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Basics & Behaviors

The Basics

Teams are typically formed to accomplish a particular function that cannot be accomplished by individuals. Teams are identified by the interdependency of their members and commitment to a common purpose. The healthcare industry conducts operations in teams that vary from well formed teams to those formed extemporaneously to respond to single events.  Trust is an essential component of an effective team, especially for those operating in environments that expose humans to risk of serious injury and death.  Teams in high reliability organizations (HROs) learn to develop this trust through the consistent utilization of specific behaviors.  These behaviors are usually accompanied by tools that foster the sharing of mental models, recognition of adverse events and the efficient communication of deviation from expectations.  The same teams rely on good leaders who are expected to bring their teams together, facilitate the sharing of a common mental model and set the stage for encouraging team members to speak up when events are not happening as expected.  An airline crew, for instance, expects the captain to brief the common mission, engage the crew in discussion and encourage input (behavior) from all crew members.  He or she usually reinforces this expectation during the pre-flight briefing.



A select group of organizations typically operate at levels of effectiveness that  consistently operate at levels of safety that are several orders of magnitude better than most.  These organizations, typically called High Reliability Organizations (HROs), include aircraft carriers, nuclear power industries, airline and military aviation organizations.  They typically measure their failure rates in terms of mishaps per million opportunities (flights, hours, etc.).

Key characteristics of HROs include their  assumption that accidents are inevitable and that  processes and crosschecks must be in place to mitigate adverse consequences of those actions.  These same organizations operate with considerable flexibility and are especially proficient at learning from their experiences.   Another characteristic of these HROs, is that that they train team members to recognize and respond to system aberrations, empower their staff to act, and design redundant systems that are error tolerant1.

Error trapping and mitigation is an organizational skill that might be best summarized by the mantra of  See It, Say It and Fix It.  As described below, the mantra refers to the idea of looking for potential failures, identifying them to the crew (team), and ensuring that they are addressed.  Let's be a bit more specific.

SEE - IT.  Effective teams learn to establish standardized procedures and to share a mental model of what is currently happening, as well as what should be expected.  The Joint Commission mandated Universal Protocol is an example of a set of standardized procedures designed to avoid wrong surgeries.  Because all team members are expected to know the procedures associated with the Universal Protocol, they are also expect to recognize (See It) deviations from the protocol.  One subroutine of the Protocol, the Time Out, is a guide for sharing the mental model.  Guidelines call for the verification of the patient's name; specification of the procedure and the operable site, as well as verification of essential patient information. 

SAY - IT.  The sharing of a mental model is key to the efficient functioning of a team.  Not only do team members know what to expect, but they are prepared to identify deviation from that model.  High Reliability Teams develop precise methods for communication this information, especially during time critical situations.   The guidance of the Federal Aviation Administration, for example, call for pilots to broadcast on a discreet emergency frequency.  The phrase "May-Day, May-Day, May-Day," is recognized universally as a distress call.  When issued by any aircrew, controllers are required to give precedence to that aircraft.  Likewise, the phrase "Clear," is recognized by healthcare teams as an indication of impending electroshock therapy.  Healthcare workers universally understand that when hearing this term, they should stand clear of the patient and any equipment attached to the patient.  Failure to do so tends to be self critiquing.

FIX - IT.  Finally, a deviation must be addressed until it is "fixed."  Teams in HROs understand that the failure to address the problem can cause serious injury or a fatality.  In HROs, however, the motivation to follow through on this final step is usually much greater than in the healthcare environment.  There is an old saying that the pilot is the first to arrive at the scene of the accident.  The immediate threat to the health and welfare of team members is a major difference between these HROs and teams in non-HROs.

Next we will address a few of the basic tools that crews (teams) in HROs use to coordinate their action and communicate effectively.  Note that although many of these tools originated within HROs, all have been found to have utility in healthcare when properly tailored to the environment.


Red Flags.  One effective method for team identification of potential adverse events is for the team to agree upon a basic set of Red Flag indicators.  Two examples might include a) conflicting inputs and 2) violation of procedures.   Some units have established physiological parameters as Red Flags, such as blood pressures or oxygen saturations exceeding certain limits.  Effective teams ensure that all team members are trained on recognition of Red Flags.

2. SAY-IT.  In addition to sharing the mental model and identifying potentially adverse events, good team learn to communicate consistently and precisely.  These teams learn to avoid the "hint and hope" method of talking around an issue (ex: "Are you sure you want to do that?").  While effective teams know how to address routine issues, they learn different techniques for calling attention to more critical needs.  They also learn how to handle these situations in an escalating fashion.

Relay Information.  The lowest level of communicating a potentially adverse event is simply relaying information.  "Doctor, blood pressure is continuing to drop."

Add "Check" to input.  The next level of adding emphasis to a statement.  "Doctor, check the blood pressure."

Use Assertive Statement.  A more formalized statement of urgency.  Designed to get the attention of a specific person and to ensure that action is taken to stop progress of a potentially adverse situation.


A effective Assertive Statement is designed to address a critical deviation from the shared mental model in a timely manner, while avoiding defensiveness from any team member.  The assertive statement looks like this:

Get someone's attention.  Do so by identifying the person by name.  "Doctor Jones...

Express personal concern.  A good expression of personal concern is to say "...I am concerned."  The purpose of this statement is to reflect the concern on you and avoid defensiveness by another team member.

Objectively State the Problem.  Now that you have someone's attention, objectively state what you see... "...blood pressure is now 72 over unreadable."  Try to not make this a statement of judgment such as, "... the blood pressure is way too low!"

Recommend a solution.  Now it is time to recommend a solution in order to ensure that the message has been received and that the team members are engaged in fixing the problem.   It is best to state this as a "we statement."

Let's try to put this together.  Here is what the statement might sound like:

"Doctor Jones, I am concerned.  The blood pressure is now 72 over unreadable.  I recommend that we stabilize blood pressure before proceeding."

3. Fix It.  Finally, if you discover signs of a potential adverse situation, you own the problem until the problem is fixed, or until you are able to confirm a hand-off to someone willing and able to solve the problem.

The Tools (click on tools at the upper left for detail)

Briefings - Briefings are designed to share a mental model of what is about to happen with all team members.  They are typically standardized, scripted, and very brief.  There should be an opportunity to ask questions.

Checklists - Checklists are designed to standardize certain baseline functions.  They are good tools for room and instrument set up, patient preparation and assessments.  A single checklist can be designed to serve as an orientation tool, a daily procedure and an emergency checklist. 

Debriefings - Debriefings are learning tools.  When conducted properly, they can capture process and personal performance issues, and address conflict management.

Hand-offs - Hand-offs involve the transfer of responsibility for a patient, or the transfer of patient information, from one clinician to another.  According to the Joint Commission, an effective hand-off must include:

  • "Interactive communication allowing the opportunity tor questioning..."
  • "...up-to-date information regarding the patient's care..."
  • Minimizing interruptions
  • "...a process for verification of the received information,"

Real Time Risk Assessment
- Real Time Risk Assessment is a checklist-style tools for identifying potential risks at a point in time.  The assessment tool should be designed to assign metrics to all major factors associated with performance (e.g., staffing, experience, patient census, etc.).  Threshold criteria should be established for up-channeling status.  Personal and subjective remarks can be used to raise, but not to lower assessed risk.

Read Files - Read Files are designed to ensure that all team members "got the word" about all important issues.  The power of the Read File is in documenting the communication of these issues to all members.  Management personnel can use the Read File to identify anyone not yet aware of critical policy/procedural issues and potential restrict their activities until compliant

Special Interest Items - Selected "Hot Topics" can be identified and brought to the attention of appropriate team members.  Reminders of the Special Interest Item can be tied to every pre-event briefing.  "Hot Topics" can be identified and changed each month.