High Reliability Healthcare: Applying CRM to High-Performing Teams, Part 5

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. 19.

Element #4 – Assertiveness

In the 1960s and 1970s, Dutch psychologist Geert Hofstede conducted extensive research on how humans interact in a culture or organization. One of the measures he used to define this interaction is known as the power distance index, or PDI. This index measures power distance among cultures and indicates attitudes toward hierarchy – in particular, how a culture values and respects authority. The higher the power distance in a culture, the less likely those in subordinate roles will question the actions or directions of individuals in authority.

This problem of power distance led to some terrible airplane accidents over the years. In 1978 a DC-8 flying from Denver to Portland crashed when the airplane ran out of fuel while holding to address a landing gear malfunction. They circled for an hour while the crew coped with the problem and prepared the passengers for an emergency landing. The crew was so distracted by the emergency that the plane ran out of fuel and crashed 6 miles from the airport, killing 11 people.

The cause of the accident was determined to be poor teamwork in the cockpit where the captain failed to monitor the aircraft’s fuel state and to properly respond to the crewmember’s advisories. The two co-pilots were cited for failing to fully comprehend the criticality of the fuel state and successfully communicate their concerns to the captain.1 One of the copilots knew the plane was getting low on fuel but he never requested a change in plan or voiced a concern in an assertive manner.

In order to help overcome this reluctance to cross a perceived power distance or authority gradient, airline crews have used CRM training to help copilots become more assertive when they have a safety concern. This technique has been translated to healthcare with the development of a number of different tools, one of which is the acronym ARCC. ARCC stands for ask a question, make a request, voice a concern, and if all else fails, seek help from the chain of command. It gives healthcare workers a measured way to elevate their concerns for a patient’s safety, working up the ladder until the concern is resolved. The third level – concern – should be thought of as a safety code word. So whenever somebody verbalizes a concern, internal bells and whistles should go off causing staff and physicians to stop and address why this person has a genuine worry that a patient is about to be harmed. Ultimately, ARCC is a respectful way to voice a concern to other members of a team without bringing offense.

High Reliability Tip #4 – Use ARCC (ask, request, concern, chain of Command) to overcome perceived authority gradients while respectfully voicing a concern for safety.

Watch for the next post in this series, Element #5 – Adaptability, on Thurs., Jan. 12.

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.comThis e-mail address is being protected from spambots. You need JavaScript enabled to view it .


  1. NTSB Aircraft Accident Report, AAR 79-7, United Airlines, Inc. DC-8-61, N8082U, Portland, OR. June 7, 1979.