Fear of speaking up is a broader problem, not just in military medicine

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Here's a troubling article from the New York Times:

“Military Hospital Care Is Questioned; Next, Reprisals“

As I've often written about here, the first step in solving problems, especially those related to patient safety and quality, is people speaking up to point out risks, unsafe behaviors, problems, near misses, and incidents that cause harm.

If people aren't speaking up (and we know healthcare risks and errors are severely underreported), we shouldn't blame those who aren't speaking up. We should be Lean problem solvers and ask, “Why?” Why aren't people speaking up?

Listen to Mark read this article (learn more):

They're often not speaking up due to fear. Fear of punishment, fear of retribution, fear of blame, fear of being ridiculed, fear of not being taken seriously.

Leaders must create an environment where it's safe to speak up. One example was my friend Paul Levy, when he was CEO of a Boston hospital, instituted a program that celebrated people for calling out problems. That's an important first step in fixing things.

We can't just tell people to not be afraid. People are afraid of losing their jobs. Why? Because they have families to feed and retirements to worry about. We all love a good whistleblower story, but things don't always turn out well for whistleblowers, even with laws that are intended to protect them.

So, what's happening in military medicine, according to the Times?

A medical technologist had complained of dangerous lapses in the prevention of infections. The inspectors planned to follow up.

But Teresa Gilbert, the technologist, said supervisors excluded her from meetings with the inspectors from the Joint Commission, an independent agency that accredits hospitals. “I was told my opinions were not necessary, nor were they warranted,” said Mrs. Gilbert, an infection-control specialist.

…it made her a pariah — shunned by co-workers and marked for dismissal… Mrs. Gilbert was transferred to a clerk's desk, without a computer, a telephone or duties. “People I have known for 20 years were afraid to talk to me,” she said.

There were serious problems that prevented the Joint Commission from immediately renewing the Army hospital's accreditation.

But, what happened to Gilbert?

It was disastrous for Mrs. Gilbert, too. She said she was reprimanded for being an obstructionist, reduced to part-time hours, investigated for what she called trumped-up charges and transferred to a clerk's job.

The message to Womack workers, she said, was clear: “You don't go against us. If you do, we will get you.”

These aren't just military medicine problems. I could easily imagine this happening in many civilian hospitals.

Was this an isolated case with Gilbert or a broader cultural problem?

In interviews and email exchanges, many doctors, nurses and other medical workers said military hospitals fall short of that objective [of being “free to speak bluntly to — and about — higher-ups without being ignored or, worse, punished].”

…

Physicians and nurses described in follow-up interviews how they were brushed off, transferred, investigated, passed over for promotion or fired after they pointed out problems with care.

Senior military health officials said they were working aggressively to instill a culture where complaints are welcomed and addressed.

What did other people claim happened to them?

• A former military surgeon was passed over for promotion after pointing out an error made by his supervisor
• A psychiatrist said her boss tried to oust her after she complained about a patient care issue
• A former anesthesiologist had his credentials reviewed by their boss after questioning why certain errors were made in the O.R.
• A nurse “resigned in disgust after the complaints were ignored”

In another story:

Dr. Gayle Humm, an emergency room physician under contract at Evans Army Community Hospital in Colorado, said she refused to prescribe narcotic painkillers for patients she suspected were addicted. When some patients complained, her supervisor told her that “the only thing that mattered was that the numbers were affecting his promotion,” she said.

In another story, a physician claimed:

“Basically, I was told that training residents was more important than patient safety,” she said.

The pressure to “make the numbers” isn't just a healthcare problem. I saw the same thing in manufacturing, including this story from my GM days.

I appreciate that senior military leaders are working to change the culture. This is not easy and it takes time. But, it also takes sustained effort, leadership, and perseverance.

“We want people to come forward,” Lt. Gen. Patricia Horoho, the Army surgeon general, wrote in a statement. “We are committed to patient safety, we are committed to transparency, and there will be NO COMPROMISE.”

This reminds me of GM CEO Mary Barra who reacted to major GM quality problems by creating a program called “Speak Up For Safety.” The implication, as I wrote, was that workers were at fault for not speaking up. The program should have been directed at leaders and called “Listen Up for Safety.” I wonder how that is working for GM? I did see one article recently, which I can't find now, about an employee being celebrated for speaking up. I tried speaking up once at GM and wasn't listened to.

This is another good read on the topic, from HBR.org: “Can GM Make it Safe for Employees to Speak Up?”

There's a great shake-your-head quality story in there from Maryann Keller, who said:

“… for years it was considered bad for your career if information filtered up to the highest ranks.” I had people tell me that everyone would know about a problem, but no one would speak about it,” she explains. “The goal was to insulate the senior executives and hope that nothing happens.”

So these aren't just military medicine problems or even just healthcare problems. These are human problems…. management challenges… and organizational culture problems. People get conditioned over time to keep their heads down and to not speak up. Even Toyota had to fight that notion from Japanese society (where the tallest blade of grass gets mowed) when they instituted an “andon cord” process to help people be able to “speak up” physically when they saw a problem.

There does seem to be a few wrinkles that are unique to military medicine. One is that rank matters and a nurse might be of a higher military rank than a doctor, which turns the usual hierarchy upside down a bit. The second is the idea of following orders.

“In the military you are not taught to question; you are taught to obey. And that's great on the battlefield,” said Bill Benham, until recently first sergeant of the hospital at Fort Knox in Kentucky. “But health care is another beast.”

I've heard the same thing from people I've worked with in civilian medicine who had long careers in military medicine. One leader said that “command and control, do as I say” can be a matter of life or death in battle. But, in military hospitals, the environment was meant to be much more collaborative and something that more resembles a Lean culture.

The New York Times piece is long, but I hope you'll read it. I'm curious to hear your thoughts about what your organization is doing to change the culture to make it safe to speak up. I hope they're doing more than just hanging signs and posters demanding that people speak up. How are leaders behaving differently?

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