Three Steps to Build Psychological Safety in Health Care
By Thomas H. Gallagher, MD, MACP, Professor and Associate Chair, Department of Medicine, University of Washington. Executive Director, Collaborative for Accountability and Improvement
The copilot who knew the pilot was not flying at the assigned altitude but kept that information to himself.
The patient who said nothing even as they were being wheeled off to an invasive procedure they were almost certain they were not scheduled for.
The surgical resident who stood by and watched the attending general surgeon begin to erroneously cut into the common bile duct during surgery.
The challenge of speaking up
Safety experts have long been aware of and confounded by the observation that the root cause of many harm events is the fact that someone involved in the situation knew something was going wrong but didn’t say anything. What can we as individuals and as organizations do to make such situations less likely to happen?
The challenge of speaking up can occur across a wide array of situations. One member of the care team might have concerns about the safety of the proposed plan. A medical student or resident might witness an attending behaving in a way that is unsafe or unprofessional. A physician reviewing a patient’s chart might have concerns about the quality of care a colleague provided. We have conducted extensive research on situations where patients feel something has gone wrong in their care. In one of our studies, nearly 30% of patients thought something had gone wrong in their care, yet only 10% had shared their concern with their clinical team.1,2
Early attempts to address this challenge focused on encouraging people to speak up if they noticed a problem. Clinicians may recall campaigns at health care organizations where they were asked to wear buttons that read, “Ask me if I’ve washed my hands.” Posters in nursing lounges and patient rooms proclaimed, “Speak up for safety!” Yet these strategies aimed at reminding people that “if you see something, say something” were unsuccessful, largely because they misunderstood the fundamental nature of the problem.
Speaking up can feel risky
From the perspective of the person noticing the potential safety problem, the very act of speaking up can feel unsafe and risky. For example, patients worry that sharing a concern about their care could somehow disrupt their relationship with the clinical team and endanger their health care. Especially in situations when the person noticing the problem is in a position of less power, such as when a resident has concerns about the behavior of an attending, it is understandable that they might worry about potential blowback from speaking up. A strategy based largely on encouraging people to overcome their fears and speak up when they observed a problem was destined to fail.
“Since the major barriers to speaking up about safety issues relate to a health care culture in which it feels unsafe to raise concerns, the most successful solutions are likely to be ones in which organizations are responsible for making people feel psychologically safe sharing concerns.”Thomas H. Gallagher, MD, MACP
Creating psychological safety
In our work with patients who had concerns about their care, this meant “speak up” was turned on its head, and became a comprehensive organizational initiative called “We Want To Know”. Through We Want To Know, the health care organization communicated to patients that they were eager to hear from them when they thought something had gone wrong, and that sharing their concerns would be met with a real-time response to address the problem.1 Many health care organizations have also adopted initiatives aimed at increasing health care workers’ perceptions of psychological safety. Training programs such as TeamSTEPPS normalize communication about problems within care teams and provide helpful language for sharing concerns in a standardized way.3
Three steps to build psychological safety in health care
As organizations work to create a culture of psychological safety for patients and clinicians, what can individuals do to increase the chances that people will speak up if they observe a potential problem?
- Express willingness to hear concerns. A critical first step is for clinicians to tell their team (and trainees, if the clinician is in a teaching setting) on a regular basis how eager they are to hear if anyone has concerns about the quality, safety or patient-centeredness of care. Clinicians should deliver a similar message to their patients. I have found it to be natural and effective to say something to my new patients like, “As you know, health care today can be very complex, and sometimes things don’t go the way that we intended. If you have any concerns whatsoever that there might be a problem in your care, please let me know right away so that we can work together on understanding the problem and getting it addressed.”
For care team members who want to share feedback that something is going wrong but are uncomfortable addressing it face to face, TeamSTEPPS provides communication language that can help raise concerns in situations where patient safety is at risk. Standardized culture assessment tools can also help team leaders determine whether significant gaps exist in areas such as clinicians’ willingness to share safety concerns.
- Respectfully listen to and acknowledge the concern. Creating an environment in which those around you feel confident that you want to hear any concerns they have is essential but insufficient. The second critical step is responding effectively when someone raises a concern. First, sincerely thank that individual for sharing their concern. Then, use open-ended questions to allow the individual to describe their concern in as much detail as possible. Statements such as, “I can see why you would be concerned about what happened” provide validation and are important even if your perspective on what took place is fundamentally different from that of the person who is raising the concern.
- Gain clarity and reflect on the concern While sometimes the concern being raised can be effectively addressed in the moment, more often it is helpful to use the initial discussion simply to gather information about the perspective of the person raising the concern. Afterwards, you can take some time to reflect on what was shared and potentially solicit input from others on what occurred. Our immediate responses when someone raises a concern, especially if the concern being raised relates to our own behavior, have the potential to be defensive and less conducive to productive discussions. Therefore, scheduling a brief follow-up discussion later provides time to process the concern and formulate a balanced response. In addition, many organizations also provide experts such as ombudsmen and resources to help address such concerns most effectively.
It is impossible to address problems and concerns that we do not know about. Enhancing the quality, safety and patient-centeredness of health care ultimately will hinge on creating environments in which everyone feels comfortable sharing concerns about care and receives a supportive and productive response.
- Fisher K, Smith K, Gallagher T, Burns L, Morales C, Mazor K. We Want to Know: Eliciting Hospitalized Patients’ Perspectives on Breakdowns in Care. J Hosp Med 2017;12:603-9.
- Mazor KM, Roblin DW, Greene SM, et al. Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. J Clin Oncol 2012;30:1784-90.
- TeamSTEPPS Tools and Materials. 2009. (Accessed August 18, 2009, at http://teamstepps.ahrq.gov/abouttoolsmaterials.html.)
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