Jan 10, 2016 Research has shown that both lack of communication and miscommunication are a source for many errors in hospitals and other high reliability organizations. Techniques have been adopted and studied, such as I-PASS, to minimize handoff communication errors. Some institutions use the acronym SBAR (situation, background, assessment, recommendation) to optimize exchange of information. Organizations face an enormous hurdle when a team member has a concern and wishes to communicate but never speaks up. The results can be catastrophic. A simple technique I call “C-Squared: Concern and Clarity” described below can be adopted and practiced to avoid potentially devastating consequences.
The military and airline industry have studied and trained extensively to enhance team communication skills. The failure to adequately verbalize a concern must be avoided. A very tragic example occurred in 1977 on a foggy night on the island of Tenerife where the most deadly aviation accident in history killed 583 people including over 50 children. Due to a series of misfortunes two planes ended up on the same runway in dense fog. A KLM flight started down the runway without clearance while a Pan Am jet sat parked in front of it. Communication failure played the largest role in the subsequent investigation of the crash. Non standard language was used, technical issues garbled transmissions, but most glaringly the copilot voiced concerns and requested clarity which never occurred. The details are chilling.
The KLM plane had just started its takeoff roll. The tower told the Pan Am crew to "report when runway clear." The Pan Am crew then stated: "OK, we'll report when we're clear." The KLM flight engineer immediately expressed his concern about the Pan Am not being clear of the runway and asked both pilots , "Is he not clear, that Pan American?" The captain of the KLM flight and Chief of flight training, Veldhuyzen van Zanten emphatically replied "Oh, yes" and continued with the takeoff. The ensuing human tragedy was immeasurable
The flight engineer, who was correct, expressed his concern but stopped there. Had he requested clarity, the takeoff roll may have been aborted; the status of the Pan Am plane could have been verified and all the lives could have been saved.
The use of “C-Squared” is to be sure team members recognize the importance of voicing “Concern”, the first “C”, and requesting “Clarity”, the second “C” of C-Squared. There are those who would immediately state that in a true culture of safety, all members should engage in free discourse and do not need to use this technique.
While we would hope the work environment treats all employees as equals in delivering service to patients, I would suggest the perceived subordinate relationship frequently present, nurse/physician, house officer/attending, CEO/staff physician can thwart open discourse. Fears of retribution or alienation also remain an impediment to open discussion. By adopting the C-Squared technique, training with it and practicing it, the organization promotes safe culture. The use of the key words “clarity” and “concern” not only can eliminate errors but also act to protect those who use them. Expressing these terms notifies the team of a significant issue and suggests a good faith effort by the speaker to identify a safety concern. In an environment of type A personalities and oversized egos, some see any questioning of their opinions or orders as disruptive, undermining and disobedient. The team can be protected from this unfortunate attitude by using the recognized C squared terminology which all will recognize as raising a point to avoid an error.
Forty years after Tenerife, we can remember and learn. Few if any institutions have a formal policy or training in critical words and language in place. Adopting the C- Squared technique is low cost and helpful. Concomitantly C-Squared mitigates dangerous situations by avoiding communication errors and is a vehicle to protect a staff member who speaks up. Let us take advantage of another opportunity to avoid liability, minimize wasted resources, and eliminate untold pain and suffering.
Nicolas Argy, M.D., J.D.Health/Business Consultant/Educator, Patient Safety, Quality, Risk Management, Public Health Advocate, Witness Prep