This was just published on the BMJ blog.

The oval, mahogany table dominates the center of the large conference room. A number of chairs circle the table and dot the perimeter of the room. Every week, a group of high level hospital administrators, physician leaders, and leaders of other professional and occupational disciplines—physical therapy, social work, clinical directors of nursing, housekeeping, etc—gather in this room to discuss hospital function. They call themselves a “team” and the gathering a “team meeting.”

Nothing indicates that places at the table are reserved for particular participants. But today, as happens every week, when physicians and hospital administrators enter the room, they immediately occupy the chairs at the table. As nursing and other professional and occupational “leaders” enter the room, they sit around the perimeter, even if seats at the table are empty. The discussion is largely conducted by, and includes mostly, people sitting at the table. Occasionally, someone chips in from the outfield, as it were, but not too often and certainly not with much vigor.

I have been invited to this hospital to consult about teamwork, patient safety, and “professionalism” particularly among the nursing staff. The hospital has sent people to do TeamSTEPPS, a healthcare team training developed by the Department of Defense and the Agency for Healthcare Research and Quality. It has hired consultants to teach people the principles of high reliability organizations (HROs). It is concerned about the fact that non-physician personnel do not speak out about patient safety and, as the Chief Nursing Officer puts it, do not behave in a “professional manner” when at work. Maybe, she muses, nurses would speak up more if they all wore a standard uniform instead of scrubs adorned with flowers or smiley faces. Come and observe us function, and tell us what you think, is my mandate from the executive team.

So when I observe how “team” meetings are conducted at the highest levels, I am expected to ask some questions. Which I certainly do.

After the meeting is over, I ask nursing clinical directors and “leaders” in social work and other disciplines, why they do not take a seat at the table when one is empty. They all say they same thing.

“Those seats are reserved for physicians and hospital administrators.”

“How do you know this,” I ask, “were you specifically informed of this rule?”

“You don’t have to be told,” they reply, “We just know.”

” Why do non-medical personnel speak so infrequently?” I then query.

“Well,” someone stammers, “it’s not clear anyone really wants to hear from us.” They also add that when non-physician staff finally do say something, they do it tentatively, rather than presenting their concerns in a compelling and confident manner. Or they stick to commenting on issues pertaining to their particular profession or discipline, even when they have things to say about broader issues. They say they tell me that they know it’s critical to have new perspectives on patient care issues, but they just don’t feel safe to address them.

In their excellent paper on the choreography of power during morning rounds, Elise Paradis, Myles Leslie, and Michael Grooper point to the same persistent problem in a year-long ethnographic study of morning rounds. They report that, “Operational conditions on the units, despite interprofessional commitment and engagement, appeared to thwart ICU teams from achieving these goals. Specifically, time constraints, struggles over space, and conflicts between morning interprofessional rounds. Educational and care-plan-development functions all prevented teams from achieving collaboration and patient involvement. Moreover, physicians’ de facto control of rounds often meant that they resembled medical rounds (their historical predecessors), and sidelined other providers’ contributions.”

Institutional leaders may exhort staff to speak up to protect patients, present their ideas for quality improvement, and help build a high reliability organizations. They may even provide some training in the skills needed to enact teamwork and high reliability. These, however, may be undermined by behaviors that reinforce traditional patterns of reverence and deference and locate “expertise” and vest authority in those who have the most years of higher education and initials after their last names.

One of the most critical tenets of high reliability is deference to expertise. In their book Managing the Unexpected, Weick and Sutcliffe define expertise in terms of front line experience, with decisions and authority, as they put it, migrating to people “with the most expertise, regardless of rank.” When rank defines authority and expertise, it undermines the kind of psychological safety, Schein and Bennis and then Edmondson describe as critical to institutional learning and safety.

As we saw in the “team” meeting described above, you don’t have to tell people to “shut up” in so many words. Particularly when you are dealing with “lower status” groups, all you have to do is send signals that they and their input is unwelcome. If a nurse or social work leader is informally prohibited from sitting next to an MD or executive at a conference table during a meeting about quality and safety, is it surprising that nurses on the wards won’t tell a physician he has forgotten to clean his hands or that she is about to deliver the wrong dose of a medication?

We have largely left the era when surgeons throw scalpels in the OR and physicians expect nurses to give them their chairs when they enter a room. What we have not engaged in, however, is the kind of profound behavioral culture change that helps people check their concern for status at the door so that they can learn and listen from people who are not at the same level in the hierarchy as they are. This requires not only an actual seat at the table, but inviting input of not the usual suspects, noticing silence, and helping people to contribute. So keep your eyes open. When you see a circle of exclusion, expand it and invite people to enter. Don’t wait for people to speak up, ask them about their concerns. And most importantly, when someone of lower rank sits on the periphery when a chair is open at the table, ask them to fill it.

Suzanne Gordon is a healthcare journalist and co-editor of  The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.