Messy moments: Someone to blame

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Your clinic staff continually snipe at one another. The PA blames a tech for a task going wrong. The NP barks her orders so that everyone hears. The MA came to you to tattle on the PA.

People being mean slows work down. Sniping and blaming are awful to be around.

It’s also not safe patient care.

What IS the problem? People may feel overworked. Some may be nervous know knowing how to do their new jobs. Some belittle others because everybody does it. Many possibilities….

This blame culture pervades medicine. When things don't go as expected, blame someone. Everyone - especially MDs - tend to think they are personally responsible for everything. When something goes wrong, it’s their personal failing. They blame themselves… Then they often turn around and blame others.

It's contagious: the meanness spreads. Blaming others jeopardizes patient safety. Stressful, complex work requires people treat everyone respectfully – so they coordinate care clearly and smoothly. It also begs for kindness so people feel safe at work.

But it’s hard to change the blame habit.

You really want staff to cooperate with more kindness. It will reduce errors. You really want the sniping and blaming to stop. Your patients’ experience will improve, and so will everyone’s. You really want to stop spending time to arbitrate all the arguments.

Reducing workplace hostilities will benefit you, your patients and your staff.

• Your practice will have fewer errors and near-misses. People blaming others fail to tell each other critical information or cooperate with the patient in mind.
• Better collaboration will make the work flow more predictably and smoothly. Patients will like it.
• Staff understand that everyone is accountable and responsible in some way. When they know that mistakes will be treated fairly, they feel safer talking about problems. They’re alsomore likely to take responsibility for them.
• Staff will feel more motivated. Blaming is demoralizing: one tells the other they are incompetent.
• People who feel safe speaking up when things go wrong feel valued as part of the team, part of the solution. They’ll be more willing to contribute candidly in a no-blame culture. Raising concerns is expected. They likely engage more fully
• Absences, withdrawal and turnover fall. Staff want to work there because they feel they contribute value to the practice.
• The atmosphere dramatically improves when everyone knows the focus is safety and solutions, and that they won't be blamed for something outside their control. Mistakes become learning moments where everyone searches for improvements, rather than a chance to make others feel bad about themselves.

What one thing can you do to improve work relationships and clear the air?

You count on clinicians’ candor. That requires you to be candid.

• Look at problems and sticky situations with curiosity. A curious mindset frees you of assumptions from the past and invites new thinking. Before thinking about who to blame, think: ‘I don't know the answer yet.’
• Pause. Pause just a moment between seeing something and deciding what the problem is. This is very hard. The pace is fast, and everyone expects you to declare what’s wrong and demand a change. Many leaders fear pausing because they’ll be perceived as weak. If you need help pausing your thinking, say aloud in a neutral tone: ‘What seems to have happened here?’ That returns you to observations and to thinking. Then wonder: What else might be going on? Who else is involved outside your current frame of reference?

Role-model no-blame behavior:

• When you make a mistake, bring people together in an after-shift huddle or brief hallway conversation away from the exam room.
  • Take a visible pause – two slow breaths.
  • State very briefly your mistake and the reason it matters.
  • Ask:
    • What else might have led to this situation?
    • Where did our processes break down?
    • Make sure many if not all contribute to the discussion. Acknowledge and appreciate each comment.
    • Really listen to observations and background facts you likely don't know.
    • Your curiosity and listening are contagious. You invite theirs.
• Recap what you learned together. Clarify that system failures cause most mistakes. That doesn’t remove responsibility. It does mean that rarely is only one person the cause
• Ask: Now that we understand more about how this happened, what can be done differently to get a better outcome in a similar situation in the future?
• Then offer what you yourself will do to improve the situation and when.
• Tell everyone when you’ll check in to assess together how the effort has improved similar situations… or not.
• Then remember to do it!

Blaming – treating others like they are the problem – is a hard habit to change on both individual and organizational levels. It feels natural. Most of us don't realize we’re doing it! The truth is that errors are rarely caused by one individual in complex environments. So blame is almost always unjust. It is also unsafe.

A culture of curiosity and kindness will improve patient care. It can break the persistent culture of silence about care problems. People become less afraid to point out problems if they won’t be blamed or shamed.

People will also feel better about coming into work.

The task though is not one-and-done. It takes time for people to trust that they won’t be blamed if they present a problem. It takes time for them to believe that their observations and thoughts really matter. If questions are asked and answered together when things go wrong, the sense of psychological safety will develop. When everyone feels safe to speak, they will learn their voices are important. You expect their comments. They will see that they all share the responsibility to improve patient care. Everyone needs to approach problems like this persistently and consistently over time.

Nance Goldstein, MDc, ACC, PhD, partners with physicians as a leadership coach to find ways through today’s tough times and enjoy medicine more. She’d like to hear what troubles you in your practice. Email her: Nance.goldstein@post.harvard.edu