I have seldom used guest columns in Doc in the D, but I found this story so compelling and indicative of such a positive safety culture that I wanted to share it with you.
This is a piece written by Dr. Manu Malhotra, one of our Associate Chief Medical Officers at Henry Ford Hospital and a long-standing member of our Department of Emergency Medicine. Dr. Malhotra provides a “speak up” story that could have had a much different interchange between the physician and a respiratory therapist. He astutely observes the power of honoring someone speaking up, not in the circumstances that prevented an error but honoring the environment that empowers all to speak up, even if not correct.
Great tribute to all and indicative of a culture we wish to build and a behaviors we wish to have second nature.
The patient story I have to share with you today does not come from a patient letter – positive or negative. It is a story about the impact of the culture we create and about what happens behind the curtain.
About a week ago, one of our trauma surgeons was called up to the ICU to evaluate a critically ill patient. The surgeon had just finished with a trauma in the ED, and on this Saturday night, he would inevitably be dealing with many more. After evaluating the patient, the surgeon announced his decision to perform a bronchoscopy through a tracheostomy the patient had, and began preparations. For those unfamiliar with these terms, a bronchoscopy involves guiding a small camera to look into the lungs, while a tracheostomy is a small opening created in the trachea (windpipe).
The respiratory therapist at the bedside said, “No. You cannot do a bronchoscopy through a tracheostomy. That is against policy.”
The surgeon responded, “No, that’s not right. It is allowed, and I have been doing it for years. Trust me.”
Nevertheless, the respiratory therapist persisted. Seeing this, the surgeon stepped back and asked her to call her supervisor to see if they could get to the bottom of it. The respiratory therapist was able to reach a supervisor who informed her that, in fact, it was allowed. The procedure was then completed without incident.
The following Monday morning, the respiratory therapist came to her manager’s office and, without preamble, asked, “Am I in trouble?” The manager actually knew exactly what she was talking about, because she had already received an email from the surgeon – thanking the respiratory therapist for speaking up.
In this situation, we had a respiratory therapist who felt empowered to “speak up” to a surgeon and a surgeon who “listened up.” But perhaps my favorite part of this story is that the person who spoke up was wrong.
It is easy to speak up when you are certain, when you are right, and when people are patting you on the back for a good save. The true test of our safety culture is how we treat people when they speak up and turn out to be wrong.
Do we chastise them, “reeducate” them, “provide feedback,” or engage in any number of other subtle discouragements? Or have we created a just culture that will applaud them for speaking up in service to patient safety, despite the risks of being wrong. The bar for speaking up cannot be set at 100 percent certainty.
We have spent enormous time and effort encouraging “speak up,” but not nearly enough on the concept of “listen up.”
“Speak up” doesn’t always sound like “That is against policy!” Sometimes it sounds like, “…Um, I thought the surgery was supposed to be on the other leg, um…but I am not sure…” If we can’t recognize that this is someone trying to say, “I have a concern,” then we will never reach the level of reliability that we are striving for.
On the other hand, if we can, essentially, stop a scalpel in the hands of a surgeon, be wrong about it, and then move on as if nothing happened, then we may just be on the right track.
A powerful story about doing the right thing, creating culture that reinforces safety of patients above all, and teamwork that uses that culture for greater good.