‘‘Among all of the skills for improvement, the most crucial one
may be the skill to cooperate across traditional boundaries.’’47 For
example, a study examining the adoption of new CT scanners
in two hospitals in the 1980s found that a crucial step in the
integration and safe reliable use of the new technology was
the willingness of radiologists to allow themselves to be
instructed and informed by CT technicians about using the
new equipment and reading its images.48 In a study of 16
hospitals implementing new minimally invasive cardiac
surgery technology, more rapid and successful learning
depended on high status surgeons empowering lower status
operating room team members to contribute to the learning
process: ‘‘The ability of the surgeon to allow himself to become a
partner, rather than a dictator, is critical [for creating a] free and
open environment with input from everybody.’’17
Progress toward the deep stage of systems understanding
helps to integrate local, control, and open practices