Johns Hopkins, Cambridge work together on healthcare culture of safety

At Johns Hopkins University and Health System, a long-standing culture of fear and intimidation among clinical staff once prevailed.

Residents, medical students and nurses often felt that they couldn't challenge or bring up patient safety concerns to tenured physicians. The result was not only a hostile work environment, but one that could lead to profound patient safety issues.

“If someone doesn't feel like they can say, 'I think you missed this, or this should be done,' that is a safety issue,” said Janice Clements, vice dean for faculty at Johns Hopkins School of Medicine.

To get at the well-known problem, in 2013 Johns Hopkins developed the Safe at Hopkins program, which offers staff an outlet to anonymously report concerns about colleagues. But the service was underutilized and the culture wasn't changing, Clements said.

“It seemed like we needed to do something more global to really say to people, 'We are interested in hearing from you,' ” Clements said.

In 2014, Johns Hopkins leaders decided to partner with researchers at the University of Cambridge to address the problem. The British researchers asked Johns Hopkins staffers what prevented them from raising concerns with co-workers. Emails were sent out to staff asking for their voluntary participation in the survey. Twenty senior leaders and 47 frontline personnel responded.

The interviews were conducted anonymously over the phone. Johns Hopkins wasn't involved in the process.

“It was a safe space for people to share, and I think that's part of the reasons we got such rich information from people about what their concerns were,” said Mary Dixon, leader of the project and director of the Healthcare Improvement Studies Institute at the University of Cambridge. 


The researchers found that Johns Hopkins staff were afraid to speak up about issues with superiors. Participants characterized some senior physicians as “untouchable,” and felt these physicians didn't follow safety protocols and were excluded from disciplinary action because they were big revenue generators. Additionally, the participants described a tense, conflict-laden work environment.

Dixon, who has a history of researching employee beliefs, said a culture of fear is common for workers in industries where critical safety issues come into play.

Dixon presented her findings to the Johns Hopkins board and the entire system through several presentations, with a few hundred people attending each. The meetings helped change the culture, Clements said. “It gave people permission to think about speaking up.”

After the results were presented to staff, Johns Hopkins began to reshape its Safe at Hopkins program. Instead of focusing on just the individual who has been named in a complaint, entire unit teams where the individual works are now part of the investigation. And rather than asking questions about the individual's behavior, team members are asked to describe the culture on the unit and to disclose issues that make work challenging.

Clements said that tactic makes it easier for frontline staff to be honest about concerns. She and another colleague lead the investigations. Human resources staffers often provide additional resources and support.

Most health systems have hotlines that let staff report compliance issues, but the Safe at Hopkins program goes further in that staff can report any incident that makes them feel uncomfortable or unsafe like bullying or swearing.

Most of the time the problems can be resolved through facilitating productive discussions with unit staff members. Clements said conflicts often arise because of the stressful nature of the profession. When issues are more serious like a breach in Johns Hopkins policy, disciplinary action is taken.

During the two-year study period, 382 individual reports of disruptive behavior were made, which is a substantial increase, Clements said.

“It's seen as a safe place where you can talk to people,” she said.