Ophthalmology Business

JUL 2013

Ophthalmology Business is focused on business topics relevant to the entrepreneurial ophthalmologist. It offers editorial, opinion, and practical tips for physicians running an ophthalmic practice. It is a companion publication of EyeWorld.

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The ethics of speaking up by John D. Banja, PhD S tudies of preventable disasters and catastrophes have frequently noted that they have long "incubation" periods wherein personnel knew about serious problems leading up to and causing the disaster but either 1) failed to speak up about them or 2) did speak up but supervision or leadership was nonresponsive. To take some dramatic examples, for at least six years before the Challenger disaster of 1986, NASA knew about problems with the O-rings of the shuttle's external fuel tanks. On the morning of the launch, engineers who worked with the O-rings were calling their supervisors and urging postponing the mission because they knew the Orings were particularly fragile in cold temperatures, and it was near freezing at the launch site. Seventeen years later, the falling debris that damaged and doomed the space shuttle Columbia was a recognized problem for more than 20 years, but because nothing bad had happened during that time, the problem had been downgraded to a low-risk hazard. In medicine, perhaps the most recent example of recognizing but not responding to a disaster-in-themaking is the case of Dr. Nidal Hasan. Dr. Hasan was the army psy- 20 chiatrist who, in 2009, opened fire in Fort Hood, Texas, killing 13 people and seriously wounding 29 others. In the months preceding his unspeakable act, Dr. Hasan's superiors had been noting his behavior growing increasingly erratic and bizarre but failed to take any action that might have prevented the tragedy. Although less dramatic, we know that failing to speak up or take decisive action despite knowledge of an employee's problematic conduct is frequently discovered in root cause analyses of harm-causing medical errors. Sometimes personnel directly involved in the error will be known to have been acting strangely or carelessly prior to the error occurrence. Or a subsequent risk management investigation will discover a prolonged period wherein people knew about equipment failures, poor documentation or communication practices, poor attention to details, or personnel failing to follow standards, rules, or regulations. I point all this out not only to call attention to the very common failure to speak up about on-the-job problems, but to acknowledge the difficulty in doing so. We hate to confront a colleague or speak to a supervisor about a colleague's job performance because we fear retaliation; or we believe that even if we do Ophthalmology Business • July 2013 call attention to a problem, administration will do nothing about it; or we experience a failure of nerve because we don't have the skill set to approach and manage the problem (or the person) in an effective way. As I have studied the problem of taking constructive action over the problematic practices of employees— and this is very common—I have come across a number of suggestions from the literature that I'd like to share. The first is that if you want to have staff members who are willing to speak up about policies not being followed or other employees' problematic behaviors, personnel must feel safe enough to do so. Administration or leadership must protect individuals who have the courage to call attention to the problematic behaviors of others and must convince staff that they can always feel safe in doing so—which can be challenging if the individual alleging fault occupies a lower rung on the organizational ladder than the individual whom he or she is complaining about, e.g., a nurse calling attention to a physician's behavior. Nevertheless, if an employee fears that he or she will be harmed by speaking up, the odds are that it won't happen and performance misbehaviors will continue. A second reason why personnel don't speak up is that they might believe nothing will result from their doing so. If employees are confident that leadership will be unresponsive to their efforts, they will probably not risk their personal welfare. A third reason for not speaking out is that personnel might feel they simply don't know how. Beginning such conversations can be especially difficult, and I've supplied a list of suggestions as to how one might

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