By LISA SHIEH MD, PhD, and JINGYI LIU, MD

There have been disturbing reports of hospitals firing doctors and nurses for speaking up about inadequate PPE. The most famous case was at the PeaceHealth St. Joseph hospital in Washington, where Dr. Ming Lin was let go from his position as an ER physician after he used social media to publicize suggestions for protecting patients and staff.  At Northwestern Memorial Hospital in Chicago, a nurse, Lauri Mazurkiewicz warned colleagues that the hospital’s standard face masks were not safe and brought her own N95 mask. She was fired by the hospital. These examples violate a culture of safety and endanger the lives of both patients and staff. Measures that prevent healthcare workers from speaking out to protect themselves and their patients violate safety culture. Healthcare workers should be expected to voice their safety concerns, and hospital executives should be actively seeking feedback from frontline healthcare workers on how to improve their institution’s Covid-19 response.

Share power with frontline workers

According to the Institute for Healthcare Improvement, it is common for organizations facing a crisis to assume a power grab in order to maintain control. As such, it is not surprising that some hospitals are implementing draconian policies to prevent hospital staff from speaking out. While strong leadership is important in a crisis, it must be balanced by sharing and even ceding power to frontline workers. All hospitals want to provide a safe environment for their staff and high-quality care for their patients. However, in a public health emergency where resources are scarce and guidelines change daily, it’s important that hospitals have a systematic approach to keep up.

Learn from the aviation industry

The aviation industry is an example of an industry that has benefited tremendously from protocolizing safety culture. Flight recorder data from the 1970s suggested that many aviation disasters occur because communication breaks down between crew members. The KLM Flight 4805 crash in 1977 and the United Flight 173 crash in 1978 were caused by captains overruling the concerns of their copilots. For this reason, the aviation industry created the Crew Resource Management (CRM) protocol. CRM emphasizes teamwork and communication and is based on the premise that everyone: captains, co-pilots and flight attendants alike, have equal responsibility in maintaining safety. CRM harkened a paradigm shift from the previous culture of ‘captain is god’. The incorporation of CRM into aviation training is a major reason why aviation is much safer today.  Hospitals should strive to create a similar safety culture in responding to COVID, where physicians, nurses and hospital leadership have equal responsibility in maintaining the safety of patients and providers.

How to maintain safety culture during a pandemic

Below, we have provided some principles and examples for a healthcare focused “CRM” to help hospitals maintain safety culture during the Covid-19 pandemic.

1. Adopt a team mindset: Hospitals are large hierarchical institutions often driven by top-down management. This can lead to operational disasters such as dwindling PPE supplies, prolonged turnaround times for COVID testing, inadequate safety protocols, and more. Hospital leaders should make themselves accessible to the input of frontline workers. They should view their staff as not just pairs of hands, but as employees with crucial knowledge to improve the hospital’s Covid-19 response.
2. Solicit feedback from frontline workers: Hospital leadership should actively solicit feedback from frontline workers to identify opportunities for improvement. At Stanford, we hold weekly virtual town hall meetings where all staff are invited to virtually send questions and concerns to Department of Medicine leadership. The answers are recorded and then made available on the internet for anyone to access. We also conducted focus groups with representatives from across Stanford Healthcare. Topics which consistently arose during discussion include access to appropriate PPE, being exposed to Covid-19 at work and taking the infection to family and not having rapid access to testing if needed, just to name a few.
3. Communicate with regularity and transparency: Covid-19 is a rapidly evolving situation. Timely and transparent communication regarding the state of the hospital and foreseeable challenges is critical to maintaining provider trust.  Many difficult truths will arise during these conversations, but if they are not shared, they will never be addressed.  At Stanford, we receive daily newsletters on how many SARS-cov2 tests were run in the last 24 hours, how many were positive, how many patients are on the floor/ICU and other metrics. We are also updated on how many days of PPE we have available, and what additional sourcing options the administration is pursuing in case we run out.
4. Maintain psychological safety: Psychological safety is defined as the belief that one will not be punished or humiliated for speaking up. Psychological safety occurs when there are safe spaces that expect individuals to speak up. The goal is to encourage honest feedback from every corner of the hospital, from the linens department to the intensive care nurses. Psychological safety is destroyed when management implements draconian consequences for speaking up, as was the case at St. John’s Health Center in Santa Monica, CA when nurses were suspended after they requested N95 masks while working in a coronavirus ward. In addition to the ongoing pandemic, another crisis emerges when healthcare workers are afraid to speak up.
5. Establish expectations of speaking up: Workers should not only feel empowered to express concerns regarding safety, they should know that there’s an expectation that they will do so. There are many widely available tools that healthcare workers can use to express and escalate safety concerns. At Stanford, one of the commonly used tools is ARCC (Ask a question, Request a change, voice a Concern, Chain of Command). For example, a resident physician could inform their chief residents, “Are you aware that we are only being limited to one N95 mask per week? I’d like to request more masks as I am concerned that reusing N95 masks will increase our risk for contracting Covid-19. This is a safety issue that endangers both residents and patients, I’d like to discuss this issue with the department of medicine leadership”. 

Healthcare workers should not be punished for speaking up, especially when their primary goal is to protect themselves and patients. We hope the above suggestions will help hospitals maintain a strong safety culture during their Covid-19 response. Maintaining a safety culture during the time of Covid-19 is not just important, it’s a matter of life or death.

Lisa Shieh, MD, PhD is a clinical professor in the division of hospital medicine and department of medicine at Stanford Healthcare, as well as an associate chief quality officer for Stanford Healthcare and medical director of quality improvement programs for graduate medical education.

Jingyi Liu, MD is a resident physician in internal medicine at Stanford Healthcare.  Twitter: @JingyiLiu8