Dear Editor

In the lexicon of hospital emergency management, few concepts are as deceptively simple—and as profoundly difficult to achieve—as readiness. We speak of it in metrics, checklists, and accreditation standards, yet true readiness is not a static state; it is a dynamic, behavioral shift. Nowhere is this paradox more pronounced than in preparing for Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) events. These low-frequency, high-stakes scenarios demand more than intellectual familiarity with an Emergency Operations Plan (EOP). They require an operational readiness to change—a collective cognitive and behavioral flexibility that allows a team to transition instantaneously from routine operations to crisis mode, from theoretical knowledge to intuitive action.Reference Qzih and Ahmad ¹

We recently undertook a training workshop for our hospital’s disaster management team with a singular mission: to move our CBRNE EOP from a binder on a shelf to a lived, actionable reality. Our methodology was deliberate and immersive—high-fidelity simulation, iterative practice, and structured “hot wash” after-action reports. But the true innovation lay in our assessment framework. We anchored our evaluation not merely on knowledge retention, but on the team’s readiness to change, operationalized through the lens of the Transtheoretical Model (TTM).Reference Tavan, Farahmandnia and Sedri ^{2 ,} Reference Moslehi, Tavan and Narimani ³

The outcome was decisive: a quantifiable improvement in overall preparedness exceeding 50%, as measured by a rigorous post-test designed to capture decision-making agility, role clarity, and protocol adherence under duress. Yet the numbers, while impressive, tell only part of the story. The real transformation was in the team’s orientation—from passive acknowledgment of the plan to active ownership of it. As illustrated in Figure 1, our intervention targeted each stage of the TTM, with simulation serving as the critical catalyst for moving the team from precontemplation to action.

Figure 1.

Transtheoretical model–based pathway for enhancing hospital crisis management team preparedness.

Figure 1. Long description

The flowchart is organized into three main horizontal sections.

At the far left is the starting point titled FROM COMPLIANCE: Plan on the shelf. It features an image of an E O P binder and lists challenges like awareness of the C B R N e plan, limited role ownership, and uncertainty about practical performance.

The central section, THE STAGES OF CHANGE, consists of five numbered boxes connected by blue arrows.

1. PRECONTEMPLATION: The plan exists, but readiness is assumed. Features a group of four medical staff and bullet points on passive compliance and overestimation of readiness.

2. CONTEMPLATION: We recognize the gap. Shows staff discussing communication failures, P P E logistics gaps, and unclear roles.

3. PREPARATION: I know my role, and I must practice it. Shows staff reviewing documents, focusing on commitment to change and skill building.

4. ACTION: We practice, adapt, and perform. Depicts a simulation of a patient on a stretcher with staff in full protective gear, focusing on role execution and real-time problem solving.

5. MAINTENANCE / OPERATIONAL COMPETENCE: We embody the plan. Shows a confident team in front of a hospital and helicopter, highlighting coordinated team performance and operational muscle memory.

At the far right is the goal titled TO COMPETENCE: Plan in action. It shows a green shield icon and claims a greater than 50 percent improvement in overall preparedness, specifically in decision-making agility, role clarity, and protocol adherence.

Below the stages is an ITERATIVE LEARNING LOOP: THE ACCELERATOR OF READINESS TO CHANGE. This circular path includes four steps: SIMULATION, HOT WASH (immediate debrief), CORRECTIVE ACTION, and RE-SIMULATION and REPETITION.

The footer lists KEY ENABLERS OF SUCCESS: Leadership Commitment, Psychological Safety, Realistic Training, Feedback and Reflection, Repetition and Reinforcement, and Sustained Readiness.

The infographic illustrates the progression of a hospital crisis management team from compliance-based preparedness to operational competence across the 5 stages of change: precontemplation, contemplation, preparation, action, and maintenance. High-fidelity simulation acts as a catalyst for recognizing the gap between perceived and actual readiness, while immediate, no-blame hot wash debriefings accelerate reflection and corrective action. Through an iterative learning loop of simulation, feedback, corrective action, and repeated practice, the team develops clearer roles, improved decision-making, protocol adherence under stress, adaptive coordination, and operational muscle memory, resulting in enhanced overall preparedness.

Why did this approach succeed where traditional drills often fail? Because we deliberately targeted the psychological barriers to change that are rarely addressed in conventional exercises.

Confronting the “Pre-Contemplation” Trap

For years, many team members existed in a state of pre-contemplation or contemplation regarding our CBRNE plan.Reference Moslehi, Khezeli and Tavan ^{4 ,} Reference Kikuta, Kawase and Yagata ⁵ They knew it existed; they vaguely understood its structure; but they harbored unspoken doubts about its practicality and their own efficacy within it. The simulation served as a controlled, high-fidelity disruption—a mirror held up to the gap between their perceived readiness and their actual performance. This cognitive dissonance was not punitive; it was catalytic. It forced an immediate, visceral recognition that their readiness to change was not optional, but essential. The post-test results confirmed this shift: the team moved decisively from “I know we have a plan” to “I know my role, and I must practice it.” This was the transition from contemplation to preparation and action—the very heartbeat of the TTM.Reference Tavan, Farahmandnia and Sedri ²

The “Hot Wash” as a Change Accelerator

The structured “hot wash”—an immediate, candid debrief conducted while the adrenaline was still high—became our most powerful tool for accelerating readiness to change. These sessions were not bureaucratic formalities; they were raw, solution-oriented dialogues held in a strict “no-blame” culture. By dissecting micro-failures in real-time—communication breakdowns, decontamination bottlenecks, PPE supply chain hiccups—we did more than troubleshoot. We normalized the act of critical self-reflection. We conditioned the team to embrace adaptive change during the exercise, not just after it. This real-time feedback loop, repeated across multiple simulation iterations, shortened the team’s change curve dramatically. They were no longer rehearsing a script; they were co-creating a more resilient response in real time.

Iterative Practice: Building Muscle Memory for Change

A single drill tests readiness; repeated practice builds readiness. Our workshop structure allowed for multiple simulation cycles, with each hot wash feeding directly into the next iteration. This cyclical process of action, feedback, and modification refined the team’s operational muscle memory. The same team that hesitated during PPE doffing in the first run executed it with smooth, silent efficiency by the final run. This is the essence of operationalized readiness to change—not just knowing what to do, but being able to execute it under stress without conscious deliberation. The 50% improvement is a testament to this shift in operational identity: the team transformed from a group of individuals with a plan to a cohesive unit that embodies the plan.

The Critical Takeaway for Hospital Leaders

This experience carries an urgent message: A binder on a shelf is not readiness. Accreditation checklists and annual tabletop exercises are necessary, but they are insufficient. They may certify compliance, but they do not guarantee competence. True readiness to change is a behavioral and cultural attribute—it must be forged through experiential stress, honest feedback, and repetitive practice.

The 50% gain we observed is a powerful validation of our methodology, but it is not an endpoint. It is a starting point. Our next challenge is sustainability—embedding these exercises into our routine training calendar, developing just-in-time tools for rotating staff, and using the rich data from our hot wash AARs to simplify and refine our EOP itself. The plan must remain a living document, continuously reshaped by the insights of those who execute it.

In an era of increasing global instability, our patients and communities deserve more than our assurance that we are “prepared.” They deserve evidence of our readiness to change—our capacity to adapt, learn, and execute when the unthinkable becomes reality. Our workshop has proven that this capacity can be accelerated dramatically. The question for every hospital leader is not whether we can afford the time and resources for this level of training, but whether we can afford not to.

This is not about passing a post-test. It is about being ready for the day we hope never comes—and being able to say, with confidence, that we are.