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

(Editor's note: This is the second part of a series on staff keeping silent when danger looms.)

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

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

  • Personal motivation. If it were up to them, would they want to speak up? Does it feel like a moral obligation or an unpleasant annoyance?
  • Personal ability. Do they 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?
  • Structural motivation. Does the organization reward people who speak up or 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 these conversations and use these measures to keep management focused on this issue?

The Silent Treatment also recommends how organizations can use this approach to create a culture where people speak up effectively:

  1. Establish a design team.Enlist a small team that includes senior leaders; managers in targeted areas; and opinion leaders among caregivers. This team works with all caregivers to identify crucial moments, vital behaviors, and strategies within each of the six sources of influence. The team provides a few initial strategies within each source 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 put safety protocols at risk. The team needs to spotlight these moments so that people will recognize them. An example of one is when the surgery schedule is pushed later 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.
  4. Develop a playbook. Safety requires that the vital behaviors be acted on in a highly reliable way. Create a multifaceted influence plan that uses all six sources of influence.