The Quality-Cost Connection Manage organizational fear to improve safety

What are the people in your organization afraid of?

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Patient safety experts advocate elimination of fear in the workplace so staff members can more effectively identify and resolve safety concerns. The elimination of fear is necessary to create an environment of trust and cooperation, essential ingredients of initiating and sustaining patient safety improvements. Unfortunately, there is little concrete guidance on how health care managers should deal with fear in their environment. It’s easy to say, "change the culture," but that can’t be accomplished until managers first understand this complex organizational phenomenon. Fear is a human emotion that can never be completely eliminated, but it can be managed.

Fear that affects patient safety initiatives is present in every health care organization. If you have any doubts that there is fear in your facility, just observe how people behave in root cause analysis meetings or other discussions of patient incidents. Many of the behaviors that you observe during these meetings can tell you a great deal about the culture of your organization. It is dangerous to rely on patient incident data that are contaminated by fear. This is why it is so difficult to address the technical problems of patient safety without addressing the social systems of the organization.

What are the people in your organization afraid of? Most fears are related to position, authority, power, and psychological and social factors of organizational or professional life. Let’s take a look at some of the most common types of fear:

Fear of reprisal. This type of fear generates "look-good-at-any-cost" or "just-do-what-you’re-told" behavior. Fear of being disciplined or receiving poor performance appraisals can lead to behavior that inhibits patient safety improvement efforts. Fear of making a mistake is tied to fear of reprisal; reprimands are often viewed as an outcome of failure. Defensiveness, skepticism, and apathy are behaviors of people who are avoiding failure.

Fear of success. While it may seem odd, it is not uncommon for people to be afraid that success will damage their relationships with their peers. Staff members sometimes can be afraid of the repercussions of success (e.g., jealousy, envy, being ostracized as a snitch, higher performance expectations, or fear of failure following a promotion).

Fear of change. Resistance to change and the attitude "We’ve always done it this way, why change now?" are very common. Employees often resist process changes because they are generally content with what is familiar. Change may cause people to fear that they are going to lose something or feel that their autonomy or power is being diminished. Many see change as a threat to their security or to highly valued beliefs.

Fear of speaking up. Staff members who bring attention to patient safety problems can become targets of criticism. It is common to find that people are afraid of speaking up about mistakes because they fear management will punish the whistleblower. When there are lots of people who are afraid to admit their department is violating safe practices, the organization is missing out on chances to learn. Leaders must forgive unsafe practices and mistakes and provide a secure forum in which everyone can learn from failures.

Managing fear in the workplace should start with acknowledging fear’s presence. Then you need to learn about the level of fear in your organization. Use the following questions for a quick assessment of organizational fear:

  • Do people accept responsibility for suboptimal performance? Or is the finger of responsibility often pointed at another department or professional group or at issues considered to be beyond the person’s control (for example, lack of resources or unreasonable expectations)?
  • Do people make an effort to maintain the status quo rather than introduce new work processes or technologies, even when changes might improve patient safety?
  • Are practitioners willing to discuss the shortcomings of their patient care practices freely, or do they have a "bad things happen elsewhere, not here" attitude?
  • Can you recall the last time a member of the leadership team openly admitted making a mistake and then shared with others what they’d learned from this mistake?
  • Are people quick to protect their department or professional group from criticism, even when high priorities for improvement have been identified?
  • Do people spend more time discounting the reliability of comparative performance data than they do analyzing how the organization’s processes can be improved?
  • Are people satisfied with being just "good enough?" Are improvement actions reserved only for those situations in which your organization’s performance exceeds two standard deviations of the average performance reported by other facilities?

Analysis is useless without action

Many hospitals are using more detailed staff questionnaires to gather information about the cultural factors affecting patient safety. Data analysis, however, will do nothing to change the culture if it is not followed by actions. It is the responsibility of management to initiate efforts to minimize and manage fear. There are no examples of organizationwide cultural changes that originated from the bottom of the organization. This is because only top management can make policy or establish the set of core values for the organization. To minimize and manage fear, leaders must create an environment where employees can share patient safety information without fear of repercussion.

Leaders must respond quickly to employees’ patient safety concerns and ideas. A lack of response sends the message that nothing here will change. A quick response is the best incentive to ensure people will continue to communicate their concerns and thoughts regarding better ways to do things. Leaders must reward cooperation and innovation. They must reward efforts as well as outcomes.

Organizational fear will diminish as employees develop confidence and trust in the leaders’ commitment to patient safety. Creating trust is not easy. Trust takes many years to build and just one act to destroy. People must be confident that unintended mistakes will not result in repercussions to them or others and that their improvement ideas will be dealt with responsibly and not be rejected without careful consideration. In general, patients are safer in an environment where trust is high and communication is open and honest. On the other hand, low trust leads to employee uncertainty and defensive behaviors that negatively affect patient safety.

In the spirit of building trust, senior leaders and managers must share their mistakes with others as a signal that mistakes are considered opportunities for learning. In addition to questioning staff members and observing signs of fear, management should take the lead on speaking up about fear. Broaching the subject of fear informally (e.g., sharing with others one’s personal experiences of failure) plants the seed that it is OK to talk about mistakes and unsafe practices and the fears surrounding these types of situations. Leaders can set the tone by being skeptical when no mistakes are reported. Lack of information about unsafe practices may be a sign of fear in the workplace. Managers should not kill the messengers; better yet, messengers should be rewarded. When people do speak up about patient safety concerns, leaders must listen and collect data before passing judgment on employees’ suggestions and actions. It takes patience and understanding to manage fear.

Don’t expect dramatic results when attempting to minimize and manage fear. There are no quick fixes, and serious efforts to reduce debilitating organizational fear must be continual. Incremental progress, though it may seem to take forever, is how a climate of trust is established. The benefits of managing fear are many — improved patient safety, lower staff turnover, lower absenteeism, and better communication and coordination among all employees. Less time and energy will be spent defending current practices, which will allow process improvement and innovation to flourish.