Do staff speak up when safety or compliance is in jeopardy?
Openness must be part of culture
The health care community has long endorsed staff and patients speaking up when necessary to protect patient safety, but in the heat of the moment, a staff member can be intimidated by superiors and fearful of rocking the boat.
How can you tell if your colleagues will speak up? Finding the answer requires some digging, according to Grena Porto, RN, MS, ARM, CPHRM, senior vice president with Marsh, a health care management company in Philadelphia. Employees quickly get the message that the correct response when patients or subjects are at risk is to speak up, but that doesn't mean they really feel empowered to do so, she points out.
"A lot of people want to just say, 'We'll train them, tell them what to do, and they will do it.' In fact, they don't," Porto says. "The culture really needs to support what you're telling them to do. Organizations that want to put all their focus on training the staff are missing the boat, because you have to create a systemwide culture."
Nurses and other staff are astute observers of the employer's culture and will respond accordingly, she says. They are quick to recognize that leaders are preaching about the virtues of speaking up for safety or compliance but at the same time dismissing staff concerns or even punishing those who speak. "It only takes one or two instances to undermine your whole effort. The staff will say they're not going to speak up because they saw what happened to someone else who opened their mouth," Porto says. "Of course, they'll still tell you that they will do the right thing and speak up, because that's what you want to hear. I see that a lot."
Be an agent of change
For a "stop-the-line" culture, in which even the lowest-ranking employee can intervene when patient safety or compliance is threatened, that attitude must be modeled across the board, up to the highest levels of management, Porto says.
At the Clinical Trials Administrators Conference: Fresh Perspectives on Fundamentals held in March in Atlanta, Woody Woodaman, president & CEO, Synergy Clinical Research Centers, San Diego, CA, recounted a favorite story that illustrates this kind of behavioral modeling.
While working as an administrator in a hospital setting years ago, Woodaman conducted his own informal experiment. It wasn't about direct patient care, but more about the work environment and the image the institution was giving patients and visitors.
"To create change I knew I needed to be a visible example of the change I wanted to create," he said. "So from time to time when I was walking down a corridor, I would bend over and pretend to pick up something and then go throw it away in the trash can."
The results were impressive. "It only took a few times before others had observed my behavior and began picking up after themselves. It was a spark that helped create the ownership and accountability we wanted in our staff."
Local culture can be important
The effort to encourage staff to speak up is worthwhile because each instance of an error, near miss, or policy violation is an opportunity to improve patient safety or compliance, says Lori A. Paine, RN, MS, patient safety manager at Johns Hopkins Medicine in Baltimore.
"If we merely see nurses as the executors of provider orders, we miss the opportunity for the nurses to be that final check," she says. "That's how we see nurses, as a vital part of the system, sometimes the last gatekeeper for safety. If they are not empowered to speak up and if we don't listen to them, the organization misses a huge opportunity to improve safety."
Paine points out that, while organizational culture is important, the "local" culture of a staff member's unit or work area can be the driving factor in whether someone speaks up. Even if the overall culture of an organization is on the right track, there may be considerable variability from one unit to another, she says.
"We see this sometimes in our event reporting, which we watch carefully and mine for any signs of problems that we need to address," Paine says. "Sometimes we will see reports that a nurse or supervisor is resistant to reporting from others, or we may also see a sharp discrepancy in the number of event reports coming from one unit. That can suggest that the staff in that particular unit are feeling discouraged from reporting these events to us."
Follow through with support
Staff must be assured that they will be supported by the institution when they act on behalf of a patient or regulatory concern, says Christy Dempsey, BSN, MBA, CNOR, previously vice president and director of perioperative services at St. John's Regional Health Center in Springfield, MO, and now senior vice president of clinical operations for PatientFlow Technology, a health care consulting firm in Boston.
"From a management perspective, that's what I did to encourage people to speak up and act," she says. "I told them that as long as they followed the proper procedures [and acted in the best interests of the patient, the institution, or the project], I would stand by them completely and support their actions. I wanted them to feel that they weren't going to be out there by themselves if they stuck their necks out."
Sources
For more information, contact:
- Christy Dempsey, BSN, MBA, CNOR, senior vice president of clinical operations, PatientFlow Technology, Boston. Phone: (617) 358-5060. E-mail: [email protected].
- Lori A. Paine, RN, MS, patient safety manager, Johns Hopkins Medicine, Baltimore. Phone: (410) 955-2919. E-mail: [email protected].
- Grena Porto, RN, MS, ARM, CPHRM, senior vice president, Marsh, Philadelphia. Phone: (215) 246-1144. E-mail: [email protected].
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