The complexity of team training: what we have learned from
aviation and its applications to medicine
W R Hamman
Qual Saf Health Care 2004;13(Suppl 1):i72–i79. doi: 10.1136/qshc.2004.009910
Errors in health care that compromise patient safety are
tied to latent failures in the structure and function of
systems. Teams of people perform most care delivered
today, yet training often remains focused on individual
responsibilities. Training programmes for all healthcare
workers need to increase the educational experience of
working in interdisciplinary teams. The complexities of
team training require a multifunctional (systems) approach,
which crosses organisational divisions to allow
communication, accountability, and creation and
maintenance of interdisciplinary teams. This report
identifies challenges for medical education in performing
the research, identifying performance measurements, and
modifying educational curricula for the advancement of
interdisciplinary teams, based on the complexity of team
training identified in commercial aviation.
flight crew may lead to a loss of life. Hackman1
notes that ‘‘it is the team, not the aircraft or the
individual pilot, that is at the root of most
accidents and incidents’’.
Traditionally, pilot training has concentrated
mainly on the development of the technical skills
and performance of the individual pilot. Indeed,
both researchers and practitioners suggest that
more emphasis should be placed on the perfor-
mance of the crew as a team and on factors that
Hackman, Johnston,2and Diehl3further point
out that ideally team skills and the principles of
crew resource management (CRM) need to be
reinforced, and reviewed during flight training.
Similarly, Johnston2stresses that ‘‘if we want
pilots to perform as a crew—as team members—
we should train them as a crew throughout’’.
The same situations exist in medicine. In
health care, team errors encompass all settings
in which care is delivered and engage all
categories of healthcare workers. Errors in health
care that compromise patient safety can be tied
to latent failures embedded in the structure and
function of systems. The Institute of Medicine’s
(IOM) report, To Err is Human, bluntly states,
‘‘most care delivered today is done by teams of
people, yet training often remains focused on
individual responsibilities, leaving practitioners
Captain W Hamman,
University, 237 N. Helmer
Road, Battle Creek, MI
49015, USA; william.
he importance of effective teamwork in
health care is as critical to safety as it is in
aviation. The failure of a healthcare team or
inadequately prepared to enter complex settings.
…the ‘‘silos’’ created through training and
organisation of care impede safety improve-
The complexities of team training require a
multifunctional (systems) approach. This train-
ing moves beyond the training of individuals in
an educational setting, to a dynamic team
training system that crosses divisions within
accountability, and the creation and mainte-
nance of interdisciplinary teams. Commercial
aviation has created a multifunctional system
based on three principles that health care can
team training. Health care should adopt a similar
approach because ‘‘… in healthcare organisa-
tions, much of (the) learning is aimed at
improving individuals 2 physicians learning to
become better physicians, nurses learning to
become better nurses 2 rather than learning
how the system as a whole can improve’’.5Both
fields require high levels of selfconfidence and
decision making abilities. Most strikingly, within
their respective fields, practitioners of both
disciplines function largely in the absence of
direct supervision; individual performance is
seldom directly observed or monitored. Errors
in both fields can have devastating effects. Over
the last 30 years, commercial aviation has devel-
oped meaningful measures of individual, team
(aircrew), and system performance.6Aviation
has been able to translate these measures into
standardised best practices. By specific assign-
ment of accountability, aviation system manage-
ment assures adherence to these best practices.
Although all three principles (transparency,
standardisation, and team training) are critical
for success of a dynamic healthcare education
that crosses divisions within the healthcare
system, this paper will primarily focus on the
element of the team training process developed
in the aviation community.
The focus of our discussion will be on the
complexity of effective team training identified
in aviation. Team training:
N Requires management to address the chal-
lenge for crosscultural training.
Abbreviations: AAIB, Air Accidents Investigation Branch;
AQP, Advanced Qualification Program; ATC, air traffic
control; CRM, crew resource management; IOM, Institute
of Medicine; NASA, National Aeronautics and Space
Administration; PAC, pulmonary artery catheter; RHC,
right heart catheterisation; SOP, standard operating
procedure; SPO, supporting proficiency objective; TPO,
terminal proficiency objective
induced by faulty systems that set people up to fail’’.4
Medicine needs to understand the complexity of effective
medical team training and focus research to address this
challenge. Much work is needed to build an effective team
training programme in medicine. Research needs to be
conducted to identify the team topics and specific team skills
for the medical profession. When this is complete, perfor-
mance standards must be identified to create performance
improvement measurements. This work must then be
designed into a curriculum that supports integration of team
training with technical performance. Finally, performance
measurements must be conducted to identify the change in
outcomes this training and simulation are effecting. This
footprint for training must cross cultural boundaries and be
part of an environment that is supported by the senior
healthcare leadership. The primary similarity to aviation is
that medicine also should no longer wait.
Competing interests: none declared
1 Hackman RJ. Teams, leaders, and organizations: new directions for crew-
oriented flight training. In: Wiener E, Kanki B, Helmreich R, eds. Cockpit
resource management. San Diego, CA: Academic Press, 1993:47–70.
2 Johnston N. Intergrating human factors training into ab initio airline pilot
curricula. ICAO J 1993;48:14–17.
3 Diehl AE. Cockpit decision making. FAA Aviation Saf J 1991;1:14–16.
4 Kohn L, Corrigan J, Donaldson M, eds. To err is human: building a safer
health system. Washington, DC: National Academy Press, 2000:146.
5 The President’s Advisory Commission on Consumer Protection and Quility in
the Health care Industry. Quality first: better health care for all Americans.
Final report, Washington, DC, 1998:186.
6 Salas E, et al. Team training in the skies: does crew resource management
(CRM) training work? Hum Factors 2001;43:641–74.
7 Fulginiti VA. The right issue at the right time. In: Holmes DE, Osterweis M, eds.
Catalysts in interdisciplinary education: innovation by academic health
centers. Washington DC: Association of Academic Health Centers, 1999.
8 Air Accidents Investigation Branch. Aircraft Accident Report 4/90: Report on
the Accident to Boeing 737–400, OBME near Kegworth Leicestershire on Jan,
8, 1989. London: Department for Transport. Available at: http://
9 Cardosi KM, Huntley MS. Cockpit and cabin crew coordination. DOT/FAA
report No. DOT-TSC-FAA-87-4. Washington DC: US Department of
Transportation (NTIS No. DOT/FAA/FS-88/1), 1988.
10 Brindle M, Mainiero LA. Managing power through lateral networking.
Westport, CT: Quorum Books, 2000.
11 Cooper GE, White MD, Lauber JK, eds. Resource management on the
flightdeck: proceedings of a NASA/industry workshop (NASA CP –2120).
Moffett Field, CA: NASA-Ames Research Center, 1980.
12 Helmreich RL, Foushee HC. Why crew resource management? In: Wiener E,
Kanke B, Helmreich R, eds. Cockpit resource management. San Diego, CA:
Academic Press, 1993:1–45.
13 Hamman W, Seamster T, Smith K, Lofaro R. The LOE Worksheet developed to
provide clear structure to the assessment of both CRM and technical crew
performance. ATA Conference 1993.
14 Bernard GR, Sopko G, Cerra F, et al. Pulmonary artery catheterization and
clinical outcomes: National Heart, Lung, and Blood Institute and Food and
Drug Administration Workshop Report. Consensus Statement. JAMA
15 Iberti TJ, Daily EK, Leibowitz AB, et al. Assessment of critical care nurses’
knowledge of the pulmonary artery catheter. The Pulmonary Artery Catheter
Study Group. Crit Care Med 1994;22:1674–8.
16 Iberti TJ, Fischer EP, Leibowitz AB, et al. A multicenter study of physicians’
knowledge of the pulmonary artery catheter. Pulmonary Artery Catheter Study
Group. JAMA 1990;264:2928–32.
17 Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for
health care professional skills training and assessment. JAMA
18 Derossis AM, Fried GM, Abrahamowicz M, et al. Development of a model
for training and evaluation of laparoscopic skills. Am J Surg
19 Colluccio M, McGuire P. Collaborative practice: Becoming a reality through
primary nursing. Nurs Admin Q 1983;7:59–63.
N Team training skills must be identified by task analysis,
have identified TPOs, SPOs, skills, and behavioural
markers of performance.
N From the first day of training, team skills are integrated
into the curriculum lesson plans and supported by
N Team training skills must share equal importance with
the technical skill requirements.
N The curriculum must be designed to support cross-
N The curriculum must integrate carefully designed
simulation that is based on scientific models of team
training generated from performance data from the
N The team training elements must be integrated into the
event set design with defined criteria for successful
Medical team training i79