#MEQAPI – Tweetchat June 1st 2017 3:00ET: Speaking Up

Topic:  “Speaking Up” vs unprofessional behavior

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org.

Fear of repercussions and scapegoating is a major impediment to safety, and frequently results in increased waste and lost lives.

A basic principle of quality improvement is the establishment of a “no-blame” culture in which every stakeholder feels an obligation to report quality risks or issues, but also knows that the response will be to focus on the problem and a solution rather than on blaming the individuals.

The need for “Speaking Up” is applicable to every healthcare facility and specialty, regardless of whether they are public or private institutions. The idea that if you “see something, say something” is very important no matter your “position” at the facility. Advocating for the patients is very important, and often times people will keep quiet because they are afraid of repercussions if they do speak up.

Deming included “Drive out fear” in his list of 14 Points for quality. He exhorted organizations to encourage effective two way communication as a means  to drive out fear throughout an organization. This enables everybody to work effectively, productively, and safely.

This chat is based largely on the BMJ paper by Martinez et al “Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents

Recent articles from Physician’s Weekly on unprofessional behavior in healthcare:

We will take a QI approach, and discuss the  topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

Speaking Up

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including MU, HIPAA, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Workload: demands of the job, and whether they exceed the resources and ability to meet the demand.
      • Human Resources Policies
    • Machines (equipment, EHR)
      • Medical or office equipment
      • Home equipment specific to the patient condition
      • Integration/interoperation with other office or medical systems, or user personal health records
      • Access Control
    • People
      • Staffing: sufficient and qualified staff
      • Training: base training, ongoing training, CME, and patient or carer training
      • Attitudes: staff attitudes to technology, adoption vs resistance, bullying, supporting
      • Fatigue (especially alert fatigue)
      • Values and traditions
      • Friends and family
      • Role Models
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc
      • Internet sources
      • Employment Handbook
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Incentives and rewards
      • Adverse Effects reporting
      • Disruptive Incidents reporting
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Traditions

Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.


  1. What METHODS increase or reduce unprofessional behavior or ability to speak up
  2. What MACHINE factors increase or reduce unprofessional behavior or ability to speak up
  3. What PEOPLE issues increase or reduce unprofessional behavior or ability to speak up
  4. What MATERIALS increase or reduce unprofessional behavior or ability to speak up
  5. What MEASUREMENT factors increase or reduce unprofessional behavior or ability to speak up
  6. What ENVIRONMENTAL factors increase or reduce unprofessional behavior or ability to speak up

… and the numbers:

June 1 MEQAPI numbers


MEQAPI Participants June 1


MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.





Published by

Matthew Loxton

Healthcare Analyst using Lean Six Sigma, Knowledge Management, & Organizational Learning to improve healthcare http://linkedin.com/in/mloxton

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