Table 4 Possible focus points for the debriefing of Hand-it-on

• Ask participants to describe what events occurred during Hand-it-on (e.g., things being dropped, wrong sequence, little talking, confusion). Collect such descriptions until “complete” and possibly take notes on a flipchart. Initiate a reflection on the differences in participants’ perceptions and memories. Discuss relations of the issues observed to clinical practice (e.g., “Where do you experience ‘wrong sequences’ in your clinical practice? See Table 1 for inspiration). Investigate the basis for the relevant events (“What triggered you to start using names before passing objects?”).

• Ask participants to relate the issues of Hand-it-on to non-technical skills and their relation to healthcare, for example, by asking them to sort what happened into the ANTS categories [16] or the principles of crisis resource management [20]. Correcting a colleague who passes to the wrong person can be seen as an example of “Use Good Teamwork”. Other participants might see the same act as an example of “Leadership and Followership”. The differences in such interpretations can stimulate discussions that aid participants’ learning around the concepts involved [35]. Differences in interpreting the efficiency/accuracy trade-off [51] can be used to discuss “Set Priorities Dynamically”.

• Ask the participants what the core processes, routine tasks and unexpected events in their organization are. Discuss any different views relating to these questions or uncertainties in finding an answer. This would be especially interesting when working with actual work teams.

• Ask the participants to identify the strengths of what happened in the organization and analyze what helped to create them [5]. For example, what facilitated correcting a colleague who made a wrong decision? Further, discuss the consequences of weak points. For example, why was there little communication in the beginning and what were the effects on the processes.

• Ask the participants to reflect on their technical skills and how those are acquired and refined over time. Participants often experiment, more or less consciously, with different movements while handing on objects. For example, how did you learn to find a good way of passing on a small coin? What did you learn from observing others? What could you acquire only by performing the task yourself? Are there parallels of learning in handing on an object to, for example, learning how to intubate?

• Ask the participants to discuss the effects that improvement initiatives had on the different processes. Typically, there is a marked drop in speed when the group tries to `optimize any aspect of the processes (e.g., combining the unexpected events with the routine tasks or starting to use names). Discuss how any changes in a group have an impact on what happens to routine tasks.

• Ask the participants to reflect on violations of procedures [53], for example, whether participants make “fun” of the tasks or try to trick their team members by making it difficult to receive the objects (for example, by purposely not looking at them when handing them an object). Discuss differences between the levels of stimulation people seek in their jobs and how willingly they accept rules.

• Ask the participants to discuss any kind of role distribution during Hand-it-on and how these roles were assigned and how clearly they were accepted. Who helped others? Who concentrated mostly on their own tasks? What are the advantages and disadvantages of such different focus points? Are such roles known in the participants’ organizations? Do the different crews involved in treating the patient actually become treatment teams? [54] Are those persons aware of the effects they have on the organization? Do they want to have these effects? How do their colleagues react to them?

• Ask participants to reflect on the challenges to really understand how organizations function [55]. The simple simulation presented here can illustrate this point by generating complex patterns of interactions from a combination of very simple tasks. Ask participants to draw parallels to their actual work settings and the much higher complexity there. This insight might enable participants to better appreciate the complexity of their work systems. It might create new ways of thinking about how to interact with those systems and how to relate to colleagues who might also struggle with fulfilling their tasks with the given complexity of the system.

• Ask participants to discuss the many idiosyncratic ways of interpreting the instructions and aligning them according to different personal priorities. Who was trying to work fast, for example? Who tried to avoid any errors? Were participants aware of different interpretations by their colleagues?

• In the debriefing of the variation for two large groups, explore the respective perceptions of each group. What did they do? How were these actions interpreted by the other group? How is the other group seen? To what extent was each group aware of what was happening in the other group? The events provide rich material for discussion about the relation to “clinical practice” and different professions, specialties, departments, hospitals: How do “the anesthesiologists” see “the surgeons”, how do the “clinicians” see the “administrators”? How relevant are those relations for the patient’s treatment and the interaction with his or her relatives? Be prepared for what could be a surprisingly strong group dynamic between the groups.