Want staff to speak up? Use step-by-step process

To improve patient safety by encouraging healthcare providers to speak up about their concerns, risk managers should focus on the influences that have the strongest effect on behavior, suggest the authors of The Silent Treatment, conducted by VitalSmarts, a corporate training company in Provo, UT, the American Association of Critical-Care Nurses, and the Association of periOperative Registered Nurses.

The authors suggest focusing on these six sources of behavioral influence:

• Personal motivation. If it were up to them, would the nurses want to speak up? Does it feel like a moral obligation or an unpleasant annoyance to them?

• Personal ability. Do the nurses have the knowledge and skills they need to handle the toughest challenges of speaking up?

• Social motivation. Are the people around them (physicians, managers, and co-workers) encouraging them to speak up when they have concerns? Are the people they respect modeling speaking up?

• Social ability. Do others step in to help them when they try to speak up? Do others support them afterward so the risk doesn't turn against them? Do those around them offer coaching and advice for handling the conversation in an effective way?

• Structural motivation. Does the organization reward people who speak up, or does it punish them? Is speaking up included in performance reviews? Are managers held accountable for influencing these behaviors?

• Structural ability. Does the organization establish times, places, and tools that make it easy to speak up, such as surgical pauses and handoff procedures? Are there times and places when caregivers are encouraged to speak up? Does the organization measure the frequency with which people are holding or not holding these conversations and use these measures to keep management focused on this aspect of patient safety?

The Silent Treatment also offers four recommendations for how health care organizations can use this multifaceted approach to create a safety culture where people speak up effectively when they have concerns:

1. Establish a design team. Enlist a small team that includes senior leaders; managers in the targeted areas; and opinion leaders among physicians, nurses, and other caregivers. This design team works with all caregivers to identify crucial moments, vital behaviors, and strategies within each of the six sources of influence described below. The design team then provides a few initial strategies within each of the six sources and helps teams in patient care areas select, modify, and create additional strategies.

2. Identify crucial moments. There are a handful of perfect-storm moments when circumstances, people, and activities combine to put safety protocols at risk. The design team needs to identify and spotlight these crucial moments so that people will recognize when they are in them. An example of one of these crucial moments is when the surgery schedule is pushed into the evening, and people are in a rush.

3. Define vital behaviors. People need to know what to say and do when they find themselves in these crucial moments. These are the vital behaviors that keep patients safe. Examples of vital behaviors include "200% accountability." Each staff member is 100% accountable for following safe practices and 100% accountable for making sure others follow safe practices.

Another example is saying "thank you" when you have been corrected. This helps make it make it safe for everyone to hold others accountable. When staff members are reminded of a safety practice, they thank the other person and redouble their efforts to keep the patient safe.

4. Develop a playbook. Safety requires that the vital behaviors be acted on in a highly reliable way, especially during crucial moments. The most powerful way to make sure these behaviors are consistently followed is to create a multifaceted influence plan that uses all six sources of influence. This plan is captured in a playbook that can be disseminated throughout the organization.