The article “Leveraging the Perfusionist-Surgeon Dyad to Improve the Culture of Safety” explores how structured cultural transformation in a high-risk cardiac surgery environment can meaningfully improve teamwork, psychological safety, and ultimately patient care. Authored by Kenneth G. Shann and Thoralf M. Sundt of Massachusetts General Hospital (MGH), this 2025 publication in the Journal of ExtraCorporeal Technology outlines a decade-long effort to reshape operating room culture by focusing on the powerful working relationship between cardiac surgeons and perfusionists .
Cardiac surgery operating rooms are among the most complex clinical environments in modern healthcare. Successful outcomes depend not only on technical excellence but also on seamless interdisciplinary communication among surgeons, anesthesiologists, perfusionists, nurses, and support staff. Historically, however, rigid hierarchies have limited open communication. Surgeons often occupied the top of a steep authority gradient, while other team members hesitated to voice concerns. This dynamic undermined psychological safety — defined as the ability to speak up without fear of punishment or humiliation.
The authors emphasize that psychological safety is foundational to high-reliability organizations. Without it, preventable errors may go unchallenged, shared mental models may fail to develop, and cognitive overload on the surgeon may go unmitigated. Research cited in the article highlights how variability in mental models across disciplines can impair coordination. In prolonged and increasingly complex cardiac operations, shared situational awareness becomes essential.
A central thesis of the paper is that the perfusionist-surgeon dyad represents a uniquely influential partnership within cardiac surgery. Unlike other interdisciplinary relationships, the perfusionist works in continuous, real-time collaboration with the surgeon during cardiopulmonary bypass (CPB). Decisions regarding flow rates, myocardial protection, oxygen delivery, temperature management, and hemodynamics require synchronized communication. Because of this intimate operational interdependence, the dyad offers a strategic lever for broader cultural reform.
To guide transformation, the team adopted Edgar Schein’s Organizational Culture Model (illustrated in Figure 1 on page 3), which describes three cultural layers: artifacts, espoused values, and underlying assumptions . Artifacts are visible behaviors and systems; espoused values are stated principles; and underlying assumptions are deeply embedded beliefs that shape behavior unconsciously. Sustainable culture change requires addressing all three layers.
At MGH, leadership articulated clear espoused values: prioritizing patient needs, contributing to research and innovation, and recognizing that individual success depends on collective success. For perfusion services, a formal mission statement reinforced commitments to innovation, evidence-based practice, fiscal responsibility, and patient-centered extracorporeal care.
Equally important was confronting entrenched assumptions. These included beliefs such as “this is the way we’ve always done it” and the acceptance of unprofessional behavior as inevitable in cardiac surgery. Leaders explicitly rejected practice variation based solely on personal preference and affirmed that each discipline holds expertise within its domain. Critically, they established the expectation that all team members are not just encouraged but required to speak up when concerned.
To translate values into action, the team developed structured clinical artifacts. They introduced comprehensive cardiopulmonary bypass (CPB) guidelines created collaboratively by perfusionists, anesthesiologists, and surgeons. These guidelines, reviewed annually, standardized expectations for oxygen delivery thresholds, staffing models, phenylephrine consultation triggers, and read-verify safety checks .
Formal checklists for CPB initiation and weaning (Figure 2, page 3) were implemented. These checklists are verbally performed by perfusionists at the surgeon’s request, creating deliberate pauses for interdisciplinary confirmation of readiness. The checklist elements include confirmation of anticoagulation, arterial and venous line verification, indexed oxygen delivery targets, temperature goals, and hemodynamic parameters . Importantly, these pauses promote shared situational awareness and communication, not merely procedural compliance.
The program also introduced a multidisciplinary preoperative briefing for every cardiac surgical case. Unlike standardized checklists, this briefing is patient-specific and participatory. As shown in the structured form displayed in Figure 3 (page 4), the briefing addresses demographics, surgical plan, perfusion strategy, myocardial protection approach, circulatory arrest planning, anesthesia considerations, and blood management . The circulating nurse leads the session, reinforcing team inclusivity and flattening hierarchy.
The impact of this cultural transformation has been profound. Recruitment improved dramatically across multiple disciplines. The cardiac anesthesia service, once avoided due to a difficult work environment, became highly competitive. Perfusion programs from leading academic institutions began sending top trainees who chose to remain at MGH. The cardiac surgery residency, previously struggling to fill positions, regained competitiveness and internal interest. The unit now attracts external observers seeking to study its high-reliability model.
While the article does not present quantitative outcome metrics, it provides compelling experiential evidence that structured cultural reform—anchored in leadership alignment between surgeons and perfusionists—can reshape operating room dynamics. The authors conclude that consistent leadership, explicit value-setting, artifact creation, and reinforcement of psychological safety are reproducible strategies that can enhance cardiac surgical team performance and potentially improve patient outcomes .
For healthcare leaders, cardiac surgeons, perfusionists, and hospital administrators seeking to improve patient safety culture in high-acuity surgical environments, this article provides a practical blueprint grounded in organizational psychology and real-world implementation.
