure between surgeon,anesthesiologist, nurse, and technician (albeit per JCAHO requirements they may nowstop to insure the correct side of the procedure—an act that is a fraction of the fullbriefing that should occur). The operating room team's optimal functionality dependson the open discussion of teamwork and team expectation, and that is greatlydependent on how the hospital culture promotes such discussions. It is quite possibleto envision strategically, and then produce structurally, an environment where eachindividual's personal concerns can be voiced about that particular surgical case, and tovoice concerns when they arise, in real time, to the best advantage of the patient. Howour hospitals strategically approach accountability, followed by the structures put intoplace to make the strategy manifest, will greatly affect whether the care providers willspeak up in that operating room. This will in great part determine the speed andefficacy in surfacing a problem, which affects the reliability of operating room care.The opportunities for improved care are endless, through improved communicationand other systematic improvements directed by the knowledge gained from voicedconcerns. What would this look like in real life? A perinatal unit provides a goodexample.

Clinical Example: Brigham and Women's Hospital (BWH) Perinatal Unit

BWH in Boston delivers about 8,600 babies each year, and a significant percentage ofthose patients are delivered by private practice obstetricians, individuals with excellentreputations. A pregnant woman chooses an obstetrician to care for her (presuming shehas the insurance to do so), and over the course of the pregnancy develops a bond withthat physician. The obstetrician is duty bound—and accountable—to deliver the bestcare possible to the couple, and shepherds the pregnant woman over 9 months with theone goal of a healthy child and mother. The obstetrician may be part of a group, but ifthe patient is asked, she is likely to identify whom she thinks of as “her” obstetrician.

When the expectant mother enters the hospital, she expects expert decisions to bemade about her labor by her skilled obstetrician, and because many of the obstetriciansat the BWH deliver hundreds of babies each year in an environment where excellenceis the norm, she is quite likely to achieve her desired outcome. But obstetricians arehuman and fallible. What happens when obstetricians mis-step, when they becomefixated on a particular diagnosis they have made and/or ignore new information that isclinically relevant? When they become fatigued, preoccupied, or are slightly less thanexpert in a given situation? The unique bond between physician and patient actuallyundermines the ability of other physicians or providers to even know that a poordecision has been made and to intervene. In the current environment on mostobstetrical units today, only some percentage of the nurses would feel comfortablespeaking up with their concerns if they perceived a problem with the patient's care.

The BWH has instituted twice daily “board” rounds where each patient is discussedjointly with the group of physicians and nurses covering the obstetric service at thatpoint in time. There are always a fair number of providers present, with physiciansrepresenting both the teaching service and private staff. Through the board rounds,these clinicians have an opportunity to hear from their equals about the care beingdelivered—in real time. While it is quite likely the majority of their thinking will beprecisely on target, there is now an opportunity for input and reconsideration of thecare plan from additional experts. This added perspective is perceived as valuable, notmeddling, and is now accepted as the norm. Teamwork, team coordination, andcollaboration have been artfully developed by Dr. David Acker, BWH's Chief ofObstetrics and Margaret Hickey, R.N., Nurse Manager for Labor and Delivery, throughthese twice daily board rounds. Nurses can speak their minds without fear ofrepercussions and actively advocate for the patients. So can residents-in-training andthe more experienced senior staff. The rounds are not just an opportunity for teaching;they are, following the example of their two designers, manifest teamwork in action,based on the concepts of transparency engendered by a Fair and Just Culture;secondarily, and of equal import, they promote cross-professional and cross specialtyteaching.


Develop a Just Culture Strategic Vision Document

Ultimately, a Just Culture is about fair, enlightened, and reasonable assessment ofbehavior and produces a work environment that supports high reliability. Health careorganizations are now writing and promoting Just Culture documents. PartnersHealthCare and the Dana Farber Cancer Institute have similar Commitment to PatientSafety (Frankel, Gandhi, and Bates 2003) statements, developed by the organizations'Patient Safety Leaders, signed by the Boards of Trustees of each componentorganization. While a Just Culture is not derived from the documents alone, a criticalstep is the clear articulation of the principles to be followed. The commitments state,in essence that:

What are the components of an organization that will make these principles comealive?

Use the Unsafe Acts Algorithm

A mechanism to assess individual versus system accountability has been developed byJames Reason in his “Unsafe Acts” algorithm (Reason 1997), and is a practical methodof ensuring a just assessments of individual acts. (The full algorithm may be viewedon the National Health Systems NPSA website.) Kaiser Permanente has adapted thisalgorithm into practical use for hospital managers by streamlining the process to foursimple questions:

Did the employee intend to cause harm?

Did the employee come to work drunk or equally impaired?

Did the employee knowingly and unreasonably increase risk?

Would another similarly trained and skilled employee in the same situation act in asimilar manner (Reason's substitution test)?

If the first three answers are “No” and the last “Yes” the origin of the unsafe act lies inthe organization, not the individual. This algorithm is currently actively used in threehospitals in Boston (North Shore Medical Center, Dana Farber Cancer Institute, andBrigham and Women's Hospital), has been adopted by many other U.S. hospitals, andis available in the United Kingdom nationally through the National Patient SafetyAgency website.

Open Commitments to “Good Citizenship”

Another structural component being used by hospitals to support the development ofJust Culture is open commitment to good citizenship. Employees and all careproviders should understand that they have a responsibility to support transparencyand open communication. OSF Saint Francis Medical Center in Peoria, Illinois has alimited number of “red rules,” which if broken will result in censure and potentiallydismissal. One “red rule” is not participating in briefings before invasive procedures.Strategy, structure and design for transformation to reliable care are elegantly evidentin this practice (Whittington 2006).

Educate in Safety Concepts

The basic concepts underlying patient safety and reliability are human factors, systemcomplexity, high reliability, and effective communication and teamwork. Each hasteachable core components, which should be an integral part of physiciancredentialing, nursing competencies and new employee orientation. Education effortsin these three areas should be integrated to produce consistent thematic content.


Coordinating Organizational Departments

As noted in the Just Culture section, every individual involved in the organization—patient, employee, physician, unit secretary—should feel safe to voice their concerns,know how to do so, and be able to do so easily. With leadership oversight, thedepartments of quality, safety, risk management and patient advocacy should jointlyreceive and evaluate such concerns and comments. Each of these departments hasparticular expertise and areas of unique responsibility. In the evaluation processemphasizing these distinctions can undermine the potential organizational benefit.Their common interests with reported information are essentially the same—what arethe contributing factors leading to a voiced concern, adverse event or comment, andhow can the organization learn and improve itself? Engaged leaders manage theserelationships and deftly guide the process of identifying addressing factors thatcontribute to risk and suboptimal care.

Use Data Wisely: VA Administration Patient Safety Center

A useful example of how the lessons from contributing factors may be used comesfrom the Veterans Administration Patient Safety Center in Detroit. Here Jim Bagianand John Gosbee oversee the collection of root cause analyses from their 144hospitals, analyze the findings and develop algorithms and protocols that are thendisseminated back to the hospitals for evaluation or required implementation (Bagianet al. 2002). While this is an example from the largest U.S. health care system, it isequally applicable in a single small hospital. The VA hospitals have effectivemechanisms for performing root cause analyses on real cases and near misses, and thefruits of those efforts are sent to the VA Patient Safety Center. Frontline providersmust be able to comfortably express their concerns in those RCA sessions, and whatmakes them feel that these sessions are worthwhile is the assurance that theirinformation will be acted upon. The structure to actualize this is quite straightforward:common sense combined with rigorous attention to detail.

This common sense use of information requires a committee or relational structurewithin the organization that ensures any learning gathered from the frontline will beturned into action that makes a difference. A paradigm for this process is the Executiveor Leadership WalkRounds (Frankel et al. 2003).

The Cyclical Flow of Information: WalkRounds

The WalkRounds concept has now been widely applied in hospitals, but manyorganizations mistakenly think the key component is leadership walking around, andthat WalkRounds is an informal conversation between leadership and providers. Infact, the real power is that these conversations elicit useful information within a formalstructure, the information is then documented and analyzed, combined with relevantinformation from root cause analyses and other reporting systems, and regularlydiscussed in meetings involving the Clinical chairs, chiefs, and senior leaders. Theseleaders of the organization accept and have clear responsibility for actions to resolveidentified problems. Learning around these issues and the actions to be taken thenbecome part of the operations-committee agenda. Patient safety personnel areresponsible for tracking the intervention and no issue is considered closed until it hasbeen fully explored and the information sent back to the provider(s) or employee(s)who voiced the concern that began the process. Cyclical flow of information, leadingto action that can be tracked over time—this is the power of WalkRounds—and thestructural component that matches the articulated vision of transparency and openness.

WalkRounds should not stand alone in manifesting this cyclical process. All elicitedinformation should have a cyclical component to it, so that the providers from whomwe ask for transparency, from whom we expect the courage to speak their concerns,constantly receive affirmation that their efforts to promote open communication arerewarded by changes in their work environment for which they can feel they played arole.


Critical Components

It is increasingly clear that future improvements in health care will dependprogressively more on our ability to promote excellent teamwork and effectivecommunication across the spectrum of clinical care. Our technology infrastructure,now on a fast track deployment of electronic medical records and the spread ofcomputerized physician order entry, is ultimately an enabler to the “peopleware,” theclinicians who must translate such information into clinical practice, and comprise theteams effectively applying protocols and guidelines in the care of patients. Currently,we can assure our patients that their care is always provided by a team of experts, butwe cannot assure our patients that their care is always provided by expert teams. Thereare two components required to successfully train and implement effective teamworkand communication in clinical practice. First, there are critical tools and behaviors thatsupport effective collaborative work. At a minimum, structured language, effectiveassertion/critical language, psychological safety, and effective leadership are requiredcomponents. The second aspect is the use of medical simulation to embed and practicesuch skills. The current question is how to most practically teach and practice suchskills so they become embedded in the delivery of patient care systematically and in amanner that provides value to patients, clinicians and institutions. Teamwork requireslearned skills in leadership, group participation, and communication—but such skillscannot be fully implemented by those who have them unless co-workers have beenafforded similar new insights and language. The time has come to evaluate the effortsunderway in our numerous simulation centers and educational departments, and tostrategically define how to bring excellent teamwork and communication consistentlyinto our hospitals. We can reasonably expect that an investment in teamwork andcommunication strategies will do more than improve quality and safety. The efforts arealso likely to decrease patient harm, potential malpractice suits, and increase patientsatisfaction. There is extensive experience in other high reliability industries, likecommercial aviation, the military, etc., that we can draw on.

We have at our disposal today three main mechanisms to teach teamwork and effectivecommunication skills (Figure 3), and as a result of extensive teamwork training inother industries we can define the most useful components.

Figure 3

The spectrum of teamwork training

Visible Leadership Involvement

To successfully apply and sustain effective teamwork and communication requiresthree components: visible and consistent senior leadership involvement, clinicalphysician leadership, and embedding the tools and behaviors in clinical work thatpeople do every day. The key and consistent message by senior leaders must be thatthese efforts are important, and appropriate resources will be available to supportthem. In the culture of medicine, with physicians being de facto leaders, respectedphysicians as champions is critical. This requires physicians who are willing topublicly commit their support among their peers and express the importance of suchefforts. They must also be willing to openly deal with resistance from their colleaguesin an open, constructive manner. When clear physician support is lacking, and it is leftto nurses and others to deal with physician resistance, the results will be suboptimal.

Practically applying the tools and behaviors needed for effective teamwork andcommunication is challenging because clinicians are busy and not terribly interested inmore work to do. Framing the adoption of such techniques as practical tools to makeone's day simpler, safer and easier is a good approach. Being seen as practical andrelevant to the clinical work makes it far easier to embed the changes so they becomethe way care is routinely delivered.

Teaching Tools and Behaviors of Effective Teamwork and Communication

The basic core skills are structured language (SBAR, which stands for situation,background, assessment, and recommendation), effective assertion, critical language,psychological safety, and effective leadership. Situational awareness and debriefing arealso valuable.

Structured language increases predictability and provides a common template forcommunication. Communication styles are personality dependent, and effectivecommunication is affected by factors such as the confidence and skill of a nurse andhow receptive a physician is to the communication. SBAR is a situational briefingmodel adopted from the U.S. Nuclear Navy that helps providers organize theirthoughts and communications to increase the likelihood of a mutually understood andagreed upon conclusion.

Assertion/critical language is a core element of effective teamwork, as it provides amechanism that allows any team member to voice a concern relative to patient careand trigger active communication among the team about the expressed concern.Having structure to this process is quite important, as we know from risk managementdata that often people speak up softly, indirectly, or not at all.

Psychological safety means that one can voice a concern or ask for help and know thatthe response will always be respectful. Unless this environment of respect isconsistently present, and a basic property of the organizational culture, people willhesitate to express concern and avoidable harm will occur.

Effective physician leaders actively work to flatten the existing hierarchy, share theplan of care with other team members, actively and repeatedly invite others into theconversation, and create familiarity by knowing the names of individual teammembers. Some doctors naturally have these skills. Many do not, and we have notsystematically taught leadership skill in medical education.

The Spectrum of Teamwork Education

Teamwork training falls along a spectrum from interactive classroom training to full-bore simulation where skills can be practiced in realistic scenarios, evaluated, anddebriefed. Low fidelity simulation models include table-top simulations or simplywalking through the steps of a process. Although there is a tradeoff with regard torealism and complexity, the advantage is low cost and flexibility. Mid-range simulationis done with computerized mannequins that allow multiple protocols and provide adynamic response depending on the effectiveness of the team in responding to thesituation. Another advantage of this mode of simulation is that training can be done inthe clinical units where people regularly deliver care, so it is quite realistic and oftensystem weakness is readily uncovered. High fidelity simulators provide a great degreeof realism and are very effective. The potential limiting factor is they are resourceintensive by their very nature. They are also generally removed from the clinical careunits. Historically, these devices originated medically in the domain of anesthesia andoperating rooms. They have become quite sophisticated and are now applied in cardiaccatheterization techniques, surgical skills, and other domains.

As the pyramid in Figure 3 suggests, the number of individuals an organization islikely to be able to teach using interactive classroom training is significantly higherthan in the high fidelity simulators, which are much more costly, and are not as easy orsimple to access.

Interactive classroom training requires a curriculum, as noted above, and a skilledfacilitator who is able to combine didactic material with audience engagement and roleplaying. Multidisciplinary classes are essential but no specific technology is required.This teaching should incorporate an explanation of each of the components ofteamwork, how human factors knowledge identifies why they are critical to deliveringsafe care, and how they may be implemented. Fully robust interactive classroomtrainings would likely be taught by a clinician known to, and respected by, the groupbeing trained, repeated on a regular basis, and required of all the disciplines in a unitwho work together. For example, on an obstetric floor, the group attending a sessionwould include an anesthesiologist, obstetrician, neonatologist, nurse, nurse midwife,secretary, and cleaning staff—and all would be required to, together, attend thesesessions.

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Each simulation modality has a valuable role to play in a robust teamwork andeffective communication development plan, but to understand their roles, it is useful toexamine the history of high fidelity training, specifically to appreciate that high fidelitysimulators have been available to health care for many years and have had, at best,limited impact. Why? High fidelity simulators, beginning with anesthesia simulation,have played a major role in improving the safety of surgical procedures. Participantscome away with awareness that a different set of skills is required to manage availableresources than is required to manage the concomitant clinical problems. Ananesthesiologist or surgeon may have the clinical knowledge necessary to stop massiveblood loss or control an intraoperative cardiac arrhythmia, but to actually do so alsorequires an ability to maintain oversight of the emergency, and direct others to workcollaboratively and effectively with regard to specific task and communication. JeffCooper and David Gaba's sentinel efforts in the development and implementation ofthese simulators into health care has been a significant factor in saving untold lives inour operating rooms and elsewhere (Cooper, Gaba 2002; Lighthall et al. 2003; Gaba2004). However, for all its positive benefit, the acceptance of simulation into healthcare training has been slow at best, and in the initial evaluations of patient safety,beginning in 1999 with the IOM report, the role of simulation was not highlighted, norsuggestions made at that point to extensively incorporate simulation. There are a fewplausible answers as to why.

Simulation: Strengths and Weaknesses

Simulators have been expensive to buy and maintain, and the need for actors,technicians, and facilitators to run them meant with each training ongoing expensewere upwards of a few thousands dollars for a day's training of 10 or 12 individuals.Second, while almost every clinician who has trained in a simulator appreciates thenew insights they gain, they do not necessarily enjoy the experience. Physicians do notusually comfortably or willingly “suspend disbelief” when acting out a simulatedscenario, and often find the experience inherently uncomfortable even before thescenario exposes their knowledge limitations and forces them, as a teaching process, tofail. More problematic, and an essential drawback that is less a fault of simulation thanof the health care profession as a whole, is that the select group that is trained often goback to work in hospital environments with other providers who neither understand orappreciate the lessons learned. This can make the training difficult to use, and untilvery recently hospital leaders have not fully appreciated how better teamwork lessenserror and improves the reliability of care. Hospital leaders often have not felt capableof influencing their providers, specifically physicians, to participate. None of thesequalities endear simulation to its participants. Lastly, a single day's simulation training,as powerful as the experience might be, still has limitations, encapsulated by oneobserver who stated, “It was like watching a religious conversion because theexperience was powerful enough to generate in a single day whole new insights ineach person about the importance of Team Behavior and how to manage resources in acrisis, but the problem was that the conversion was solely of each individual, not thegroup. Very few left the sessions with enough understanding of the concrete behaviorsto utilize in the clinical care setting, nor did they really understand the concepts ortheories that would make sense of the behaviors. Each individual knew, and mostimportantly believed, that when they went back to work they needed to do somethingdifferently, but not necessarily exactly what, with whom, or how” (Maynard 2005). Agreat credit to these simulations is that they create the environment to generatewholesale conversion of skeptics into believers in less than a full day, but then there isnot enough time to also expand the new belief into usable knowledge. This commentleads back to the overall issues of strategy, structure, and implementation.

Teamwork: Strategy, Structure, and Implementation

The high fidelity simulators are a component of the structure and implementation ofteamwork—but their power to effect change is thwarted if they are not part of a healthcare-wide organizational teamwork and communication educational strategy. That is, astrategy with thematic content taught through physician credentialing, nursingcompetency, and new-hire orientation that is repeated appropriately and evaluatedperiodically with surveillance and audit. The evolution of thinking about patient safetyis leading organizations to think more globally about this issue, and to consider howthe extraordinary teachings promulgated by Gaba, Cooper, Salas, Simon (Salas andCannon-Bowers 2001), Helmreich (Helmreich 2000; Helmreich, Musson 2000), andothers may be more widely disseminated into the health care environment. This willrequire an organization wide coordinated effort of interactive classroom trainingcoupled with periodic low fidelity skill drills, managed cohesively by clinical chairsand hospital administrators, and supported by facilitators who will likely be trained inthe high fidelity simulated environment. In conjunction with and linked to thisorganizational effort, specific high fidelity skills training will need to be available inthe student period of training (i.e., medical and nursing school environments), thespecialty period of training (residency programs) and, afterwards, as a part of specialtyrecredentailing. There are so many nascent efforts in these areas; the time to developthis strategy is now—before the small projects become better formed and lessmalleable.


Leadership by our trustees, CEOs, and physician leaders is the single most importantsuccess factor to turning the barriers of diminished awareness, accountability, ability,and action into accelerators of performance improvement and transformation (Denham2005). Awareness is the first critical dimension of innovation adoption. Leaders mustbe aware of performance gaps before they can commit to adoption of any innovation.Few leaders are fully aware of the magnitude of the problem common to organizationslike their own. Fewer still are aware of the performance gaps at their own organizationthat can only be defined by direct measurement and communication to leadershipteams.

Accountability of leaders for closing performance gaps is critical. For innovationadoption to occur, leaders need to be directly and personally accountable to close theperformance gaps. Although initiatives like pay for performance are re-calibratingmany to focus on quality as a strategic priority, few leaders are directly accountable forspecific patient safety performance gaps, especially in the difficult to measure arena of“culture.” Organizations must also be accountable to their patients, their communities,and the national community through public reporting.

Leaders can be aware of performance gaps and accountable for those gaps; however,they will fail to close them if their organizations do not have the ability to adopt newpractices and technologies. The dimension of ability may be measured as capacity. Itincludes investment in knowledge, skills, compensated staff time, and the “dark greendollars” of line item budget allocations. Finally, to accelerate innovation adoption,organizations need to take explicit actions toward line of sight targets that closeperformance gaps that can be easily scored. Miscommunication, for example, is acomponent of almost every adverse event, but difficult to measure. Barriers exist alongeach of these dimensions. Such barriers can often be converted into accelerators byspecific performance improvement interventions (Denham 2005, 2006).

It is clear that leaders drive values, values drive behaviors, and behaviors driveperformance of an organization. The collective behaviors of an organization define itsculture (Rhoades 2005). Without the right values supported by robust structures andsystems established and sustained by the governance boards, senior administrativeleaders, and clinical leaders it will be impossible to become a high reliabilityorganization that embodies a true culture of patient safety.

A Just Culture, the engagement of leadership in safety, and good teamwork andcommunication training, are critical and related requirements for safe and reliable care.Developed and applied concurrently they weave a supporting framework for theeffective implementation of new technologies and evidence-based practices. Themechanisms and tools now exist to do this work. We are late in development andimplementation because we have relied too heavily on technology-based solutions andthe broad expectation that every clinical project, even those based on social science,must have numerically measurable results. Numerical results for these endeavors areindirectly attainable (through outcome-based projects) if appropriate effort isapportioned to developing mindfulness through the tools described.

Figure 2


Thanks to George Thibault for his guidance and advice in the writing of this paper.


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