High Reliability Healthcare: Applying CRM to High-Performing Teams, Part 2

In this series, Steve Kreiser describes a model for applying aviation’s crew resource management to healthcare. This model incorporates different elements inherent in most CRM programs but has an additional benefit of including simple error prevention tools and techniques that help reduce human error. These seven tools, essentially a “people bundle” to make humans more reliable, can help individuals experience fewer errors while encouraging teams to catch and trap those errors that do still occur in complex systems. The series will continue on Tues. and Thurs. through Jan. 12.

Element #1 – Leadership

The success of any team – whether in sports, business, or healthcare – starts and ends with its leader. Some leaders are collaborative by nature and some are not. Those leaders with a dictatorial style that inhibits the flow of information will have a difficult time making crew resource management (CRM) work in their team settings.

A survey conducted by the Institute for Safe Medication Practices (ISMP) in 2003 serves as a good indicator of this effect. Of the 2,095 nurses and pharmacists surveyed, 88% had at one time been subjected to condescending language or tone from physicians or other providers, 79% had experienced a reluctance or refusal to answer questions or phone calls, and 48% had been subjected to strong verbal abuse.1 Unfortunately, this behavior serves to denigrate subordinates and coworkers, intimidates others, is bad for morale, and inhibits the flow of information. It also can have an adverse affect on patient care, as evidenced by the same survey, which found that, because of the intimidating atmosphere, 34% of respondents had avoided order clarification and 31% had allowed a physician to give a medication despite concerns.

In his book Why Hospitals Should Fly, John Nance refers to CRM as being based upon collegial interactive teams (CITs).2 According to Nance, successful CITs are based on “barrierless” or open communication where the culture encourages people to speak up with safety concerns. This open communication cannot occur if the team leader’s control is based on hierarchical snobbery, defensiveness, or strong authority gradients. A 1993 study by NASA provided a very simple tool for taking down these barriers – a pre-job brief. In a pre-job brief, the leader gets the entire team on the same page and sets the tone for the procedure or plan of care, creating an environment where speaking up with safety concerns is not just encouraged but explicitly made part of the job expectation. Team introductions, politeness, eye contact, tone of voice and the use of a collective vocabulary – “We” and “Us” versus “I” and “You” – all serve to engender mutual respect and a team goal of doing what is best for the patient.3

There has been some amount of pushback to the use of briefs and checklists in healthcare by some providers.  Derided as time-consuming and inefficient, detractors argue the use of checklists and briefs in aviation have little value in medicine. And yet a 2009 research study at William Beaumont Hospital in Royal Oak, Michigan, spanning more than 37,000 briefs and debriefs, resulted in 90% of respondents agreeing briefs improved teamwork and communication.4 Running counter to the argument that briefs and checklists waste time, a separate study from the November 2008 Archives of Surgery showed that briefs actually decreased unexpected delays in the OR by 31%.5

High Reliability Tip #1 – Leaders use briefs to create an environment that promotes information sharing, using structured methods (checklists) to get the team on the same page while covering all contingencies.

Watch for the next post in this series, Element #2 – Resource Management, on Tues., Dec. 27.

Steve Kreiser is a consultant with Healthcare Performance Improvement (HPI). previously, Kreiser was an FA-18 pilot with more than 21 years of experience in the U.S. Navy, and a first officer for a major airline, where he worked extensively in the area of crew resource management. Mr. Kreiser can be contacted at steve@hpiresults.com.


  1. Institute for Safe Medication Practices. (2004, March 11). Intimidation: Practitioners speak up about this unresolved problem.
  2. Nance, J. J. (2008). Why hospitals should fly. Second River Healthcare Press, 66-67.
  3. Crew resource management: Design and evaluation of human factors training in aviation. FAA Grant Award #92-G-017.
  4. Berenholtz, S. (2009, August). Implementing standardized operating room briefings and debriefings at a large regional medical center. The Joint Commission Journal on Quality and Patient Safety.
  5. Nundy, S. et al. (2008). Impact of preoperative briefings on operating room delays. Archives of Surgery, 143(11), 1068-1072.