Tag: <span>Interventions</span>

10 lessons for speaking-up: learning from Virginia Mason’s PSA system.


Virginia Mason (VM) Medical Center based in and around Seattle consists of one 350 bed hospital facility and 9 satellite units. They employ 5000 staff, 500 of which are physicians.

The Patient Safety Alert (PSA) system was introduced in 2002 following a staff survey. This showed that staff were fearful of speaking-up about concerns. Also, staff doubted that information generated from concerns would improve the safety of care. At the time of the survey VM staff wishing to raise concerns had to complete a quality incident report (QIR). Typically, QIRs would sit on a shelf collecting dust for months, then filed away and forgotten. As we know from countless reports and commentaries into safety failures in healthcare and other industries, perceptions of fear and futility around speaking-up are inimical to creating a positive speak-up or open culture.

Patient Safety Alerts (PSAs).

The philosophy of PSAs is based on Toyota’s “Stop the line” policy, which  empowers any employee to stop the multi-million pound production line to prevent a defect occurring. Specifically, the philosophy being replicated at VM is that instead of criticizing or silencing employees who raise concerns, they offer support and resources to fix the problem. PSAs have a broad remit and are intended to capture all events involving the safety and well-being of a patient.

Results of implementing PSAs.

Result 1: From March 2002 to January 2014 staff raised concerns a total of 43,615 times. This has grown from around 10 or so reports a year in the period 2002-2004, to 850 reports a month in January 2014.

Result 2: Between 2004 and 2014 there has been a 74% reduction in insurance liability premiums paid by staff, which is an indicator of a major shift in “risk perception” by insurers. This shift in risk perception is probably based on insurers having paid out less in liability payments related to claims against VM staff – think “no claims bonus” with car insurance! Complaints and claims management go down as PSAs go up.

Result 3: PSA reporting has provided intelligence to drive improvements to quality. An improvement system where priorities are often identified and owned by sharp-end employees, who are supported by senior leaders and executives in the organization. Bottom up meets top-down.

Lessons from Virginia Mason…..

The rate change in PSAs reported in 2004-05 and
2009-10 seem to be linked to specific events which the
executive team subsequently used to publicise the
PSA’s philosophy to all employees. These events
seemed may have built employee trust in the system. Examples of events included what was termed “You call in a
PSA, we’ve got your back” which publicized how the PSA system supported a nurse speaking-up about a physician’s lack of compliance with safety procedures. Similarly, another event publicized how a senior physician used the PSA to report his own drug error. The “showcasing” of these series of events enabled the executive team to establish a new narrative supplanting traditional norms of skepticism and silence about reporting concerns with a “new” narrative of trust , openness and improvement stemming from raising concerns.

10 lessons for speaking-up in the NHS

1. VM didn’t get the PSA system right first time. It took almost a decade of learning.
2. They still haven’t got it right all the time, but reporting of concerns and responses to concerns are significantly better.
3. The PSA system has undergone continuous improvement.
4. Executive leadership is a prerequisite to building a culture of speaking-up.
5. Extensive staff education around listening and responding to employee concerns needed.
6. Publicizing positive case studies can dictate a safety narrative and create a new norm around
7. Mechanisms for speaking-up should be easily accessible, with multiple options available.
8. Rapid feedback to staff in the first instance. Keep staff updated with progress thereafter.
9. “Significance” is in the eye of the beholder: Open the floodgates to all concerns.
10. Be prepared to change as the organization learns from speaking-up.


Kenney C. A Leadership Journey in Health Care: Virginia Mason’s Story. New York: CRC Press; 2015.

Furman C, Caplan R. Applying the Toyota Production System: Using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007; 33(7): 376-86.

Embedding a System to Protect Patient Safety


Literature review update

Having previously blogged about registering the literature review see here the team have subsequently spent the last few weeks diligently searching numerous literature databases. We have also reviewed several hundred titles, abstracts and full text of papers.Time, therefore for an update on progress.

A reminder that the scope of the narrative review is to search and critique research studies of workplace initiatives designed to promote speaking-up, and responding to speaking-up. Initiatives within healthcare and other industries/sectors are of interest. Some of the headlines from the review include:

  • Overall, the quality of the research is poor.
  • We have broadly divided studies into reports of
    • Educational initiatives – speak-up learning interventions undertaken within universities with undergraduate students.
    • Workplace initiatives: speak-up interventions undertaken within workplaces not involving formal training or educational input.
    • Workplace/workforce training initiatives: mostly voluntary, occasionally mandatory enrolment of employees onto formal training courses, often involving simulated practices and/or team-working interventions.
  • There were no published, peer review studies of initiatives resembling the Freedom to Speak Up Guardian (FTSUG) role.

However, as we have learnt from our interviews (more of which in the next blog post) FTSUGs design and implement speak-up training initiatives and undertake a variety of workplace initiatives to promote speaking-up. Therefore, the review of literature will be useful in terms of helping us understand some of these activities. We are preparing a paper for submission in the new year to an internationally acclaimed peer reviewed journal.

Grey literature

We are also undertaking a review of grey literature. Grey literature publications are usually not from peer reviewed academic journals. This can include policy documents and reports/evaluations of speaking-up initiatives by organisations, charities and commercial companies. The team have identified speak-up initiatives from various sectors such as humanitarian aid, telecommunications and law enforcements. We are always on the lookout for more, so please get in touch if you know of any interesting grey literature in this area.

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10 lessons for speaking-up: learning from Virginia Mason’s PSA system.

Background.  Virginia Mason (VM) Medical Center based in and around Seattle consists of one 350 bed hospital facility and …