What the military taught me about culture of safety.

Empowered by the "Training Time Out" !


As a new accession to Navy Basic Training, I was unaware of how impactful the first week would be on the rest of my career. #Safetyculture wasn't a mainstream thing back then. One of the first things I was introduced to, after the head shaving of course, was the “Training Time Out”. The TTO as we called it was a chance to stop the line in any situation, at any time, by anyone that felt something was unsafe or even trending in that direction. The TTO was introduced and conferred as a sort of “superpower phrase” – 3 words with universal understanding and acknowledgement. I recall thinking that perhaps this was only a way to pacify new accessions to make us feel better about the intensity that was to come – until a shipmate (aka Navy jargon for a colleague) decided to use it.


One of the things that is crucial to membership in the Navy is one's ability to swim. Recruits are required to demonstrate their ability to float and swim for a period of time (aka swim qual); simulating a fall over the side of a warship or vessel. After a few days, swim qual arrived and as my group prepared, a shipmate recognized a potentially unsafe situation on the 20-foot pool platform. So, in the middle of a busy swim qual exercise with swimmers and evaluators in the water; he raised his hand and yelled “Training Time Out”. The utterance of that phrase magically set a range of actions in motion. Everyone left the pool. Pool managers and evaluators huddled and medical staff grabbed their supplies and took to their stations. My drill instructors (aka Company Commanders in the Navy [CC’s]), hurried over to my shipmate to address his concerns. I stood in awe! The response to his use of the new superpower phrase invoked a respectful and authentic response that was executed with near precision......WOW! Little did I know that this seemly well-rehearsed reaction, was my introduction to #safetyculture 101 in the Navy.


Honestly as a recruit, I could not help but feel afraid for my shipmate and our group because he literally stopped EVERYTHING. So, back in our living quarters I was ready for the shoe to drop (in the form of intense exercises or some other mental strengthening activity, lol) due to delays from the resulting lull in daily activity. But to my surprise, there was absolutely no reprisal. In fact, our CC's reinforced the value of the TTO, celebrated our shipmate, and encouraged its use to take care of one another. It did not matter that we were new accessions, we had the same power that regular Sailors had! Talk about feeling empowered!


Interestingly, over the next 20 years I witnessed the TTO used in all types of settings; on warships, in the field environment, and even during busy flight operations (planes and helicopters taking off and landing). In every instance of the TTO's use, there was always a sense of respect and honor that a member of our team cared enough to speak up to mitigate an unsafe issue. It was not just a slogan but a time honored part of our collective cultural DNA.


So, as I reflect on my career in healthcare quality, I surmise that our industry needs a universal superpower phrase. We need a word, or two, or three that has the power to halt questionable and potentially unsafe situations – without REPRISAL. Our work in healthcare can be as dangerous in many of the same ways as the operational military environment. The biggest insight from my experiences as a recruit and later a Sailor was the level of authenticity of our leaders around the use of the TTO. If not familiar with U.S. military recruits, they are individuals who are not regular members of the service until graduation. As such their opinions on many things tend to have less weight since they are trainees. However, when it came to safety we were welcomed, encouraged, and even celebrated to ensure that everyone's well-being was top-of-mind!


There is a lot out there about culture of safety in healthcare and what it means, but our industry still grapples with preventable mistakes and unsafe care. You see, safety culture goes beyond slogans on the back of badges and campaigns before an accreditation survey. It requires an enterprise approach and authenticity that welcomes the perspectives of those who we may not immediately recognize as worthy of speaking up. Maybe the person who speaks up is not a clinician, maybe he/she doesn't have a fancy title, maybe they just joined your organization as a new "recruit"! The key is to establish an atmosphere for professional safety in risk taking.

Create your superpower phrase!

While we are a long way away from an industry superpower phrase, maybe it can be done in your hospital, department, or unit. Let me share some steps for consideration in creating your superpower phrase and process:

1. Choose an area to pilot: Consider a section where there is high engagement for adoption. Create and customize a superpower process (that includes your word or phrase) and a timeline.


2. Establish a baseline for performance: Gather data from processes from mistakes/near misses in non-critical areas where engagement can potentially make a difference. It is better to experiment in low-risk areas where members of your team can fail forward. Also, collect data on the baseline of how your employees see #safetyculture. I suggest a small simple qualitative survey that can give some pre and post insights.


3. Initiate the pilot and collect data – Start your pilot, collect data on mistakes averted, number of times the new superpower phrase is used, and if possible those who report the issues.


4. Reward those that use the superpower phrase – Recognize those who took the personal and professional risk in use of the new process. When the word gets out that risk-taking for improvement is authentically celebrated, the sproutlings of a new #safetyculture will start to grow!


5. Document lessons learned – Record the things that went well and any opportunities for improvement. This is an important part of knowledge management for the next step.


6. Share – Adapt – Diffuse: Share the learnings, adapt to another areas, and diffuse where appropriate in the organization. Continuously refine and learn from every area that adopts.


Thank you for reading! Feel free to comment, share, or like this post on social media!


Dr. Rich Greenhill, is an honorably retired Navy Hospital Corpsman and healthcare change leader; now an Assistant Professor at TTUHSC and TTU Rawls College of Business. He holds many credentials in performance improvement and healthcare quality; both nationally and internationally.

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