Critical Success Factors: From Cycling to Healthcare

By Bonnie Hutchinson

9From cycling to health care?


The experience of a British cycling team has been applied in many different fields: sports, business, aviation – and health care. You can benefit from what they’ve learned. As well, Hone Virtual Education is developing a new resource that provides practical help so you can apply what’s been learned to your practice. Read on…

The story: from “laughing stock” to world champion

In 2002, the British Cycling team was known as a laughing stock within the sport.[1] In its 76 year history, British Cycling had won just one gold medal. The team’s record was so bad that some companies refused to sell cycling equipment to the UK team because that might harm the company’s reputation!

Enter a new head of British Cycling, Sir Dave Brailsford. Under his leadership, the British Cycling team improved so much that by 2008 at the Beijing Olympics, the British team won seven out of ten gold medals available in track cycling.

That win was not a one-off. British Cycling dominated cycling events in the 2012 London Olympics and 2016 Rio Olympics.

Beyond Olympic wins, in Tour de France events, a British cyclist has come in Number One in six out of the past seven years, including five consecutive years from 2014 to 2018. To put that in context, Britain had not won the Tour de France in the preceding 99 years!

What made the difference? Marginal gains.

New coach, new approach

Sir Dave Brailsford is a former professional cyclist who also holds a Master of Business Administration (MBA) – an interesting combination! While working on his MBA, he’d been fascinated by “kaizen” – a Japanese word meaning “improvement.”

Kaizen is a process improvement technique based on the idea that small, ongoing positive changes (“marginal gains”) can add up to major improvements. Sir Dave thought the techniques could be applied to cycling. He gambled that if the team analyzed everything that goes into competing on a bike and then improved each element by 1%, they would achieve a significant increase in over-all performance.

Their consistent stunning record in the past ten years speaks to the success of that calculated gamble.

Three “podium pillars”

In an interview with Eben Harrell,[2] Sir Dave explained, “We had three pillars to our approach, which we called ‘the podium principles.’ The first one was strategy. The second was human performance. We weren’t even thinking of cycling, but more about behavioral psychology and how to create an environment for optimum performance. The third was continuous improvement.”

So what does this have to do with health care – and you?

What can health care – and you – learn from the British Cycling experience? More importantly, how can you apply it in your health care practice?

Let’s focus on strategy, Sir Dave’s first pillar. Then we’ll talk about how health care, and you, could apply the strategy principles, and how Hone Virtual Education is using the same principles to benefit you.

Strategy A: Look everywhere for potential small improvements

For this strategy, British Cycling analyzed the demand of each event and spent a lot of time trying to understand what it would take to win. As one example, they analyzed how much power a cyclist needs to get the start required for a winning time. Then their analysis progressed to what kind of training each cyclist needed to be capable of that much starting power.

As well, they analyzed everything from the aerodynamics of their bikes to the mechanics area in the team trucks. They improved the diet of the cyclists. They hired a physician to teach the team to use antibacterial hand gel and other techniques to cut down on infections.

Later, when Sir Dave became general manager of the UK’s Tour de France team, he redesigned the team bus to improve cyclists’ comfort and recuperation.

Everything was examined for potential opportunities to improve performance.

Health care application

In North America, the third leading cause of death (after heart disease and cancer) is medical error. It’s a serious problem. A Johns Hopkins study found that every year in North America, medical errors claim more than 250,000 lives.[3] These mistakes shouldn’t happen but they do, again and again.

A Seattle hospital, Virginia Mason, decided to initiate a process of marginal gains in order to reduce medical errors. Staff members were encouraged to file reports if anything went wrong, like accidentally prescribing the wrong medicine. That gave the hospital an opportunity to make small improvements, like changing the labelling on drugs so they could be quickly and easily identified under time pressure.

The commitment to continuous improvement led to numerous small changes in every part of their operation. Though each improvement seemed small, the benefits quickly added up.

The result? Since Virginia Mason began its marginal gains approach, the hospital has seen a 74% reduction in liability insurance premiums and is now regarded as one of the safest hospitals in the world.[4]

How you can apply this strategy

If you’re a student paramedic, nurse or physician, the odds are good that every day in your training or practicum placements you are seeking and/or being taught ways to improve the accuracy and effectiveness of your observations, decisions and actions.

In every setting, you can have a “look for potential personal improvement” mindset. Notice. Ask questions. And you might want to check out Hone Virtual Education’s simulation training which is focussed on continuous small improvements (more information is below).

If you’re already a registered health care practitioner, your experience puts you in an even better position to watch for opportunities for improved patient safety and care – in your own patient-care practices, and in the processes and environments of your organization.

You too might want to check out Hone’s simulation training, to see if it has the potential to enhance your already-excellent practice, or to see if it’s something you’d recommend to less experienced practitioners.

How Hone Virtual Education applies the strategy of fostering small improvements

Hone has developed medically-accurate Hone Cue Recognition virtual simulation training modules you can download to your augmented reality smartphone or tablet.

Each module allows you to practice specific observations and skills again and again, as often as you choose, with immediate feedback after each action. You can keep practicing until your “marginal gains” in accuracy begin to add up and your learning is embedded and anchored in your brain.

Once your accuracy is assured, the modules gradually increase the speed with which cues are presented. Your accumulated marginal gains in speed enable you to make accurate assessments and decisions ever more quickly. That’s extremely useful, especially during the first few minutes of patient contact.

Strategy B: Identify critical success factors

Back to the British cycling experience. Despite their Olympic success, when Sir Dave moved from heading British Cycling’s track events at the Olympics to heading the UK’s Tour de France Sky Team, the team’s first few races fell below expectations.

Sir Dave says, “We took an honest look and realized that we had focused on the peas not the steak. We tried so hard with all the bells and whistles of marginal gains that our focus was too much on the periphery and not on the core. You have to identify the critical success factors and ensure they are in place, and then focus your improvements around them. That was a harsh lesson.”[5]

Health care application

 In health care, accurate diagnosis is the basis of everything that comes later. The most common type of medical error? Error of diagnosis.[6] The risk of medical error begins within the first few minutes of patient contact – assessment and diagnosis, often in a high-pressure environment.

Fortunately, we know the critical success factors that contribute to expert diagnostic performance: diagnostic cue recognition and pattern recognition.

Among other research, in 2013, Loveday et al reported on two studies that examined diagnostic expertise. They said, “…experts who have been identified on the basis of their diagnostic performance are more likely to use pattern recognition in comparison to their non-expert peers” and “…experienced diagnosticians could be divided into competent and expert practitioners based on their capacity for pattern recognition or cue utilization.”[7]

In health care, especially pre-hospital and emergency health care, recognizing and attaching meaning, accurately and quickly, to the diagnostic cues presented by patients and their environments can make a life-or-death difference. That’s far more important than winning Olympic gold or the Tour de France.

How you can apply this strategy

If you’re a paramedicine or nursing student, knowing that diagnostic cue recognition is a critical success factor, you will want to emphasize improvements in that area of your professional expertise.

Even if you’re a certified health care professional, diagnostic cue recognition is so critical a skill that you may want to keep honing your skills in that area for your entire career.

How Hone Virtual Education applies the strategy of identifying critical success factors

In its medically-accurate Hone Cue Recognition augmented reality simulation training modules, the focus is on diagnostic cue recognition and pattern recognition. Those are the critical success factors identified in research by Loveday and others.

Different Hone Cue Recognition virtual simulation training modules focus on sub-aspects of diagnostic cue recognition in Airway, Breathing, Circulation, Disabilities, and Exposure. Every module is set up to allow you ever greater mastery in diagnostic cue recognition and pattern recognition.

Find out more

Hone Virtual Education will soon be releasing the first Hone Cue Recognition augmented reality virtual simulation training modules you can download to your smartphone or tablet. In the meantime, you can…

  • Learn more about Hone Cue Recognition simulation training modules;
  • Be notified of updates and launch dates;
  • Apply to be a beta tester as new modules are developed for health practitioners in high-pressure environments.



Bonnie Hutchinson is a freelance writer and lifelong learner with degrees in Education and Whole Systems Design and extensive training and experience in adult learning and teaching. She’s the author of bestselling Transitions: Pathways to the Life and World Your Soul Desires.


[1]  “The Art of Marginal Gains,” Wit+Wisdom, Ambit Search Toronto (2017).

[2] Eben Harrell: “How 1% Performance Improvements Led to Olympic Gold” (2015).

[3] A Johns Hopkins study, led by Dr. Martin Makary of the Johns Hopkins School of Medicine, was released in 2016. A follow-up about whether anything had changed was reported by Ray Sipherd, special to in February 2018.  A brief summary of the study is at

[4] Matthew Syed, “Viewpoint: Should we all be looking for marginal gains?” (2015), BBC Magazine,

[5] Harrell (2015), Op. cit.

[6] Johns Hopkins study (2016), Op. Cit.

[7] Loveday, T., Wiggins M., Fest M., Scheel Dl, Twigg D. (2013), “Pattern Recognition as an Indicator of Diagnostic Expertise” in Latorre Carmona P., Sanchez J., Fred A. (eds) in Pattern Recognition – Application and Methods, Advances in Intelligent Systems and Computing, Vol 204. Springer, Berlin, Heidelberg.

Hone CUE Recognition on the App Store

The Hone CUE Recognition App will soon be available on the App Store for early adopters. When it is available - you will be able to download it via the link below.