Just this week, concurrent with the 2011 AORN Congress, AORN released an article that was really quite interesting. The article, entitled “The Silent Treatment,” discusses the shortcomings of checklists, bundles and Safety Tools. They’re hardly the first to address this concern. While many have been insisting on culture change as an essential element to implementing these very effective Tools, the most recent authoritative voice may be that of Peter Pronovost, MD, PhD.

Most of you probably know of Pronovost’s work that resulted in the Central Line Checklist, which virtually eliminates CLABSI. A simple Tool, the key to its success according to Dr. Pronovost is culture. Dr. Pronovost insists that the checklist, protocol, or safety Tool is only going to be effective if you have a culture wherein ANY member of the healthcare team, including environmental services, housekeepers, transporters, techs, administrators, nurses, mid-levels, etc. can, and will, speak up and challenge non-compliance or safety concerns.

The AORN article is noteworthy because it presents research indicating that many times clinicians won’t speak up. In fact, they found that 58% of nurses reported a failure to speak up when they witnessed a violation of protocol or a safety concern. Moreover, 17% of the nurses polled said that this happens “a few times a month.”

My colleagues and I have been down this road and there’s an even more difficult situation than the one investigated in this study. The query in the article asks about known problems that were made evident by a Safety Tool. The more subtle and much more difficult situation is when a member of the healthcare team merely “thinks” there may be a problem. People don’t want to look silly, don’t want to make a fuss over something trivial, etc. So they don’t speak up!

While it’s a good idea for nursing executives, administrators, department chairs and others to say, “We want you to speak up if you see something wrong,” the simple truth is that this encouragement is insufficient. The best way to ensure that the staff in this OR, on this shift, on this ward, etc. will speak up is for the most empowered (licensed) person on the team to articulate this expectation in real time. It’s good to know that my hospital wants me to speak up, but if the ED physician says something like, “If anyone has any concerns about the welfare of any of our patients tonight, I expect you to speak up,” this is a very strong statement of expectation here and now, when it matters. This is the kind of action that changes culture, one shift at a time.

Safety Tools, checklists and protocols are effective ways to standardize best practices, but if they’re not embedded in a culture of mutual support they’re unlikely to yield significant improvements.