Graded Assertiveness

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Graded Assertiveness

Many adverse outcomes in healthcare are a result of absent or incomplete communication.  Strong verbal communication skills are key in coordinating teams and optimising the flow of information between colleagues.

Problems can arise for a number of reasons, but one common occurrence is failure of junior staff to question seniors about their actions.  This can be especially problematic in the event of an acute patient deterioration such as the “Elaine Bromiley” case:

The Full Video (13 minutes)

Having a specific concern about patient care is one thing, but bringing up the concern can often be a challenge.  This is especially difficult when the concern is about a Senior’s actions.  Sometimes, raising a concern can be very difficult because in an emergency situation time is limited and the clinical and personal consequences are uncertain for both parties and the process is seen as counter cultural.

Graded Assertiveness

Where your ‘boss’ is involved there may be many competing interests so raising a concern can feel like an impossible task.

This situation is (thankfully) rare but it is important to think about how you would broach the subject.  Not having an approach could lead to patient harm.

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Different Models of Communication

This brief video outlines the 4 commonly encountered communication styles in a hospital:


(1) Co-operative

(2) Assertive

(3) Submissive

(4) Aggressive

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CUSS Model for Graded Assertive Communication

One suggested method of bringing to attention a potential error is Graded Assertiveness.

We suggest that you could gently “Cuss your Consultant”:

CUSS - Concern Unsure Safety STOP

  • C – CONCERN – I’m concerned that allergies haven’t been recorded (we haven’t checked for allergies)
  • U – UNSURE – I am uncertain if this Augmentin medicine can be given to someone with a possible penicillin allergy
  • S – SAFETY – I am really worried it is UNSAFE to give this patient a penicillin like drug given his known allergy.  I think this is a patient safety issue…
  • S – STOP – Please stop – we need to take a timeout and discuss this situation further or seek an alternative

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PACE Model for Graded Assertive Communication

An alternative method, now endorsed by the Royal College of Anaesthetics in Australia and New Zealand is the SPACE Model:

This is derived from the “PACE” Model.  In the same way as ‘CUSS’ the aim is a gradual rise in the firmness of the challenge.  As a rule we should refer back to objective findings and observations about the patient rather than direct criticism of actions.

PACE - Probe Alert Challenge Emergency

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Final Thoughts

If you want to practice we suggest you try some simulation training or think about some scenarios.  It might be worthwhile having a laminated version of the PACE or CUSS model on your badge for quick reference at the crucial moment.

As we become more senior it’s important to given our juniors permission to question us.  We can teach them about Graded Assertiveness as well as consider our own potential responses to some of the key words outlined above.  Thinking of my own clinical experience I believe Graded Assertiveness can be limited by the Senior clinicians variable response to the challenge.

In contrast, the airline industry has been forced to take on changes in communication based on a ‘challenge and response model’ to prevent future crashes.  An example that comes to mind is the Tenerife Air Disaster in 1977:

Tenerife Disaster

Tenerife Disaster

The following excerpt is taken from the Journal of Air Transportation World Wide (1988):

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In the same way as changes continue to be made in the aviation industry, we need to take action in healthcare to ensure the best possible outcomes for our patients and use of communication tools is just a small part.

Further Reading


Anaesthetic Death2

100.000…Now, Let’s go for more!

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Review – Auckland HEMS app

My friends over at Auckland HEMS have just released an app for both iOS and Android (see link at “test pilots wanted - HEMS app goes live“). I was lucky enough to score a pre-release download and play with it over the past week. It’s now been released live and available to all for feedback.

I’ve been a bit of a fan of the Auckland HEMS site – along with a few other retrieval services, they’ve made a commitment to having a web-presence (good for promotion, recruitment and also promoting information sharing via feedback). Their sim resource section is one I am watching closely, as there is great scope to share sim scenarios using the in-built function of the online community functionality of the iSimulate package

Other services, notably the collective UK HEMS, Sydney HEMS, RFDS have lead the way in sharing some of their resources in open-access format, to help others to learn and develop own procedures, as below :

Putting procedures and information up on the web is one thing…but the ultimate functionality for a retrievalist would be to have all of this information available even without immediate web access. Given the space constraints of a flight suit, and the ubiquity (and of course practicality) of a smartphone, it makes sense to develop retrieval apps that can be used on the primary communication device (iOS or Android phone).

Having a smartphone allows access to not just phone calls, but messaging, web access (if in range), ability to view documents, access apps etc. Smart app developers may also take advanatage of in-built functions such as torch/vibrate/sounds to enable visual, haptic & audio prompts. Inter-app integration for access to weather and map/GPS functions is achieveable. And the new iPhone reportedly has a barometer…opening the possibility of a retrieval app that helps flight planning and working out O2 requirements.

It’s probably worth reflecting on what the ideal retrieval app would allow a user to do. My opinion is that the ultimate app would allow

  • cross-platform functionality (iOS, Android) and usable on both phone and tablet screens
  • ease of use in sunlight and at night, with clear easy to navigate buttons
  • large buttons/tab/checkboxes, so that can be used even when wearing gloves
  • capability to record day-to-day activities within a service, eg: daily kit checks, viewing of approved rosters, navigation to useful contact numbers. Daily checklists should be exportable for audit purposes.
  • ability to record case details including case times (from activation through arrival/depart scene, dropoff at destination and return-to0base for audit purposes), record mode of transport, locations, patient demographics and coding of disease, with ability to easily export such data to databases such as Air Maestro or common office-based spreadsheets (Excel, Numbers), thus avoiding the duplication of data entry across multiple sources (ie case notes-apps-database). Naturally such recording should be password protected and HIPAA compliant.
  • ability to record scene photos or videos, protected as above, to communicate scene situation (useful particularly in a major incident) as well as to facilitate audit and training
  • integration with maps functionality, with ability to record GPS points and drop pins on location
  • access to marine & weather info
  • use of barometer function on newer smartphones for use in-flight
  • access to service-based standard operating procedures (SOPs), preferably with documents in an interactive iBook-type format to optimise viewability, rather than the difficulties of navigating PDFs on a small smartphone screen
  • access to service-approved short videos demonstrating procedures for training
  • access to relevant FOAMed links inc available podcasts/vodcasts (on the outward leg, especially via fixed wing in rural Australia, it would be hard to go wrong with the audio & video content from,,, etc)
  • ability to log any issues eg: equipment failure or hot debrief for the team
  • ability to record all data and export as appropriate to both service audit and governance needs, as well as record cases/procedures for clinicians requiring for logbook purposes
  • app available for moderate fee, and sharing of content between services where appropriate ie : where benefits of open-access information offer advantages (the obvious example being developing standardisation of SOPs, equipment between a retrieval service and the rural hospitals it services eg: infusion regimens etc)

So far no such app exists…but there have been some rapid developments in this area in recent times. The Auckland HEMS app is interesting, in that the authors (Robert Gooch, Chris Denny under IT tutelage of Scott Orman) have used the iBuildapp web-based service to create the content, thus saving a huge investment of $$$ on an app developer. As they say “if you can create a powerpoint presentation, you can create an app”. What I like is the commitment to evolve the app and update in real time.

The app starts with a simple splashscreen, then once loaded moves to a very easy to navigate interface, reminiscent of the UKHEMS SOP database web-interface.

Auckland HEMS app is loading…

The initial screen has large, friendly coloured buttons that are easy to select even when wearing gloves, allowing access to each of :

  • emergency checklists
  • normal operations checklists
  • shift duties
  • major incident prompts (METHANE, NATO phonetic alphabet etc)
  • resources (including web links to FOAMed)
  • calendar
  • SOPs (standard operating procedures)
  • comms
Easy navigation to selected content

Drilling down, the content is easily displayed and large – this is a plus, as small text is both hard to read and hard to select (especially in gloves). However I was disappointed to see that checklists did not actually allow ‘checking’. This is a shame – for a daily kit check, ability to select actions completed and then archive the actions (eg: CSV export via email) would be useful.

Ventilated patient – accidental disconnect checklist

For a crisis checklist, the ability to check items or even build in audio-haptic-visual alerts using smartphone alarm-vibrate-torch functions can be very useful in a crisis, especially when time critical. The obvious example is that of RSI – and for a masterclass in how a checklist can be made part of workflow, see the excellent iRSI app, reviewed elsewhere.


The ‘hot debrief’ function accessed from the bottom navigation file was useful – easy to access wherever you are in the app, this allows quick notation of mission details such as nature of mission, team members, timings and also commentary on any issues with kit, at the hospital or in transport. Again, ability to capture this data and export it to a spreadsheet for audit or training purposes would be invaluable.

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photo 1

I was pleased to see the inclusion of some FOAMed material, including Scott’s cric-con concept for emergency surgical airway. I couldn’t find mention of the Vortex approach, but as time goes on I think this and other resources will be incorporated both into the app and into common practice. Links to relevant sites are included…





Integration of marine and weather bulletins was a nice touch…



…along with calendar and contact info for operational purposes



Ultimately it is hard to demonstrate all functions with screenshots. My advice – get in quick, download the app and give your feedback. It is available from

I am fully confident of rapid improvements with subsequent iterations. To my mind, the scope for making an open-access app with broad-brush functionality according to the list above is achievable. The question, of course, is how much content should remain in-house (mindful of the considerable investment in time, money and intellectual copyright of content) and how much can usefully be shared.

Whether making one’s SOPs and resources open access is worth it remains unanswered. For blokes like me, trying to do best for rural patients, there are clear advantages in keeping up-to-date with current practice and especially in aiming to use the same kit and infusion regimens as the retrieval service. I appreciate however that there may be concerns in making one’s protocols available for all to share.

For the present, I am grateful for the availability of online resources such as those from Emergency Medical Retrieval Scotland, SydneyHEMS and UKHEMS

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EMRS includes a ‘meet the team’ with bios of registrars and regular staff as well s access to clinical, equipment & organisational SOPs
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Sydney HEMS website is a rich repository of procedures, sim, clinical governance, review articles, videos and FOAMed links. These guys know how to make connectivity work for them!
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