Challenging hierarchy in healthcare teams - ways to flatten gradients to improve teamwork and patient care

Br J Oral Maxillofac Surg. 2017 Jun;55(5):449-453. doi: 10.1016/j.bjoms.2017.02.010. Epub 2017 Mar 23.


In healthcare, mistakes that are potentially harmful or fatal to patients are often the result of poor communication between members of a team. This is particularly important in high-risk areas such as operating theatres or during any intervention, and the ability to challenge colleagues who are in authority when something does not seem right or is clearly wrong, is crucial. Colleagues in oral and maxillofacial surgery recognised the importance of this as early as 2004, and it is now well known that failure or reluctance to challenge others who might be wrong can severely compromise a patient's safety. The Royal College of Surgeons of Edinburgh runs popular regular courses (Non-technical Skills for Surgeons, NOTSS) that teach how to ensure safety through good communication and teamwork. In this paper we introduce the concept of hierarchical challenge, and discuss models and approaches to address situations when problems arise within a team.

Keywords: Hierarchical challenge; authority; gradients; patient safety.

Publication types

  • Review

MeSH terms

  • Attitude of Health Personnel
  • Clinical Competence
  • Communication
  • Cooperative Behavior
  • Humans
  • Interprofessional Relations
  • Leadership
  • Medical Errors / prevention & control*
  • Operating Rooms
  • Patient Care Team / organization & administration*
  • Patient Safety
  • Quality Improvement*
  • Surgery, Oral*