September 9, 2013By Lance Baily

Beyond the Checklist: What Else Healthcare Can Learn From Aviation Book Review

I met Suzanne Gordon, lead author of “Beyond the Checklist: What else Healthcare Can Learn From Healthcare”, at the speaker’s reception of CAE Healthcare’s 2013 HPSN event in San Francisco. At that time, we had a lengthy conversation about the need to reform healthcare communication using proven methods and the opportunity inherent with medical simulation to help to do so.

beyond the checklist book review

Suzanne graciously provided me a copy of her book to review, which I can tell you now is a definite MUST-READ for anyone engaging within any avenue of healthcare, education, and/or simulation. This book goes beyond highlighting key examples of the poor communication practices causing systemic failures within healthcare by also providing a direct roadmap to solve these archaic human-made challenges. The authors poignantly remind us that the status quo of healthcare communication can no longer remain “just the way it is”.

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In Beyond the Checklist, Suzanne Gordon:

  1. Diligently lays out the crisis of communication failures occurring within healthcare.
  2. Reminds us of the history of similar communication failures within commercial aviation.
  3. Demonstrates the 30+ year process of research, program development, and training systems implemented within aviation with regards to communication and team-management.
  4. Powerfully explicates “Crew Resource Management” (CRM) as an evolved system for team interactions and operational success.
  5. Highlights successful uses of the initial healthcare version of CRM called TEAMSTEPPS.
  6. Directs our attention to the unavoidable future of healthcare including regulatory bodies and advanced data-capturing systems.

Most incredibly, Suzanne and her co-authors break down the individual components that make up successful team communication, demonstrates how those pieces are failing within healthcare structures, and provides direct examples of how those issues have already been successfully addressed within aviation.

Read some of the excerpts below to better understand the benefits of this work:

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“In medicine it seems now to be universally acknowledged that failures of teamwork and communication-not simply failures in technical proficiency-cause the majority of medical errors and injuries in hospitals and other health care facilities. Studies too numerous to cite have documented that it is not the incompetent surgeon or a small group of bad apples in other disciplines that cause harm to patients. It is human factors – the failure of human beings to relate effectively and productively with one another highly technological settings, to recognize human limitations in performance ability owning to “Life factors” such as extreme fatigue and emotional distress, and to actively resist the culture of blame- that are the major cause of patient harm.” p. 8.

“Even when early pilots flew with a navigator, contact was difficult and minimal. From aviation’s inception as a mode of transport, teamwork was rarely a consideration. A large part of pilot training, whether conducted in military, commercial, or general aviation arenas, is often accomplished one-on-one as flight instructors demonstrate and students unquestioningly mimic technical maneuvers-and especially behaviors. The first major milestone in any pilot’s advancement is to fly solo. Until the introduction of CRM in commercial aviation, a pilot’s primary demonstration of competency was based almost entirely on technical aptitude: the ability to perform a standard set of maneuvers and handle emergences (with little or no regard for interaction with the rest of the crew). Although commercial transport pilots flew as crews, competence had little to do with teamwork or error management in the cockpit.” p. 24.

“The aviation safety moment started out precisely because pilots did not accept their human fallibility. Mistaking the end of a very long journey for its beginning, many in medicine do not seem to understand the similarities between attitudes of pilots pre-CRM and those of physicians today. CRM did no succeed because in the 1980s pilots at United and other airlines threw their hands and said, “We give up.” A great many pilots, in fact, dismissed CRM as “Charm school”… to erode their authority. Flight attendants were also initially skeptical. The fact that human fallibility is now universally accepted in aviation is the result of a very long journey that began with a challenge to an ethos that led pilots to believe they had the power of Zeus when, in fact, many only had the hubris of Icarus. The aviation safety movement has worked not only because of the concrete lessons it teaches but also because of the reconceptualization’s ands strategic approaches it has utilized. These have been derived from, and refined through, thirty years of hands-on, human-factors research-in other words, evidence-based changes and developments”. p. 157.

Again, this 261 page book is a MUST READ for anyone engaging in medical simulation today!

Get the softcover version of Beyond the Checklist or the kindle edition through

Continue reading more great examples of the content available in Suzanne’s book by “Reading More” below.

“If CRM training is a one-shot event, no matter how thorough, its effectiveness will be limited. The key to its successful implementation in aviation is that once introduced, it was then kept in the forefront through recurrent training, and it has evolved and adapted over time”. p. 38

“CRM communications training focuses on the following:

  • Making introductions and setting the stage for teamwork
  • Conducting appropriate briefings
  • Creating/reaffirming a shared language
  • Establishing mutual understand of decisions about operations
  • Inviting participation
  • Seeking information and direction from others when necessary
  • Promoting appropriate assertiveness to maintain safe operations
  • Examining self and group, including critiquing as appropriate.” p. 47

“When United and other airlines began to videotape crew communications during simulator training in the 1980s, they brought in the cameras precisely because a lot of crew members insisted that they didn’t need extra communications and team-building training. They believe that they were not only proficient aviators but also skilled communicators.  [But] during post event debriefs, when confronted with video proof, crews were literally shocked at their own behaviors. They quickly realized that they often unconsciously adopted behaviors that silenced fellow members”. p. 50.

“In the airline industry, CRM began to produce not only a different kind of pilot but a different process through which airlines selected pilots. Today airlines are no longer interested in employing aviators solely on the basis of their technical skills. They deliberately select people who can and want to work with others. As a reflection of these values, industry leaders developed a training environment that measured “individual proficiency” by requiring “e ach captain to demonstrate the ability to handle without assistance whatever exigencies might arise. Copilots, called first officers, had their individual proficiency measured by how well they assisted the captain. In fact, as Robert L. Helmreich and H. Claton Foushee note, “in 1952 the guidelines for proficiency checks at one major airline categorically stated that ‘the first officer should not correct errors made by the captain’”. p. 78.

“Orchestrating the actions of a crew in an unusual or emergency situation is a finely honed skill. Minute-by-minute analysis of the cockpit conversation revealed a group that became hyper-organized during this crisis. Their conversations contained a series of intense interactions – averaging thirty-one communications per minute (one per second at its peak). During these conversations, junior crew members freely suggested alternatives and the captain responded by welcoming that input.” p.118.

“ Unfortunately, those imbued with a sense of invulnerability are less likely to feel the need for countermeasures against error and most likely to fail to value the support and input of other crew members. Perceived invulnerability may lead to a disregard for safety measures, operational procedures, and teamwork. Moreover, this attitude is easily sensed by other crew-members and creates barriers to effective communication and the important exchange of information about how to resolve operational difficulties – all of which are essential to the safe outcome of the flight. This is why it’s so critical to help pilots [and healthcare professionals] recognize the effects of stress and train them to manage stress by doing the following:

  • Maintain a positive emotional of “team” climate.
  • Recognize symptoms of stress in themselves and others.
  • Maintain checklist discipline and compliance with SOPs.
  • Manage low stress times to prevent complacency or lack of attention.” p. 132.

Get the softcover version of Beyond the Checklist or the kindle edition through today!

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