Case Objectives

• Recognize the role of burnout in a culture of safety.
• Review the drivers of speaking up in the health care environment.
• Understand the relationship between feedback and speaking up within a year and across years.
• Describe the role of leaders in establishing and maintaining a culture of safety.
• Discuss the foundational elements of a work environment characterized by a strong safety culture.

The Case

A 78-year-old man presented to the hospital with shortness of breath. He was admitted to the medicine service and chest radiograph revealed large bilateral pleural effusions. The bedside procedure service was consulted to perform a thoracentesis for both diagnostic and treatment purposes.

The proceduralist received a page from the medicine team requesting the procedure. The page contained the last name and room number of the patient. The physician entered the patient's room, identified the patient by his last name, introduced himself, and asked the patient's permission to use the ultrasound machine to assess the effusions. A patient care assistant was sitting by the patient's bedside and watching the patient closely. The patient care assistant explained to the physician that the patient had underlying dementia and was frequently confused. The physician scanned the patient and noted a small effusion on the right side. He was a bit surprised that the effusion wasn't larger given what he had been told by the patient's primary medicine team. He then called the medicine team and mentioned that he found a very small effusion on the right side, which he could attempt to sample if the team still felt it was clinically indicated.

The patient care assistant who overheard the phone exchange followed the physician out of the patient's room and politely informed him that he had in fact examined the incorrect patient. The proceduralist logged into the electronic health record to verify the patient information he had received in the page. He was shocked to find that the correct patient was in the next room and happened to have the same last name as the patient he had evaluated by mistake.

The physician immediately apologized to the patient with dementia and thanked the patient care assistant for pointing out his mistake. He then went to examine the correct patient and found that large bilateral pleural effusions were indeed present, just as the medicine team had stated. The physician nominated the patient care assistant for the hospital's Stand Up for Safety Award, designed to recognize providers and staff for speaking up and making good catches in the name of patient safety.

The Commentary

by Allan S. Frankel, MD; Kathryn C. Adair, PhD; and J. Bryan Sexton, PhD

To assess or improve safety culture in health care is to assess or improve "the way we do things around here." Patients often have many complex illnesses; treatments have the ability to be extraordinarily precise but require exacting steps; and our organizations are rife with complicated machinery, software, and silos of expertise that must interact. Exquisite teamwork, leadership, and communication are required for things to go well in the health care setting and are only possible in an environment that can best be described as safe. A safe environment is one in which in team members trust and support each other, defects and problems are easily surfaced and never hidden, and new ideas find fertile ground for testing to facilitate improvement. Ultimately, providing ideal care is profoundly dependent on a healthy safety culture, and a hallmark of such is the willingness of individuals to speak up.

In the case described above, a patient care assistant spoke up after witnessing a physician making a mistake. In order to provide a deeper understanding of such interactions, we analyzed data from responses of more than 12,000 physicians and 11,000 patient care assistants responding to the question: "In this work setting, it is difficult to speak up if I perceive a problem with patient care."

The results come from a rolling benchmark of the most recent 250,000 responses to the safety culture, burnout, and engagement survey from Safe & Reliable Healthcare, referred to as the SCORE survey (safety, communication, organizational reliability, and engagement) (1-3), now administered to more than 1.2 million health care workers in the United States. Notably, data from the SCORE survey indicate that while physicians are slightly more comfortable speaking up compared with other types of health care workers (4-6), overall, their scores are remarkably similar to those of patient care assistants. Although physicians are significantly higher up in the medical hierarchy and possess a greater level of responsibility with regard to patient care, there did not seem to be significant differences in speaking up between the two groups. To understand what was associated with "speaking up," we evaluated how 23,000 physicians and patient care assistants responded to other questions in the SCORE survey.

We found that a willingness to speak up is associated with less frustration and burnout based on data from responses to the following questions: (i) "Events in this work setting affect my life in an emotionally unhealthy way" and (ii) "I feel frustrated by my job." We also found that speaking up was associated with more positive responses to growth opportunities and participation in decision-making domain questions. Finally, and perhaps most profoundly, we found that speaking up is consistently associated over time and across multiple survey periods with receiving feedback about one's performance.

Rates of speaking up vary from one year to the next within a work setting. However, the association between receiving "appropriate feedback" and "speaking up" is consistent in that they tend to change similarly when looking at each survey administration, and then track together if the survey is repeated year after year. One study used 2 years of previously published safety culture data from 144 work settings (7) and found that receiving feedback predicts subsequent speaking up even better than previous speaking up does. The findings demonstrated that individuals who report having received appropriate feedback about their performance are the same ones that find it easier to speak up. The items, verbatim, were as follows: "I receive appropriate feedback about my performance," and "In this work setting, it is difficult to speak up if I perceive a problem with patient care." Perhaps a history of someone else speaking up to provide feedback models speaking up so that one feels more comfortable speaking up in the future. This is a correlation, so we can't assume causation, but the nature of this relationship suggests that feedback is central to subsequent speaking up. To surmise the reasons, we can use the correlations to all the questions above.

Receiving appropriate feedback implies that a conversation with a manager or individual who knows something about a frontline worker has taken place. We have expanded the concept of appropriate feedback to include the following behaviors by local leadership: regularly provides positive feedback about how I am doing, regularly makes time to pause and reflect with me about my work, provides frequent feedback about my performance, and communicates expectations to me about my performance.

In general, the feedback is a focused discussion between manager and worker highlighting positive aspects of work and also candor about problems. The end result must be twofold: the worker feels that they are in a trusted and safe space and that they are perceived as capable with high expectations placed upon them. Recent analysis of great teams has identified that a powerful determinant of excellence is the perception that "the people who work with me care about me."(8) Providing feedback is a way to send critical messages to the recipient, e.g., "We are listening to you, we want you to speak up, we will take action based on your safety concerns, we care." Productive feedback—talking about something really right or really wrong—can lead to useful insights and provides some confidence that when something is really wrong in the future, it is easier to say something about it. Useful feedback makes the risk of raising concerns seem reasonable and demonstrates speaking up in the process. Without that comfort and confidence that feedback provides, frontline workers are more likely to default to silence.

The connection between receiving feedback and speaking up is not widely discussed in the existing literature on safety culture. Therefore, offering feedback appears to be an untapped opportunity for leaders to enhance psychological safety in the health care environment.

The Challenges to Creating Voice

Health care needs visible role models who encourage speaking up and demonstrate the behaviors associated with a positive safety culture through their actions. However, it takes more than the presence of well-intentioned leaders and staff, or a policy of "see something, say something" to achieve a positive safety culture. We have worked with brilliant leaders who proclaim maxims such as "speak up if you have a concern, and listen if others do," only to find that in the heat of the moment, when possibly exhausted, frustrated, cynical, scared, distracted, or confused, frontline workers still do not raise concerns. Leadership is important but insufficient to ensure a culture of speaking up.

Surprisingly, our research shows that the biggest drivers of speaking up were not what we typically hear about in continuing education or teamwork training programs. Nor were the biggest drivers the willingness to report errors, the coordination of teams, or the capacity of one's work setting to learn and improve. Instead, the biggest drivers of speaking up seem to include a history of receiving feedback, lower levels of burnout, and positive engagement metrics like growth opportunities and participation in decision-making. We have to update our understanding of what it takes to achieve a positive safety culture to account for the underlying importance of workforce well-being. Creating a cultural norm of speaking up is no small feat as there are many disincentives to do so, especially when one is in a busy work setting, enduring lots of change, and managing sick patients. Moreover, as human beings, we are naturally inclined to stay silent in an instinctual effort to avoid looking ignorant, incompetent, intrusive, or negative.(9)

Speaking up isn't simply about teamwork training, psychological safety training, nurturing an environment in which raising concerns is generally valued, or any one policy. Rather, it is about what the workforce has the confidence to reliably do even when work is intense and the stakes are high. Our findings suggest that having productive or difficult conversations in an environment of caring—providing effective feedback—leads to insights about how to speak up and ensures that frontline staff will do so when they need to.

To promote a culture of safety and one that encourages speaking up, we provide a framework suggesting that it takes will on the part of organizational leaders, open dialogue about ideas and bidirectional feedback between managers and employees, and the ability to execute change on the part of organizations. Organizational leaders must believe that the safest and most reliable work settings are characterized by community, caring, and voice ("I am comfortable speaking up and when I do it results in action"). Strategic decisions, supported by resources, must then follow this belief.

In the vignette described above, we know that the patient care assistant did speak up. The physician's response was appropriately respectful, and the organization has established a patient safety award to highlight the importance of speaking up. We don't know when the patient care assistant knew that the physician was making a mistake or whether he might have spoken up sooner. Nor do we know whether the organization was attempting to overcome a culture that feels unsafe by creating a patient safety award, or whether the award is one of many actions taken to highlight the desired culture.

Every work setting in health care, from operating rooms to the office practice and visiting nurse group, has a manager or leader who should know how to give positive feedback and how to listen, learn, and act. These activities are learned skills. Feedback must occur regularly and as frequently as weekly or monthly. The feedback is not only about how the worker is performing, it is bidirectional. What is working well? What is not? Is the manager being appropriately supportive? Are there individuals who should receive kudos for their efforts? Is professionalism, respect, and just culture actively working? Insights and ideas gained from many frontline workers should become goals for the work setting and inform strategy for the organization.

Work settings should be expected to be self-reflecting and improvement-capable. Senior leaders should know how to round in work settings and see that managers gain insights from their workers, and then they should act on those insights to change and improve the work environment. Organizational resources should be focused on ensuring that work settings are supported in these efforts. Senior leaders should make clear that respect is nonnegotiable and unlinked from responsibility/hierarchy/title, and they should act to remedy transgression.

In an environment characterized by the framework put forth above, event reporting systems and good catch programs simply become a part of "how we do business." Team training, improvement training, and management training are not separate projects but coordinated efforts to achieve one vision—a culture of safe and reliable operational excellence in which speaking up isn't surprising and doesn't warrant reward, instead it is the norm.

Take-Home Points

• Awards for speaking up are a fabulous way to highlight desired actions, but they are a minor activity in creating a speaking up culture.
• Highlighting the good work of individuals is a necessary part of managing and occurs exuberantly in healthy organizations.
• Concerns about speaking up transcend hierarchy and exist at every level of the organization, from the board room down.
• Speaking up is more likely in environments of receiving feedback and lower burnout.
• The relationship between managers and workers primarily entails creating trust to examine the good and bad, while engendering in individuals that much is expected of them because they are capable.

Allan S. Frankel, MD Managing Partner and Principal Safe & Reliable Healthcare Evergreen, CO

Kathryn C. Adair, PhD Assistant Director of Research Duke Center for Healthcare Safety and Quality Duke University Health System Duke University School of Medicine Durham, NC

J. Bryan Sexton, PhD Director Duke Center for Healthcare Safety and Quality Associate Professor, Psychiatry Duke University School of Medicine Durham, NC

Faculty Disclosures: Drs. Frankel, Adair, and Sexton have declared that neither they, nor any immediate member of their families, have a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

1. Sexton JB, Adair KC, Leonard MW, et al. Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf. 2018;27:261-270. [go to PubMed]

2. Adair KC, Quow K, Frankel A, et al. The Improvement Readiness scale of the SCORE survey: a metric to assess capacity for quality improvement in healthcare. BMC Health Serv Res. 2018;18:975. [go to PubMed]

3. Schwartz SP, Adair KC, Bae J, et al. Work-life balance behaviours cluster in work settings and relate to burnout and safety culture: a cross-sectional survey analysis. BMJ Qual Saf. 2019;28:142-150. [go to PubMed]

4. Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med. 2003;31:956-959. [go to PubMed]

5. Makary MA, Sexton JB. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg. 2006;202:746-752. [go to PubMed]

6. Sexton JB, Holzmueller CG, Pronovost PJ, et al. Variation in caregiver perceptions of teamwork climate in labor and delivery units. J Perinatol. 2006;26:463-470. [go to PubMed]

7. Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study. Qual Saf Health Care. 2010;19:547-554. [go to PubMed]

8. Duhigg C. What Google learned from is quest to build the perfect team. New York Times. February 25, 2016. [Available at]

9. Edmondson AC. Managing the risk of learning: psychological safety in work teams. In: West MA, Tjosvold D, Smith KG, eds. International Handbook of Organizational Teamwork and Cooperative Working. Chichester, UK: John Wiley & Sons Ltd; 2003:255-275. ISBN: 9780471485391. [Available at]