HCA Graphic Gameplan FacilitatorsGuide

A FACILITATOR’S GUIDE
The Healthcare Adventures™

Graphic Gameplan For Patient Safety
J ay W. Vogt • M i c h a el Sa le s • S a ra J. S ing er • J effrey B . Cooper
The Center for Medical Simulation, Boston, Massachusetts

How to Use this GUIDE
Copyright © 2015 by the The first two sections (pp. 4–7) frame the theoretical and
Center for Medical Simulation evidence-based context for understanding this new tool.
All rights reserved. No portion of this The next two sections (pp. 8–21) provide a how-to guide
book may be reproduced, by any process for practitioners for using this tool.
or technique, without the express written
consent of the publisher. The appendix (pp. 22–32) provides additional useful
resources.
Published by the
Center for Medical Simulation
100 1st Avenue
Charlestown, MA 02129
1.617.726.3034 A c k n o w l e dg m e n t s
https://harvardmedsim.org
The authors would like to acknowledge, first and foremost,
the patient safety leadership teams at Massachusetts General
Library of Congress Hospital, who engaged with us in actively and creatively using
Cataloging-in-Publication Data this tool to improve patient safety outcomes in their clinical
Vogt, Jay W. — first edition. settings. In particular, we appreciate Dr. Gregg Myer, MD, MSc,
p. cm.
Chief Clinical Officer of Partners HealthCare System, Inc., and
the Principal Investigator on this project, for his willingness
Graphic Gameplan for Patient Safety /
Jay W. Vogt, Michael Sales, Sara J. Singer to support this research.
and Jeffrey B. Cooper
Includes bibliographical references. This work could not have happened without the generous
ISBN 978-0-9898777-3-2 support of The Patrick and Catherine Weldon Donaghue Medical
1. Employees — Coaching of.
Research Foundation, also known as The Donaghue Foundation.
2. Teams in the workplace — Management.
3. Employee motivation. I. Title.
We wish to acknowledge the staff of the Center for Medical
Simulation, who, in collaboration with partners, developed the
training known as Healthcare Adventures™ , and whose creativity,
tenacity, and passion for patient safety continually inspire us.
We also acknowledge with gratitude research assistance from

Jennifer E. Hayes, Mathew V. Kiang, Garry C. Gray, and Angela
Aristidou who contributed in substantive ways to the development
and evaluation of this tool and its use as part of Healthcare
Adventures.
We acknowledge the creative genius of The Grove Consultants

International, who created the first Graphic Gameplan (which
served as a template for the Healthcare Adventures™ Graphic
Gameplan), and are grateful for their kind permission to use
our adapted version in this work and in this publication.
www.grove.com/site/index.html
2 | Th e Healthc a r e Adv e nt u r e s Gr a p hi c G a m ep l a n f o r pati e n t s a f e ty | Vo gt, S a l e s, Si n g er, coop e r

Table of Contents
4 Improving Quality in Healthcare
4 Patient Safety Leadership and the Graphic Gameplan

4 The Challenge of Improving Quality in Healthcare
5 A Comprehensive Model for Patient Safety Leadership
8 The Healthcare Adventures™ Graphic Gameplan for Patient Safety
8 The Graphic Gameplan
9 The Theory of Change Animating the Graphic Gameplan
11 For Facilitators: Getting Ready to Use the Graphic Gameplan
12 The Facilitator’s Guide
12 Overview
13 Setting Up the Process
14 Introducing the Tool
15 Initiating the Gameplan Experience
16 Summarizing
16 The Gameplan Elements
20 Concluding
21 Sample Timing Frameworks for Graphic Gameplan Sessions
22 A Sample (Completed) Graphic Gameplan
22 Appendix
22 Author Biographies
23 Additional Healthcare Adventures™ Publications
28 The Center for Medical Simulation
29 Further Learning with the Center for Medical Simulation
30 Obtaining Copies of the HCA Graphic Gameplan Template
31 References

i m p r o v i n g qu a l i t y i n h e a l t h c a r e
Pat i e n t S a f e t y L e a d e r s h i p a n d t h e G r a p h i c G a m e p l a n
L
eaders and managers in healthcare must respond One of the challenges to implementing successful
to needs (and occasionally, to demands) for improve- quality improvement (QI) initiatives in healthcare has
ment in both the efficiency and the quality of the been engaging senior managers (Blumenthal and
health services their organizations provide. Patient Kilo 1998). Effective leadership by senior and middle
safety leadership in response to these needs is critical managers is critical because of their disproportionate
— and can be challenging on a host of fronts. What cultural influence, financial control, and decision-making
if leaders and managers could engage in a patient authority (Carroll et al. 2006). Healthcare is not unique
safety and quality improvement process that was out- in this regard: securing the right sort of leadership
come focused, evidence based, clear, not difficult, and engagement for quality improvement is challenging
even enjoyable? The Healthcare Adventures™ Graphic across a variety of industries (Westphal et al. 1997).
Gameplan is that process, and it elicits these kinds The issue is not simply a matter of managers’ interest
of reactions from participants: in quality (Batalden and Stoltz 1993), which, in health-
care, has increased markedly in response to both
“I have loved using the Gameplan. Our project mounting requirements for transparency around quality
is going really well, at the speed of light. People and burgeoning pay-for-performance initiatives. Rather,
have taken the bull by the horns in their roles successful quality improvement requires that leaders
now that they know what they are.” be genuinely and consistently engaged in the effort,
and that attention to patient safety be embedded in
“We had a baseline rate of 78% compliance with the fundamental DNA of the organization.
target. As a result of this discussion, we focused.
In our last measurement, compliance was 94%, An organizational climate of empowerment and con-
maybe higher.” tinuous learning results in greater quality improvement
output and performance (Carman et al. 1996). The
Before we introduce the Healthcare Adventures™ literature on organizational learning—considered here
Graphic Gameplan for Patient Safety, we offer
to be one aspect of an organization’s overall climate—
some discussion of the contexts for its utility. provides insight into effective ways to engage managers
in quality improvement. It posits that organizations are
The Challenge of Improving Quality more likely to learn—whether through QI initiatives,
in Healthcare experimentation, or reflection about day-to-day
The need for improvements in the quality and efficiency operations—if leaders create a climate of curiosity,
of healthcare continues, as is demonstrated by an exploration, and reflection (Hackman 2002).
ongoing accumulation of studies (McGlynn 2003). The
history of such improvements has been mixed, however We call this learning-oriented environment a patient
(Leape and Berwick 2005; Auerbach et al. 2007), safety leadership culture. Let’s explore it in greater
and the evidence for clear and sustained advances on depth by examining seven leadership behaviors that,
specific quality improvement initiatives is still decidedly evidence suggests, help create an organizational
limited (Landon et al. 2007; Landon et al. 2004; culture that pursues patient safety.
Mittman 2004; Shojania and Grimshaw 2005).

Really cares
Welcoming/
non-defensive
attitude
Encourages speaking up
Facilitates communication Team Group

& teamwork learning performance
behaviors
Takes action
Mobilizes information
Seeks input
A Comprehensive Model their own behavior accordingly. Managers demon-

for Patient Safety Leadership strate that they genuinely care about safety and quality
The seven behaviors identified in this graphic, and dis- in general, and about an improvement project in
cussed subsequently, comprise evidence-based leader particular, by being visible and visibly interested in
traits and actions that support a culture devoted to how safety and quality goals get enacted in daily
patient safety. operations. When leaders of an organization express
real caring, staff awareness of quality-related concerns
O n e : r e a lly ca r e s increases, resulting in fewer small mistakes that poten-
In creating a patient safety leadership culture, leaders tially could lead to larger, more-catastrophic errors
need to demonstrate what is perhaps the most critical (Weick and Roberts 1993; Garvin 2000).
behavior—to show, in ways that are discernible to staff,
that they care. How a leader spends his or her time Tw o : has a we lcomi ng, non- de f e n sive
and attention, and what she talks about, and how pas- at t i t ude
sionately, send clear signals to staff about what matters A meaningful behavior is welcoming people’s contri-
in an organization (Clarke et al. 2007). Staff members butions and responding non-defensively to them. This
observe both verbal and nonverbal cues, and model creates an environment in which people feel safe to
When leaders of an organization express real caring,

staff awareness of quality-related concerns increases, resulting
in fewer small mistakes that potentially could lead to larger,
more-catastrophic errors.

take interpersonal risks. Participating creatively and encourage them. A leader’s orientation toward learn-
effectively on quality improvement (QI) project teams ing, rather than blame, and toward safety, rather
requires individuals to take some risks, including offer- than status, is critical in setting a safe, receptive tone.
ing suggestions and experimenting with new ideas.
Evidence suggests that people often don’t take these T hree : e ncourag e s sp e aki ng up
risks because they don’t feel “psychologically safe” Another important leader behavior is encouraging
within the group, i.e., to bring up something that might interpersonal risk-taking—specifically, behaviors such
make someone uncomfortable (Edmondson 1996). as speaking up to express safety questions and con-
Taking such a risk is especially difficult in a situation of cerns—that leads to organizational learning and
unequal power, wherein the person to whom a “risky” enhanced performance. Leaders do this by asking for
comment is to be delivered has greater status and input, thanking people when it is given, and acting on
authority than the individual making the comment suggestions provided (Edmondson 1999; Edmondson
(Janis 1982). This is particularly true in healthcare, in et al. 2001; Edmondson 2003; Nembhard and
which the value of rigid status hierarchies is instilled Edmondson 2006).
across all disciplines. A leader’s response, when a staff
person takes an interpersonal risk, strongly influences F o u r: faci li tat e s communi cat i on
whether that staff member will ever do so again. Facilitating communication and teamwork is essential
A defensive response inhibits further contributions; to leaders’ creation of the conditions that foster team
a welcoming response and non-defensive attitude effectiveness. Such facilitation includes attending to the
“I have loved using the game plan. Our project is going

really well—at the speed of light. People have taken the bull by the
horns in their roles - now that they know what they are.”
P ed i at ric s T ea m M e mb er

“We had a baseline rate of 78% compliance
with target. As a result of this discussion, we focused. In our
last measurement, compliance was 94%, maybe higher.”
Obs t et ric s T ea m M e mb er
structure and composition of the team, establishing its tions prevent duplication, enhance creative problem-
purpose, providing coaching as needed, and working solving efforts, and—because staff feel that their
with the team to help members use collective resources thoughts and experiences are valued by the organi-
in pursuing team goals (Hackman 2002). Leaders can zation—improve employee morale (Husted and
also use specific processes that promote teamwork, Michailova 2002).
such as daily huddles, time-outs before implementing
key changes, and reflection following implementation S e v en: se e ks i np ut
(Edmondson 2003). Seeking input is a key behavior for leaders. A lack of
formal authority can limit the ability of frontline work-
F i v e : tak es a ct i o n ers to reach across disciplines, work units, and shifts
Taking action, even when resources are not optimal, to obtain needed information or to effect necessary
palpably demonstrates commitment to quality im- change (Tucker and Edmondson 2003). An important
provement. Lack of sufficient resources is a common function of an engaged leader is to seek this input,
explanation for the failure of QI efforts in healthcare span these boundaries, and ensure both that informa-
organizations (Shortell et al. 1995). All hospitals face tion flows as needed and that appropriate individuals
resource constraints, but leaders can make judicious gather to discuss issues of mutual importance
use of scarce resources through a systems approach (Ancona and Caldwell 1992; Argyris 1985).
to quality improvement (Shortell and Singer 2008).
For example, gathering input from frontline workers Pat ient S a fet y Lea dership Cult ure
about safety hazards and ineffective processes can Learning requires change, but too often, change is
lead to work-system redesign that yields more efficient endured rather than enjoyed (Edmondson et al. 2001).
use of financial and personnel resources, while simul- This can be as true for those initiating change as for
taneously improving patient safety (Tucker et al. 2008). those ”on the receiving end.” An important aspect of
Simple, consistent inquiry and intervention by leader- a leader’s “coaching” role is recognizing people’s dis-
ship—to ensure that reasonable actions are taken orientation and discomfort with new conditions, and
without delay—can make the difference in getting communicating a motivating rationale for expending
important work done (Weiner et al. 1997). the effort to make the change successful (Podolny et
al. 2005). Once people can envision the benefits of
S i x: mo b i li z e s i n f o r m at i o n implementing new approaches, the costs become sec-
Effective leaders ensure that QI team members have ondary, and individuals are more likely to work toward
the information necessary to achieve project aims, and a shared purpose, with end goals in mind (Batalden
that critical information is shared across the institution. and Stoltz 1993; Senge 1990). Together, these leader
Leaders must institute processes for documenting, behaviors create the conditions for a thriving patient
interpreting, and disseminating knowledge (Garvin safety leadership culture.
2000). By systematically sharing knowledge, organiza-

T h e H e a l t h c a r e Adv e n t u r e ™ G r a p h i c G a m e p l a n f o r P a t i e n t S a f e t y
H
ealthcare Adventures™ (HCA) is a customized, a specific and important quality, safety, or other team
day-long, team-training workshop for intact project to address during the program. After the simu-
leadership and management teams from lation, the team is debriefed, with the facilitator iden-
across the healthcare spectrum. The purpose of the tifying teachable moments that lead to learning and
HCA workshop is to help healthcare leaders grow actionable strategies. Participants gain new insights
individually and collectively in ways that support the into their individual and team behaviors. These are
creation of patient safety leadership culture; it employs kept in the forefront during the development of a Game-
the Graphic Gameplan as one of its tools. The HCA plan, under the guidance of the facilitators, specific to
workshop is designed to improve individual and team the team’s project. Team members go home having
performance by developing collaboration and com- done “real” work on something valuable and tangible,
munication skills consistent with the patient safety often advancing a project that had previously been
leadership model described in the previous section. “stuck.”
A typical Healthcare Adventure includes challenges
with a simulated patient in a highly realistic clinical The Graphic Gameplan
setting. Through this richly textured, simulated environ- The Graphic Gameplan is a team tool for an extended
ment, even teams composed entirely of non-clinicians (up to three-hour) exploration of a patient safety project.
actually get the chance to care for a patient, and to The original Graphic Gameplan was designed by a
experience real patient safety issues first-hand. consulting firm: The Grove Consultants International
of San Francisco. It has been adapted, with permis-
Faculty and professional organizational behavior sion, by many specialists in many fields; this Graphic
facilitators work with the team before the simulation Gameplan has been adapted by the authors specifi-
to define objectives and expectations, and to identify cally for use with healthcare leadership teams.

Graphic Gameplan Logic Model
(adapted from W.K. Kellogg Foundation 2004, 1–4)
Resources/Inputs Activities Outputs Outcomes Impacts
Management time Application Greater manager Improved More successful QI;

and participation  of Gameplan  awareness of needed  engagement in QI  better healthcare
leadership role among managers
Your Planned Work Your Intended Results
The objective of the Graphic Gameplan is to create The Graphic Gameplan is exceptional among quality
a set of strategic conversations around an important improvement team tools in that it provides an explicit
patient safety project. In the graphic on page 8, the process designed to help leadership engage in mean-
Gameplan process is represented by an arrow pointed ingful support of quality improvement initiatives. The
toward a set of outcomes. The conversations that theory of change underlying the Graphic Gameplan
ensue can take the form of a structured movement is represented as a logic model in the figure above.
from topic to topic; or they can comprise a looser ex-
ploration based on open-ended questions that allow the
facilitator to offer comments, information, and insights
as the material emerges and wherever it fits. A typical
process includes some combination of the two.
The Theory of Change Animating

the Graphic Gameplan
Managers’ intentions in healthcare are often consistent
with those that the literature suggests promote learning
and improvement. However, the quality improvement
tools that many organizations have adopted—such as
Plan-Do-Study-Act (Institute for Healthcare Improvement,
“How to Improve”), Lean (Institute for Healthcare
Improvement 2005), and Six Sigma (Kabcenell et al.
2010)—are limited in the extent to which they provide
explicit, pragmatic means of engaging managers. With-
out such a “formal” mechanism, even knowledgeable,
motivated managers often fail to engage as effectively
as they know they must. A QI tool that explicitly and
formally engages managers may yield superior results.
The Graphic Gameplan is exceptional among

quality improvement team tools in that it provides an explicit
process designed to help leadership engage in meaningful
support of quality improvement initiatives.

Developing a Gameplan requires relatively little invest-
ment of time and resources. The Graphic Gameplan
Logic Model (p. 9) suggests that developing a Game-
plan promotes awareness, among senior and middle
managers, of the leadership necessary to facilitate
a given QI project successfully, and to realize its full
potential for organizational learning. Leadership
contributions to successful QI project execution are
enhanced in two ways:
1. A clear process helps leadership become aware

of the key elements of a QI initiative, including:
desired project outcomes, project team members,
expected supporting and restraining forces, and a
sequence of action steps, information requirements,
and input necessary for attaining project objectives.
2. A visual tool helps leadership conceptualize these

elements and how they interrelate.
The Graphic Gameplan quickly generates a compre-

hensive, graphic roadmap for an improvement effort,
and highlights how managers must intervene to more quality improvement activity, leading to improved
promote project success. The tool can be applied to quality and cost of healthcare delivery.
any improvement effort and complements implemen-
tation approaches, such as Plan-Do-Study-Act cycles Our experience shows that, through its explicit process,
(Institute for Healthcare Improvement, “How to Improve”). graphic framework, and evidence-based content, the
Enhanced awareness promotes more strategic, Healthcare Adventures™ Graphic Gameplan promotes
coordinated, efficient, and effective intervention by leadership behaviors that are critical for organizational
managers and others in support of a QI project, which learning. Such leadership really cares, adopts a wel-
in turn leads to both better teamwork among stake- coming, non-defensive attitude, encourages speaking
holders and more successful QI project implementation. up, facilitates communication, takes action, mobilizes
Each successful project boosts willingness to initiate information, and seeks input.
“Most useful! Identifying team roles and

outcomes is really important. It helps to outline the help
we need and where to get it. Breaking it down into steps
facilitates the plan and timeline.”
Acu t e C a re M edic a l Tea m M ember
10 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

For Facilitators : Getting Ready to Use the Graphic Gameplan
T
he following two resources provide useful infor- • ability to manage conflict within and challenge
mation about the role of facilitators. An effective from the project team
facilitator for a Healthcare Adventures™ Graphic • understanding of project management concepts
Gameplan will have many of the general skills of a and process
professional facilitator, as described by the International • understanding of teamwork concepts and team
Association of Facilitators (International Association development
of Facilitators 2003, 1–4). Basic Facilitation Skills—a • willingness to identify and say things that others
primer published by the Human Leadership and Devel- may not want to discuss
opment Division of the American Society for Quality, • sincere interest in the team’s or group’s mission
the Association for Quality and Participation, and the and goals, including what they do, why they do it,
International Association of Facilitators—provides and how their activities impact patients
an excellent overview of the role (Burke 2002).
If you are considering using the Graphic Gameplan,
Key attributes for successful facilitation of a Graphic and your answers to the following questions are “yes,”
Gameplan with senior managers, managers, frontline it may be a very effective process to have in your
staff, and/or mixed teams include: toolkit.
• ability to assess a team and identify its teamwork 1. Do I have the passion to make a difference in
performance challenges patient safety?
• ability to create an environment of safety, learning, 2. Do I have the basic facilitation skills to lead a use
and exchange of the tool credibly?
• ability to facilitate and document group interaction 3. Do I have the humility to keep learning and
in real time continuously improve?

T h e F a c i l i t a t o r ’ s Gu i d e
T
his section discusses the elements of the Health- Organization) Center for Quality and Safety, and the
care Adventures™ Graphic Gameplan, guides Harvard School of Public Health (now the Harvard
the facilitator through the use of it, and sets out T.H. Chan School of Public Health). The Graphic
sample language that may be helpful in leading a Gameplan integrates elements of a new, evidence-
team through the process. based leadership model for organizational learning
that identifies seven key elements of successful
Overview leadership for improving patient safety culture.
The Graphic Gameplan is a visual tool for framing
a conversation about a healthcare team’s quality The foremost element—showing you really care—is
improvement project. The graphic provides an over- implicitly communicated whenever managers take the
view; the arrow indicates action toward outcomes; and time and energy to advance a safety project by using
the component parts frame the key elements of the the Gameplan. The action focus of the Gameplan
team’s work that require planning. directly addresses the three patient safety leadership
culture elements most relevant to project management:
As previously mentioned, The Grove Consultants
1. Taking action
International of San Francisco created the Graphic
2. Mobilizing information
Gameplan as a generic tool to help focus project
3. Seeking input
teams. It has been adapted for use as a patient
safety leadership training resource, with The Grove
However, the process of creating a Gameplan also
Consultants’ permission, by the Center for Medical
presents a great opportunity to practice the three other,
Simulation, the MGH/MGPO (Massachusetts Gen-
more-process-oriented elements:
eral Hospital/Massachusetts General Physicians

The foremost element—showing you really care—
is implicitly communicated whenever managers take
the time and energy to advance a safety
project by using the Gameplan.
1. Having a welcoming, non-defensive attitude patient safety or quality improvement project. We also
2. Encouraging speaking up recommend meeting with the same team six weeks to
3. Facilitating communication six months after the initial Gameplan session to follow
up on initial implementation of the patient safety
Thus, the Gameplan elegantly combines the seven project identified during that Gameplan process.
elements in one action. (For greater assurance of project completion, more
follow-up is advisable, but practically, often difficult
The two classic teamwork components common to all to achieve.)
teams and incorporated in the Gameplan include:
Setting Up the Process
1. Outcomes (goals)
The Graphic Gameplan functions best when the tool is
2. Team (roles)
physically large enough to act as a shared visual focus
for an extended team conversation. The simplest way
The “force field analysis” developed by action scientist
to create that focus is to draw the Graphic Gameplan
Kurt Lewin gives the Gameplan its final structural
template on a large roll of paper, and post that paper
components (Lewin 1951):
on a flat wall that can be a vertical work surface. A
1. Supporting forces 48” (in width) roll of white paper from an art supply
2. Restraining forces store, unrolled over a space at least 12’ long, or lon-
ger, can work well. (Alternately, see page 30 for infor-
The final element is the facilitator, who: mation on ordering preprinted, 8’ x 4’ color copies of
• frames the group’s understanding of the tool the Healthcare Adventures™ Graphic Gameplan tem-
• facilitates the group’s discussion of its project using plate.) Room seating should be arranged so that ev-
the tool eryone can see the Gameplan during the work session.
• records the group’s discussion of its project
as appropriate, using the tool in the least Although notes can be written directly on the paper
obtrusive way template, we recommend writing instead on (3” x 5”)
• feeds back to the group its conclusions so sticky notes so that ideas can be moved, clustered,
as to build understanding and consensus and replaced as the conversation proceeds. The sticky
• creates an action plan for next steps notes give the facilitator flexibility to record the group’s
conversation in a way that is nearly as fluid as the con-
Groups complete versions of this exercise in as little as versation itself. We recommend water-based markers
one hour or as much as three hours. We recommend (because they have no noxious scent and won’t stain
exploring the focus of the Gameplan at a pre-meeting clothes) that make strokes thick enough to be visible
with the group that will lead a specific and significant at the back of a small room.

Think of the Graphic Gameplan as a series of
important conversations that a team needs to have about
anupcoming patient safety project. The intelligence of many
past successful team efforts is embedded in the tool.
Introducing the Tool outcomes. When we are successful, how will

We typically introduce the Graphic Gameplan as a tool we know?
before we dive into the project content. This is lan- • The arrow starts on the left with the team itself.
guage we might typically use: Who are the players who will make this project
happen? What roles are needed to ensure the
The Graphic Gameplan is a visual tool for mapping
project’s success?
quality improvement projects in teams. It was first
• The three shafts of the arrow are three evidence-
developed by The Grove Consultants International
based components that lead to goal achievement
of San Francisco. This version is a unique adap-
and to recognition of the leadership required
tation, by practitioners at the Center for Medical
for successful organizational learning.
Simulation, Massachusetts General Hospital, and
• The first is “taking action.” What highly visible
the Harvard T.H. Chan School of Public Health,
action steps can the team take that will achieve
that incorporates evidence-based components
the desired outcomes? What leadership is
appropriate to our task.
required for these actions to occur?
• The second is “mobilizing information.” What
Think of the Graphic Gameplan as a series of
information—from any source—is needed by the
important conversations that a team needs to have
team and others, to inform actions and achieve
about an upcoming patient safety project. The
outcomes? What leadership is required to
intelligence of many past successful team efforts
mobilize this information?
is embedded in the tool. We can walk through the
• The third is “seeking input.” Who else needs to
Gameplan methodically, step-by-step, and let it
be involved in this change, either to ensure the
prompt the right conversations. Or we can talk
best possible decisions, or to secure buy-in from
more casually, letting our thinking emerge, and
key stakeholders? How should these stakeholders
capture our insights where they fit within the
be involved, and what leadership is required to
framework. Either can work, and we may well
obtain this input?
end up employing a combination of the two.
• Of course, the team does not work in a vacuum.
There are forces present in the environment—
Before we begin the discussion, we walk participants
which we’ll call “supporting forces”—that act
through the Graphic Gameplan element by element,
like wind in your sails, moving you toward your
describing the role and function of each component
outcomes. And there are forces present in the
of the process:
environment that hinder or restrain your success,
• As you can see, the Graphic Gameplan is essen- that hold you back from achieving your outcomes.
tially an arrow, and it moves from left to right, Leadership may be required to activate supporting
toward its point, where we record our intended forces and/or to overcome restraining forces.

Initiating the Gameplan Experience others if additional prompts are needed. Asking about
Having introduced the Graphic Gameplan, we can the project—overall—gets team members talking.
now begin the series of conversations that help the Sometimes their outcomes will surface. The facilitator
group map its project, and in so doing, complete the will want to post comments, as they are offered, in the
template. We often choose to start the conversation sections of the Gameplan that seem most appropriate.
with some very broad, open-ended questions. Doing Using sticky notes, the facilitator can always move the
this lets group members set the pace, begin where comment should she and/or the team change their
they want to begin, and feel ownership of the process. mind(s) about its proper placement.
We ask questions such as: The question about why a team chose a particular
project often makes overt any supporting forces in
Let’s start at the beginning with some really basic
the environment that raise this project as a priority.
questions:
Examples might be a change in insurance reimburse-
• What is the project you have chosen, in a nutshell?
ment that promotes or punishes certain outcomes, or
• Why did you choose this project, and not another?
the publication of a new, evidence-based, procedure
• Why do this project now?
protocol that is winning widespread endorsement.
• Why is this team the right team to do it?
The question about “why now” may surface supporting

When we list multiple questions like this, we don’t
forces (e.g., “encouraging developments”) and
mean to suggest that they all be asked at once. We
restraining forces (e.g., “this will be harder later”).
suggest starting with one, and falling back to the
“I’m just so admiring of this process.

There were so many ‘A ha!’ moments!”
A n e st he sia T ea m M e mb er

The question about “why this team” begins to identify • Before we dive into the Gameplan in earnest,
who is likely to be involved in the project, and what let me take a moment and briefly recap what
those individuals’ capabilities are. I heard, so you can see how the game is played.
• For example, in the category of supporting
As indicated before, we let the group share their forces, I heard . . .
answers to these questions while we, with little fanfare, • In the category of restraining forces, I heard . . .
record their comments on sticky notes and place them • In the category of outcomes, I heard . . .
wherever they most belong. Sometimes this initial con- • Is that a fair summary of what was just said?
versation can be lengthy and productive, generating • No doubt there are others, as well, which we
many sticky notes that populate the entire range of can capture as we go.
the Gameplan’s specific elements, while in many other • Now let’s now walk through the Gameplan,
cases, it is brief, and only serves as an introduction. section by section, and get your more specific
ideas.
Summarizing
After this initial conversation has run its course and we The Gameplan Elements
sense a pause in the conversation, we often take this Next, we move through each section, letting each
opportunity to do a quick recap of major comments, element serve to prompt key conversations, about the
showing how they fit with the components of the project, that need to happen.
Graphic Gameplan.

Ou tco m e s S upport ing F orc e s
We “begin with the end in mind,” as productivity expert Then we continue with the supporting forces
and author Stephen Covey has written (Covey 1989). component.
Let’s start with outcomes. • What forces in the culture and in the environment
• When your project is successful, how will you know? will act like wind in your sails, or tides lifting your
• What would indicate success? boats, generally making it easier and more likely
• What aims are you hoping to bring about? that you will succeed?
• What leadership by whom is required to ensure
We record these thoughts about outcomes. If, at that these supporting forces are activated?
any point, comments surface that relate to other
components of the Graphic Gameplan, we record If necessary, stimulate the conversation with a
those, as well, before bringing the conversation back comment.
to outcomes. This gives the participants the sense that
Think broadly about this. Supporting forces can
they are having a casual, free-flowing conversation.
be anything from an organizational culture that
The facilitator follows the team (by recording) so as not
supports experimentation, to patients who have
to lose members’ spontaneous contributions, but also
been greatly helped by the unit mounting the
leads the team (by intervening) back to the task
project and who might have resources to support
at hand.
the current effort.
Last, summarize briefly, and test for closure before

Record the supporting forces that emerge. Notice
moving on.
whether the team seems more enlivened or energetic
• So just to review, the outcomes you are aiming during this conversation, perhaps pleasantly surprised
for are . . . by the range of resources available to support its
• Anything else? success. This may be worth noting, because that
• Any ways to make these outcomes more optimism is an asset to the team when the going
measurable? gets tough.
You will notice that periodically we pause the group If, at any point, comments surface that relate to other
for reviews that summarize, synthesize, and mirror components of the Graphic Gameplan, record those,
back the work that has been done up to that point. as well, before bringing the conversation back to
This consolidates the group’s understanding of the supporting forces.
work it has done so as to build on it more effectively
during the rest of the exercise. It does slow the Last, summarize briefly, and test for closure before
completion of the plan, but we find it useful in moving on.
maintaining focus. The maxim “go slow to go fast”
• So just to review, the forces supporting your
reminds us that—to be most effective in generating
success are . . .
new thinking—people need time to reflect and to
• Anything else?
integrate.

R es trai n i ng For c e s are acknowledged and accepted, remarkable human
Next we move on to the restraining forces component. creativity often comes pouring out. Awareness of limits
can actually help teams focus on areas in which their
• What forces in the culture and in the environment
efforts can have the greatest impact. It is important to
will act like weights, holding you back and making
note these restraining forces in a clear-eyed way, and
it less likely that you will succeed?
it’s important not to get lost in them.
• What leadership by whom is required to overcome
these restraining forces?
If, at any point, comments surface that relate to other
components of the Graphic Gameplan, record those,
Record the restraining forces that are identified.
as well, before bringing the conversation back to
Notice whether the team seems drained or subdued
restraining forces.
by this conversation. Sometimes the apparent lack of
time, money, or leadership support for a project can
be profoundly discouraging. Be wary of indulging
moving on.
too much in this negativity; ultimately, great things
happen because of commitment and positive energy. • So just to review, the forces hindering your
Constraints can release team creativity, rather than success are . . .
restrict it. Though it may seem paradoxical, once limits • Anything else?
T he T ea m
Then we move on to the team segment.
• If there’s nothing else, let’s move on to the team.

Some group needs to be responsible for making
all this happen. Who will that be?
• Often a team has content experts, who may not
be regular members of the team, on whom it relies
for specialized expertise. Does this team have
such resources? Who would that be?
It may be helpful to record not only names, but also

the roles or areas of expertise that individuals bring
to the project. Note that there are instances in which
teams find it easier to identify the roles needed to
accomplish their objectives than to identify immediately
the specific individuals who can fulfill these roles.
• Teams need leadership. Team leaders can be

appointed by managers, they can be selected
by the team themselves, and they can rotate.
• How does this team plan on managing its
leadership function?

If, at any point, comments surface that relate to
other components of the Graphic Gameplan, record those, as well,
before bringing the conversation back to taking action.
• Often a team has an executive sponsor who Record the identified actions. In suggesting actions
runs interference for the team, or works to create necessary to accomplish project aims, participants
bridges across boundaries. Does this team have may recommend actions in no particular chronological
such an ally? Who would that be? order. When posting actions on the Graphic Game-
plan, try to place sticky notes into a rough chronology,
Record these team notes. If, at any point, comments from left to right.
surface that relate to other components of the Graphic
Gameplan, record those, as well, before bringing the If, at any point, comments surface that relate to other
conversation back to the team. components of the Graphic Gameplan, record those,
Last, summarize briefly, and test for closure before taking action.
moving on.
• So just to review, the team you envision is . . .
moving on.
• Anything else?
• So just to review, the actions you plan to take are . . .
Taki ng Actio n • Anything else?
We continue with the taking action segment.
M o b ilizing I nfor mat ion
• We now have a team dedicated to these outcomes.
Next we move to the segment on mobilizing
What actions does this team need to take to
information, i.e., finding and using existing
achieve those outcomes?
information that can be useful for the project.
• What actions are within your power to initiate?
Information can highlight content (e.g., a description
• What actions are outside your power to initiate,
of a similar program in another unit of the hospital)
but which you might influence?
or process (e.g., the best way to present ideas to a
• What actions do you know this team can accom-
particularly busy audience). The maxim offered by
plish regardless of any obstacles it might face?
management expert Ken Blanchard—“Feedback is the
• What leadership by whom is required to execute
breakfast of champions”—reminds us that information
desired actions?
on our performance is critical to our ability to improve
• Are all of these actions necessary to achieve
it (Blanchard 2009).
your outcomes?
• Are all of them, together, sufficient to achieve • We now have a team dedicated to these outcomes,
your outcomes? and to taking these actions. What information
• If not, what is missing? does this team need to mobilize to support these
actions and achieve its outcomes?

• Is this information available, or does it have to be • Think about input from superiors.
gathered? If the latter, how would that happen? • Think about input from peers.
• Do baseline data exist, or would they have to be • Think about input from subordinates.
gathered? If the latter, how would that happen? • Think about input from experts.
• Does the need to have this information suggest • What leadership by whom is required to secure
additional actions that must be taken? this input?
• What leadership by whom is required to access • What managers need to receive this input, and
this information? what is required to ensure they receive it?
• Who would use this information, and how would
it be shared? Record these opportunities to seek input. If, at
• What best practices exist in this area, and how any point, comments surface that relate to other
can you access them? components of the Graphic Gameplan, record those,
Record these ways of mobilizing information. If, at seeking input.
any point, comments surface that relate to other
components of the Graphic Gameplan, record those, Last, summarize briefly, and test for closure before
as well, before bringing the conversation back to moving on.
mobilizing information.
• So just to review, the input you need is . . .
• Anything else?
moving on.
Concluding
• So just to review, the information you need is . . . We have now led the group through the entire Graphic
• Anything else? Gameplan. Sometimes it is useful to give the group a
chance to take stock and catch its collective breath.
S e e ki ng I np u t
We’ve now walked through the whole Gameplan
We continue on to the seeking input segment. Input once.
serves two main purposes: (1) generating more • What do you think?
creative ideas, and (2) ensuring buy-in and support • What was that like?
from key stakeholders. • Has this been helpful? How?
• We now have a team dedicated to these outcomes,
taking these actions, and mobilizing this informa- Having acquired the perspective of the whole process,
tion. We now turn to input, which serves two main participants will sometimes want to revisit individual
purposes: (1) generating more creative ideas components. This is especially important for groups
and better decisions, and (2) ensuring buy-in that considered questions only superficially the first
and support from key stakeholders. time through.
• What input do you need before you initiate these Now that we have mapped out the whole project,
changes, and from whom? let’s take one additional look at our outcomes.
• What input do you need during these changes, • Are they attainable?
and from whom? • Are they too ambitious?
• What input do you need after making these • Are they not ambitious enough?
changes, and from whom?

“We needed this chance to be together,
to become a team and to reflect on the project.”
O r t h o p e dic S urg ery T ea m M e mb er
The final step is making plans for next steps. Some Sample Timing Frameworks for
groups like to post the actual Graphic Gameplan Graphic Gameplan Sessions
on a team room wall for ready reference; others like
A Three-Hour Session
to transfer it to a digital version; and some like to
translate it into project management software. Minutes Task
10 Introducing the tool
• What are the best next steps for the team to
25 Opening questions
take to make maximum use of the Gameplan?
15 Defining outcomes
• Who is going to make that happen?
• Exactly who is going to take responsibility to 15 Identifying supporting forces
do what? 15 Identifying restraining forces
• When do you think you are most likely to revisit 15 Break
the Gameplan again, for review and revision? 15 Defining the team
15 Identifying actions
Of course, we end by thanking the participants, and 15 Mobilizing information
wishing them success. If our relationship is ongoing,
15 Seeking input
we pledge our support and specify our next steps.
25 Closing questions
A Sample (Completed) Graphic Gameplan

The most interesting Graphic Gameplans are the ones A Two-Hour Session
you complete for a project you care deeply about. Minutes Task
Nevertheless, it can be useful to see a completed 05 Introducing the tool
sample Gameplan, which shows how a real, live team 10 Opening questions
used the tool to map out a patient safety improvement 15 Defining outcomes
project that they cared about. The sample, available
10 Identifying supporting forces
through the link below, addresses a topic area of
10 Identifying restraining forces
concern to many hospitals—infection control. This
Graphic Gameplan was developed by a team aiming 15 Defining the team
to decrease MRSA (methicillin-resistant Staphylococcus 15 Identifying actions
aureus) rates. (Note that identifying details have been 15 Mobilizing information
changed to protect the team’s privacy.) 15 Seeking input
10 Closing questions
To download this sample Graphic Gameplan,
click on the link and follow the instructions.
https://harvardmedsim.org/_media/pdfs/
HCA-Graphic-Gameplan.pdf

appendix
author biographies
Jay W. Vogt is an orga- journals such as Health Care Management Review,

nizational development Simulation in Healthcare, and Reflections.
consultant with 30 years’
experience in working with Jay is the author of Recharge Your Team: The Grounded
nonprofit organizations, Visioning Approach, a recent book by Praeger on his
corporations, government, visioning work with clients. Jay is also the author of
and small businesses. Board Roles to Board Goals: Creating an Annual
In 1982, he founded Board Workplan, by Peoplesworth Press. Learn more
Peoplesworth, a private about Jay at www.peoplesworth.com. See his TEDx
practice in strategic plan- talk on “The Art of Facilitation: Changing the Way
ning and change man- the World Meets” at http://bit.ly/JayWVogtTEDx.
agement. He holds an MA in counseling from Antioch
University New England, and a BA from Hampshire Michael Sales, EdD, is a
College. coach, program designer,
teacher, and facilitator
Jay is an accomplished facilitator, mediator, trainer, who combines detailed
management consultant, and coach. He is a master at knowledge of personal,
facilitating large groups, having led hundreds of events group, and organizational
averaging 100 or more participants. His clients have change technologies with
included: corporations such as Fidelity and NSTAR; a broad background in
small businesses such as Stonyfield Farm and Apple- business, entrepreneurship,
gate Farms; state agencies such as the Massachusetts and education. Michael
Water Resources Authority and the Massachusetts has extensive knowledge
Rehabilitation Commission; colleges such as Har- of the challenges of participatory management, the
vard University and Bunker Hill Community College; introduction of technologies into organizations, and
national trade associations such as the Organic Trade the dynamics of life in family-owned businesses. He
Association and the Social Venture Network; founda- has helped many individuals, teams, and organizations
tions such as The Boston Foundation and Two Ten achieve their objectives. His expertise is in the mobili-
Footwear Foundation; and nonprofit organizations zation of energy and talent in support of results.
such as the Massachusetts Horticultural Society and
the Massachusetts Audubon Society. Michael’s doctoral work at the Harvard Graduate
School of Education (supervised by Chris Argyris)
Jay’s healthcare clients include the Massachusetts focused on the interpersonal skills required by partici-
Medical Society, Partners HealthCare, Partners Commu- pative management. His Bachelor’s degree is from
nity Healthcare Inc., Partners HealthCare International, the University of Pennsylvania’s Wharton School; his
Physician Health Services (of the Massachusetts Medical Master’s program (in Broadcast Communication Arts
Society), Massachusetts Health Council, Massachusetts from California State, San Francisco) explored institu-
General Hospital, The Society for Simulation in Health- tional resistance to new technologies. Michael also
care, CRICO, Massachusetts Society for Medical has training certificates from the National Training
Research, University of Massachusetts Medical School, Laboratories Institute for Applied Behavioral Science,
UMass Memorial Health Care, and others. His collab- and from Global Foresight Associates, where he was
orative work with clinicians has been published in trained in scenario construction. He has served for

25 years as a senior associate of Barry Oshry’s Power Massachusetts General Hospital. Her research in the
+ Systems Training (the developers of The Organization field of healthcare management and policy focuses
Workshop), and of the Power + Systems Training Power on how organizational leadership and culture impact
and Leadership Conference. Michael was a founding efforts to implement health delivery innovations,
principal of New Context Consulting, which provides integrate patient care, and improve performance of
customized experiential education for organizational healthcare organizations. A key feature of this research
learning and change. is the development of survey instruments that measure
provider and patient perspectives on key interpersonal
Michael’s engagements as a strategy and leadership and organizational factors, enabling benchmarking,
consultant have spanned a broad range of economic rapid and reliable feedback about the effectiveness
sectors. Since 2004, he has increasingly honed in on and comparative effectiveness of delivery system
futurism as the key question confronting leaders. In innovations, and broader dissemination of more-
an era that stresses short-term thinking, it is uncommon successful interventions.
to find executives, managers, and/or line workers who
want to focus on the future in a disciplined, yet creative, Dr. Singer acts as: Co-Chair of the Harvard PhD in
way. But it is exactly these sorts of visionary leaders, Health Policy Program Management Track (2013–pres-
wherever they might exist in the organizational or ent); Implementation Research Director for the Safe
social hierarchy, with whom Michael wants to work. Surgery 2015 initiative (2010–present); Evaluation
Toward that end, he has co-founded Art of the Future Co-Chair for the Massachusetts Department of Public
(a strategy consulting firm) with co-visionary Anika Health’s Proactive Reduction in Outpatient Malpractice:
Schriefer. They published Life Sustaining Organizations: Improving Safety Efficiency and Satisfaction (PROMISES)
A Design Guide in 2011. program (2010–present); and Evaluation Team member
for the Harvard Center for Primary Care’s Academic
Michael was a contributing writer to the World Future Innovations Collaborative: Comprehensive, Accessible,
Society’s Future Survey. His authority on the dynamics Reliable, Exceptional and Safe (CARES) Collaborative
of closely held corporations is reflected in his publica- (2012–present). She also co-founded and served
tions on the subject. Michael co-authored an article, as Executive Director for the Center for Health Policy
on the management of mature workers, that was at Stanford, where she was also a Senior Research
selected by Prentice Hall in 2001 as one of the pre- Scholar and Lecturer (1993–2003). Dr. Singer served
eminent publications in the training literature. He is as Staff Director for the California Managed Care
Co-Chair of the Society for Organizational Learning, Improvement Task Force (1997–98), a Senior Legis-
North America, and a professional member of the lative Assistant for Health Policy in the U.S. House of
World Future Society. Representative (1994), and Health Policy Analyst at
the U.S. Office of Management and Budget (1992).
Sara J. Singer, MBA,
PhD, is an Associate Dr. Singer has published more than 70 articles in
Professor of Health Care academic journals, and books on healthcare manage-
Management and Policy ment, health policy, and health system reform. Her
at the Harvard T.H. Chan publications have won numerous awards, including
School of Public Health, Best Paper awards from the Academy of Manage-
and a faculty member in ment’s Health Care Division in three consecutive years
the Department of Medi- —2009, 2010, and 2011. She is the recipient of the
cine at Harvard Medical 2013 Avedis Donabedian Healthcare Quality Award
School in the Mongan from the American Public Health Association, and
Institute for Health Policy, the 2014 Teaching Citation Award from the Harvard

School of Public Health. Dr. Singer has conducted Dr. Cooper was a lead member of the group that
numerous studies—for the Agency for Healthcare created the first safety-related standards for anesthesia,
Research and Quality, Veterans Administration Health equivalent versions of which have since been adopted
Services Research & Development Service, and private in the U.S. and throughout the world. He is a Co-
foundations—related to measuring and improving Founder of the Anesthesia Patient Safety Foundation
organizational culture, learning, teamwork, patient (APSF), serving continuously on its Executive Committee
safety, integrated patient care, and the financing and and for 13 years as Chair of its Committee on Scientific
delivery of healthcare. She holds an AB in English Evaluation. He is now an APSF Executive Vice President.
from Princeton University, an MBA with a Certificate in He serves on the Board of Governors of the National
Public Management from Stanford University, and a Patient Safety Foundation and founded its Research
PhD from Harvard University in Health Policy/Manage- Program, which he chaired for seven years.
ment, with a concentration in organizational behavior.
Dr. Cooper is one of the pioneers in diffusion and
Jeffrey B. Cooper, PhD, innovation in healthcare simulation. He has led CMS
is the Founder and Execu- to become one of the premier simulation programs
tive Director of the Center in the world. Among the more-innovative programs
for Medical Simulation he has created or co-developed are the Institute for
(CMS), which is dedicated Medical Simulation live, interactive simulation video-
to the use of simulation teleconferencing, and the novel Healthcare Adventures™
in healthcare as a means (a program for training healthcare administrators and
to improve the process of leaders in teamwork via realistic simulation). He has
education and training, mentored the faculty of CMS since its inception and
and to avoid risk to pati- has stimulated, participated in, and advised on
ents. He is also Professor various research projects.
of Anaesthesia at Harvard Medical School. He received
his BS in Chemical Engineering and MS in Biomedical Dr. Cooper has been awarded several honors for
Engineering from Drexel University in 1968 and 1970, his work in patient safety, including the 2003 John M.
respectively, and completed a PhD in Chemical Engi- Eisenberg Award for Individual Lifetime Achievement
neering at the University of Missouri in 1972. Starting in Patient Safety from the National Quality Forum and
soon thereafter with the Bioengineering Unit in the the Joint Commission on Accreditation of Healthcare
Department of Anesthesia at Massachusetts General Organizations, and the 2004 Lifetime Achievement
Hospital, he led the team that conducted seminal studies Award from the American Academy of Clinical Engi-
of critical incidents and human error in anesthesia. neering. In 2013 he received the Distinguished Service
Award, the highest honor bestowed by the American
During the same period, he led a team that developed Society of Anesthesiologists, and awarded for the
one of the first microprocessor-based medical technolo- first time to a non-physician. In 2010, the Department
gies, the Boston Anesthesia System, aimed at integrating of Anesthesia, Critical Care and Pain Medicine at
functions for the ultimate purpose of reducing human Massachusetts General Hospital established the
and system errors. Both of these efforts have catalyzed Jeffrey B. Cooper Patient Safety award in his honor.
changes in anesthesia practice in the ensuing years.
In April 2009, Dr. Cooper retired as Director of
Biomedical Engineering for the Partners HealthCare
System, Inc., a technology development and service
department that he organized and led for 15 years.

Add i t i o n a l H e a l t h c a r e Adv e n t u r e ™ Pub l i c a t i o n s
Making Time for Learning-Oriented groups and behaviors that enabled higher performers
Leadership in Multidisciplinary Hospital to work together more successfully.
Management Groups
Sara Singer, MBA, PhD; Jennifer Hayes, MEd; Findings: Management groups that achieved more
Garry Gray, PhD; and Mathew Kiang, MPH of their performance goals, and whose staff perceived
Health Care Management Review, published online more and greater improvement in their learning-
ahead of print, July 15, 2014: http://journals.lww. oriented leadership after participation in Safety
com/hcmrjournal/Abstract/publishahead/Making_ Leadership Team Training, invested in structures that
time_for_learning_oriented_leadership_in.99853.aspx created learning capacity and conscientiously practiced
prescribed learning-oriented management and prob-
Background: Although the clinical requirements of lem-solving behaviors. They made the time to do these
healthcare delivery imply the need for interdisciplinary things because they envisioned the benefits of learn-
management teams to work together to promote front- ing, valued the opportunity to learn, and maintained
line learning, such interdisciplinary, learning-oriented an environment of mutual respect and psychological
leadership is atypical. safety within their group.
Purpose: We designed this study to identify behaviors Practice Implications: Learning in management
enabling groups of diverse managers to perform groups requires vision about what learning can
as learning-oriented leadership teams on behalf of accomplish; the will to explore, practice, and build
quality and safety. learning capacity; and mutual respect that sustains
a learning environment.
Methods: We randomly selected 12 of 24 intact
groups of hospital managers from one hospital to par-
ticipate in a Safety Leadership Team Training program. A Case for Safety Leadership Team
We collected primary data from March 2008 to Febru- Training for Hospital Managers
ary 2010, including pre- and post-program staff surveys, S.J. Singer, J. Hayes, J.B. Cooper, J.W. Vogt, M. Sales,
multiple interviews, observations, and archival data A. Aristidou, G.C. Gray, M.V. Kiang, and G.S. Meyer
from management groups. We examined the level and Health Care Management Review (2011) 36(2):
trend in frontline perceptions of managers’ learning- 188–200
oriented leadership following the training, and ability of
management groups to achieve objectives on targeted Background: Delivering safe patient care remains an
improvement projects. Among the 12 intervention elusive goal. Resolving problems in complex organiza-
groups, we identified higher- and lower-performing tions like hospitals requires managers to work together.
“That creaking sound you heard was us

thinking about taking an approach that is not blame
focused but learning focused.
P ed iat ric s T ea m M e mb er

Safety leadership training that encourages managers From Automatic Defensive Routines
to exercise learning-oriented, team-based leadership to Automatic Learning Routines:
behaviors could promote systemic problem solving The Journey to Patient Safety
and enhance patient safety. Despite the need for M. Sales, J.W. Vogt, S.J. Singer, and J.B. Cooper
such training, few programs teach multidisciplinary Reflections, The SoL Journal on Knowledge, Learning,
groups of managers about specific behaviors that and Change (2013) 13(1):31–42
can enhance their functioning as leadership teams
in the realm of patient safety. Patient safety in hospital settings is a major public
health problem. Several distinctive challenges combine
Purpose: The aims of this study were to describe to create a high-risk environment for patients that can
a learning-oriented, team-based, safety leadership result in grave—and costly—personal and organiza-
training program composed of reinforcing exercises; tional consequences. The authors hypothesize that
to provide evidence confirming the need for such defensive behaviors among hospital leaders, managers,
training; and to demonstrate behavior change among and staff aggravate the dangers implicit in these settings.
management groups after training. The authors describe a multidimensional training
program, Healthcare Adventures™, in which the ex-
Methods: Twelve groups of managers from an aca- ploration of so-called “automatic defensive routines”
demic medical center based in the Northeast U.S. were figures as an important focus. The subject intervention
randomly selected to participate in the program and combines a simulation of a traumatic patient safety
exposed to its customized, experience-based, integrated, event with structured reflection. Taken together, these
multimodal curriculum. Data—about the need for the kinds of learning opportunities support collaborative
training in these groups, and change in participants’ inquiry and appreciative engagement, which can
awareness, professional behaviors, and group activity improve outcomes for patients.
—were extracted from transcripts of four training
sessions, over 15 months, with groups of managers.
Design and Evaluation of Simulation Scenarios
Findings: Training transcripts confirmed the need for for a Program Introducing Patient Safety,
safety leadership team training and provided evidence Teamwork, Safety Leadership, and Simulation
of the potential for training to increase targeted behav- to Healthcare Leaders and Managers
iors. The training increased awareness and use of J.B. Cooper, S.J. Singer, J. Hayes, M. Sales, J.W. Vogt,
leadership behaviors among many managers and led D. Raemer, and G.S. Meyer
to new routines and coordinated effort among most Simulation in Healthcare (2011) 6:231–38
management groups. Enhanced learning-oriented
leadership often helped promote a learning orientation Background: We developed a training program
in managers’ work areas. to introduce managers and informal leaders of health-
care organizations to key concepts of teamwork, safety
Practice Implications: Team-based training that leadership, and simulation, and thus, motivate them
promotes specific learning-oriented leader behaviors to act as leaders to improve safety within their spheres
can promote behavioral change among multidisci- of influence.
plinary groups of hospital managers.

Purpose: This report describes the simulation scenario advice for hospital leadership on how to improve
and debriefing that are core elements of that program. observed safety and cultural deficiencies. Debriefings
after both types of scenarios were conducted using
Methods: Twelve teams of clinician and non-clinician principles of “debriefing with good judgment.” We
managers were selected, from a larger set of volunteers, assessed the relevance and impact of the program
to participate in a one-day, multi-element training pro- by analyzing participant reactions to the simulation
gram. Two simulation exercises were developed: one through transcript data and facilitator observations,
for teams of non-clinicians and the other for clinicians or as well as a post-program questionnaire.
mixed groups. The scenarios represented two different
clinical situations, each designed to engage participants Findings: The teams generally reported positive per-
in discussions, immediately after the experience, of ceptions of the relevance and quality of the simulation,
their safety leadership and teamwork issues. In the with varying types and degrees of impacts on their
scenarios for non-clinicians, participants conducted leadership and teamwork behaviors.
an anesthetic induction and then managed an ethical
situation. The scenario for clinicians simulated an Practice Implications: These kinds of clinical
emergency room consulting visit that evolved into a simulation exercises can be used to teach healthcare
problem-solving challenge. Participants in this scenario leaders and managers safety leadership, and team-
had a limited amount of time in which to prepare work skills and behaviors.
“This helps each of us frame the project in our

own minds better. The project is much clearer now.”
Ac u t e C a re M ed ic a l Team M e mber

T h e C e n t e r f o r M e d i c a l S i mu l a t i o n
The Vision Simulation training at CMS gives healthcare providers

“Experiential healthcare learning that never puts a new and enlightening perspective on how to handle
a patient at risk” real medical situations. Through high-fidelity scenarios
that simulate genuine crisis management situations,
The Mission the CMS experience can open new chapters in the
“Using simulation to improve safety, quality, level of healthcare quality that participants provide.
and education in healthcare”
At CMS the focus is on communication, collaboration,
The Center for Medical Simulation (CMS) believes that and crisis management in order to develop skills and
healthcare simulation is most effective when techniques teamwork behaviors that are best learned actively,
are drawn from multiple disciplines and are tailored under realistic conditions. Since 1993, CMS has
to the level and background of each group. conducted more than 2,000 courses and trained
thousands of participants, using its innovative and
Our elite team of more than 25 professional faculty challenging scenarios. CMS is proud to feature:
members has expertise in medicine, patient safety,
biomedical engineering, organizational behavior, and • multidisciplinary, expert staff affiliated with some
adult learning. The combined healthcare simulation of the world’s most well-known and well-respected
experience of the CMS team is unsurpassed, ensuring hospitals, medical universities, and colleges
that each simulation session is customized and • exceptionally high-quality and innovative programs
uniquely effective. in full-environment facilities
• broad course offerings
Two Decades of Simulation Training
to Improve Quality of Care The Center for Medical Simulation has been a leader
Founded in 1993, CMS was one of the world’s first in the healthcare simulation field since putting its first
healthcare simulation centers and continues to be mannequin simulator into service in 1994. It has
a global leader in the field. developed courses for clinicians, healthcare educators,
administrators and managers; conducted research
on a spectrum of topics; and helped manufacturers
conduct human factors trials of their technologies;
it also continues to innovate an array of healthcare
simulation activities.

Fu r t h e r L e a r n i n g w i t h t h e C e n t e r f o r M e d i c a l S i mu l a t i o n
Healthcare Adventures™ Leadership Optimal team size for the greatest benefit from the
and Management Training Workshops HCA workshop is 6–10 people.
for Leadership and Management Teams
(Non-Clinicians or Mixed Groups) The HCA Workshop includes:
Healthcare Adventures™ (HCA) are customized,
• pre-workshop consultation between the team
intensive team-training workshops for leadership and
leader and a CMS facilitator
management teams across the healthcare spectrum.
• pre-training team briefing on simulation objectives
Designed to improve individual and team performance
and strategies
by developing collaboration and communication, the
• customized team challenge in the simulated
HCA workshops use a simulated patient experience
clinical environment
in a highly realistic clinical environment to highlight
• debriefing and discussion to identify important
a team’s dynamics in a powerful, but non-threatening,
interactions and develop actionable strategies for
fashion. Even non-clinicians get the chance to care
implementation
for a patient and experience real-life issues first-hand,
• facilitated workshop session to apply effective group
and clinicians are challenged to think like healthcare
processes to an existing team project challenge
administrators and executives. It’s an eye-opener!
(e.g., closing a budget gap, designing a new service,
or building a charter for a new team)
CMS faculty and professional facilitators work with the
• post-workshop report from the CMS facilitator
team before the simulation, discussing objectives and
• follow-up between the CMS facilitator and the team
expectations, and again after the simulation, identify-
leader
ing important interactions, key learnings, and action-
able strategies. This allows the group to turn learning
Tuition: USD $12,000 per team (6–10 people); 
into action immediately, by working on a real-world
includes one-day workshop, pre-workshop
project with the help and support of the CMS facilitators.
consultation, and post-workshop follow-up
Depending on their needs, teams can draw on a variety
of follow-up support mechanisms and training to
For more information and/or to schedule a
advance their learning and performance. Workshop
workshop, please contact: Gary M. Rossi, COO at
topics include teamwork, effective communication,
grossi@harvardmedsim.org or 1.617.726.3041.
resource management, performance enhancement,
and patient safety.

O r d e r i n g P o s t e r C o p i e s o f t h e HCA G r a p h i c G a m e p l a n
The Grove Consultants International will provide as many 8’ x 4’ color poster

copies of the Healthcare Adventures™ Graphic Gameplan as you wish for
$45 (plus shipping) each.
For more information and/or to order, please contact Robert “Bobby” Pardini at:
Robert_pardini@grove.com or 1.415.561.2500
The Grove Consultants International

1000 O’Reilly Avenue
The Presidio of San Francisco
San Francisco, CA 94129-1124
www.grove.com
D o w n l o a d i n g d i g i t a l C o p i e s o f t h e HCA G r a p h i c G a m e p l a n
To download this sample Graphic Gameplan, click on the link and follow the instructions.
https://harvardmedsim.org/_media/pdfs/HCA-Graphic-Gameplan.pdf

references
Ancona, D.G. and D.F. Caldwell. 1992. “Bridging the Edmondson, A.C. 1996. “Learning from Mistakes Is Easier
Boundary: External Activity and Performance in Organiza- Said Than Done: Group and Organizational Influences on
tional Teams.” Administrative Science Quarterly 37(4): 634. the Detection and Correction of Human Error.” The Journal
of Applied Behavioral Science 32(1): 5.
Argyris, C. 1985. Strategy, Change, and Defensive Routines.
New York: Harper Business. ———. 1999. “Psychological Safety and Learning Behavior
in Work Teams.” Administrative Science Quarterly. 44(2):
Auerbach, A., C. Landefeld, and K. Shojania. 2007. “The 350–83.
Tension Between Needing to Improve Care and Knowing
How to Do It.” The New England Journal of Medicine 357: ———. 2003. “Managing the Risk of Learning: Psychological
608–13. Safety in Work Teams.” In International Handbook of
Organizational Teamwork and Cooperative Working. Edited
Batalden, P. and P. Stoltz. 1993. “A Framework for the Con- by M. West, D. Tjosvold, and K. Smith. London: John Wiley
tinual Improvement of Health Care: Building and Applying & Sons, Ltd.
Professional and Improvement Knowledge to Test Changes
in Daily Work.” The Joint Commission Journal on Quality ———. 2003. “Speaking Up in the Operating Room:
Improvement 19(10): 424–47. How Team Leaders Promote Learning in Interdisciplinary
Action Teams.” The Journal of Management Studies 40(6):
Blanchard, K. 2009. “Feedback Is the Breakfast of 1419–52.
Champions.” How We Lead: Conversations on Leadership
with Ken Blanchard, August 17, 2009. http://howwelead. Edmondson, A.C., R.M. Bohmer, and G.P. Pisano. 2001.
org/2009/08/17/feedback-is-the-breakfast-of-champions. “Disrupted Routines: Team Learning and New Technology
Implementation in Hospitals.” Administrative Science
Blumenthal, D. and C. Kilo. 1998. “A Report Card on Quarterly 46(4): 685–716.
Continuous Quality Improvement.“ The Milbank Memorial
Fund Quarterly 76(7): 625–46. Garvin, D.A. 2000. Learning in Action: A Guide to Putting
the Learning Organization to Work. Boston: Harvard
Burke, Dennis W. 2002. Basic Facilitation Skills. Milwaukee, Business School Press.
WI: Human Leadership and Development Division of the
American Society for Quality, the Association for Quality Hackman, J.R. 2002. Leading Teams: Setting the Stage for
and Participation, and the International Association of Great Performances. Boston: Harvard Business School Press.
Facilitators. http://disccrs.org/sites/default/files/
2002BasicFacilitationPrimer.pdf. Husted, K. and S. Michailova. 2002. “Diagnosing and
Fighting Knowledge-Sharing Hostility.” Organizational
Carman, J.M., et al. 1996. “Keys for Successful Implemen- Dynamics 31(1): 60–73.
tation of Total Quality Management in Hospitals.” Health
Care Management Review 21(1): 48. Institute for Healthcare Improvement. “How to Improve.”
www.ihi.org/resources/Pages/HowtoImprove/default.aspx.
Carroll, J.S., S. Hatakenaka, and J.W. Rudolph. 2006. Accessed 3.25.15.
“Naturalistic Decision Making and Organizational Learning
in Nuclear Power Plants: Negotiating Meaning Between Institute for Healthcare Improvement. 2005. White Paper:
Managers and Problem Investigation Teams.” Organization “Going Lean in Health Care.” www.ihi.org/resources/Pages/
Studies 27(7): 1037. IHIWhitePapers/GoingLeaninHealthCare.aspx. Accessed
3.25.15.
Clarke, J.R., J.C. Lerner, and W. Marella. 2007. “The Role
for Leaders of Health Care Organizations in Patient Safety.” International Association of Facilitators. 2003. “Core
American Journal of Medical Quality 22(5): 311–8. Facilitator Competencies.” https://iaf-world.org/site/sites/
default/files/IAF%20Core%20Competencies_1.pdf. Accessed
Covey, S. 1989. The Seven Habits of Highly Effective People. 3.25.15.
London: Simon Schuster Ltd. UK. Also, http://en.wikipedia.
org/wiki/The_Seven_Habits_of_Highly_Effective_People.

Janis, I.L. 1982. Groupthink. Second edition. Boston: Shojania, K. and J. Grimshaw. 2005. “Evidence-Based
Houghton Mifflin. Quality Improvement: The State of the Science.” Health
Affairs 24: 138–50.
Kabcenell, A., T.W. Nolan, L.A. Martin, and Y. Gill. 2010.
Institute for Healthcare Improvement White Paper: “The Shortell, S., et al. 1995. “Assessing the Evidence on CQI:
Pursuing Perfection Initiative: Lessons on Transforming Health Is the Glass Half Empty or Half Full?” Hospital and Health
Care.” www.ihi.org/resources/Pages/IHIWhitePapers/ Services Administration 40(1): 4–24. [Note: this journal is out
PursuingPerfectionInitiativeWhitePaper.aspx. Accessed of publication. The article can be accessed via subscription
3.25.15. at: www.proquest.com/products-services/abi_inform_
complete.html. Academic or municipal libraries may
Landon, B., et al. 2004. “Effects of a Quality Improvement maintain subscriptions to this service.]
Collaborative on the Outcome of Care of Patients with HIV
Infection: The EQHIV Study.” Annals of Internal Medicine Shortell, S. and S. Singer. 2008. “Improving Patient Safety
140: 887–96. by Taking Systems Seriously.” The Journal of the American
Medical Association 299(4): 445–7.
Landon, B., et al. 2007. “Improving the Management of
Chronic Disease at Community Health Centers.” The New Tucker, A.L. and A.C. Edmondson. 2003. “Why Hospitals
England Journal of Medicine 356: 921–34. Don’t Learn from Failures: Organizational and Psychological
Dynamics That Inhibit System Change.” California Manage-
Leape, L.L. and D.M. Berwick. 2005. “Five Years After To ment Review 45(2): 55–72.
Err Is Human: What Have We Learned?” The Journal of the
American Medical Association 239(19): 2384–90. Tucker, A.L., et al. 2008. “Front-Line Staff Perspectives on
Opportunities for Improving the Safety and Efficiency of
Lewin, K. 1951. Field Theory in Social Science. New York: Hospital Work Systems.” Health Services Research 43
Harper and Row. Also, http://en.wikipedia.org/wiki/ (5, pt. 2): 1807–29; published online ahead of print.
Force-field_analysis. Accessed 3.25.15.
Weick, K.E. and K.H. Roberts. 1993. “Collective Mind in
McGlynn, E.A., et al. 2003. “The Quality of Health Care Organizations: Heedful Interrelating on Flight Decks.”
Delivered to Adults in the United States.” The New England Administrative Science Quarterly 38(3): 357.
Journal of Medicine 348: 2635–45.
Weiner, B.J., S.M. Shortell, and J.A. Alexander. 1997.
Mittman, B. 2004. “Creating the Evidence Base for Quality “Promoting Clinical Involvement in Hospital Quality Improve-
Improvement Collaboratives.” Annals of Internal Medicine ment Efforts: The Effects of Top Management, Board, and
140: 897–901. Physician Leadership.” Health Services Research 32(4): 491.
Nembhard, I.M. and A.C. Edmondson. 2006. “Making it Westphal, J.D., R. Gulati, and S.M. Shortell. 1997. “Cus-
Safe: The Effects of Leader Inclusiveness and Professional tomization or Conformity? An Institutional and Network
Status on Psychological Safety and Improvement Efforts in Perspective on the Content and Consequences of TQM
Health Care Teams.” Journal of Organizational Behavior Adoption.” Administrative Science Quarterly 42(2): 366.
27(7): 941.
W.K. Kellogg Foundation. 2004. “Logic Model Development
Podolny, J.M., R. Khurana, and M. Hill-Popper. 2005. Guide.” www.epa.gov/evaluate/pdf/eval-guides/logic-
“Revisiting the Meaning of Leadership.” Research in model-development-guide.pdf. Accessed 3.25.15.
Organizational Behavior 26: 1–31.
Senge, P.M. 1990. The Fifth Discipline: The Art and Practice
of the Learning Organization. New York: Doubleday.

“This gives us an appreciation for how
complex this is. I thought we had this whole project
worked out and ready to go. Now, we see it’s not. I see
why leadership needs to be engaged enough so frontline
staff get the support they need to do this.”
P ed iat ric s T ea m M e mb er
FACILITATOR’S GUIDE

Graphic Gameplan For Patient Safety
J ay W. Vogt • Mi c h ae l Sa le s • Sa r a J. Si n g e r • J e f f r e y B . C o o p e r
The Center for Medical Simulation, Boston, Massachusetts

HCA Graphic Gameplan FacilitatorsGuide

Uploaded by

Copyright:

Available Formats

HCA Graphic Gameplan FacilitatorsGuide

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

HCA Graphic Gameplan FacilitatorsGuide

Uploaded by

Copyright:

Available Formats

A FACILITATOR’S GUIDE

The Healthcare Adventures™

The Center for Medical Simulation, Boston, Massachusetts

We also acknowledge with gratitude research assistance from

We acknowledge the creative genius of The Grove Consultants

2 | Th e Healthc a r e Adv e nt u r e s Gr a p hi c G a m ep l a n f o r pati e n t s a f e ty | Vo gt, S a l e s, Si n g er, coop e r

4 Improving Quality in Healthcare

4 Patient Safety Leadership and the Graphic Gameplan

3 | Th e Healthc a r e Adv e nt u r e s Gr a p hi c G a m ep l a n f o r pati e n t s a f e ty | Vo gt, S a l e s, Si n g er, coop e r

4 | Th e Healthc a r e Adv e nt u r e s Gr a p hi c G a m ep l a n f o r pati e n t s a f e ty | Vo gt, S a l e s, Si n g er, coop e r

Facilitates communication Team Group

A Comprehensive Model their own behavior accordingly. Managers demon-

When leaders of an organization express real caring,

5 | Th e Healthc a r e Adv e nt u r e s Gr a p hi c G a m ep l a n f o r pati e n t s a f e ty | Vo gt, S a l e s, Si n g er, coop e r

“I have loved using the game plan. Our project is going

6 | Th e Healthc a r e Adv e nt u r e s Gr a p hi c G a m ep l a n f o r pati e n t s a f e ty | Vo gt, S a l e s, Si n g er, coop e r

7 | Th e Healthc a r e Adv e nt u r e s Gr a p hi c G a m ep l a n f o r pati e n t s a f e ty | Vo gt, S a l e s, Si n g er, coop e r

8 | Th e Healthc a r e Adv e nt u r e s Gr a p hi c G a m ep l a n f o r pati e n t s a f e ty | Vo gt, S a l e s, Si n g er, coop e r

Resources/Inputs Activities Outputs Outcomes Impacts

Management time Application Greater manager Improved More successful QI;

Your Planned Work Your Intended Results

The Theory of Change Animating

The Graphic Gameplan is exceptional among

9 | Th e Healthc a r e Adv e nt u r e s Gr a p hi c G a m ep l a n f o r pati e n t s a f e ty | Vo gt, S a l e s, Si n g er, coop e r

1. A clear process helps leadership become aware

2. A visual tool helps leadership conceptualize these

The Graphic Gameplan quickly generates a compre-

“Most useful! Identifying team roles and

10 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

11 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

12 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

13 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

Introducing the Tool outcomes. When we are successful, how will

14 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

The question about “why now” may surface supporting

“I’m just so admiring of this process.

15 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

16 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

Last, summarize briefly, and test for closure before

17 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

• If there’s nothing else, let’s move on to the team.

It may be helpful to record not only names, but also

• Teams need leadership. Team leaders can be

18 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

19 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

20 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

A Sample (Completed) Graphic Gameplan

21 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

Jay W. Vogt is an orga- journals such as Health Care Management Review,

22 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

23 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

24 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

“That creaking sound you heard was us

25 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

26 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

“This helps each of us frame the project in our

27 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r

The Vision Simulation training at CMS gives healthcare providers

28 | Th e Healthc a r e A dv e nt u r e s Gr a p hi c G a m ep l a n f o r pat i en t s a f ety | Vo gt, S a l es, S i n g e r , coop e r