Encouraging employees to speak up to prevent infections: Opportunities to leverage quality improvement and care management processes

  • Julie Robbins
    Address correspondence to Julie Robbins, PhD, MHA, Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave, Cunz Hall, 2nd Fl, Columbus, OH 43210. (J. Robbins).
    Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH
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  • Ann Scheck McAlearney
    Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH

    Department of Family Medicine, College of Medicine, The Ohio State University, Columbus, OH
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Published:April 26, 2016DOI:


      • Employee willingness to speak up about errors and opportunities for improvement is a hallmark of a health care safety culture and factor contributing to successful central line–associated bloodstream infection prevention efforts.
      • Interviews with 158 key informants at 6 hospitals across the United States found that organizational quality improvement and interdisciplinary care processes, along with leader behavior, employee training, and robust reporting systems, facilitated improvement-oriented speaking up related to central line–associated bloodstream infection prevention.
      • Although initiative-specific efforts are important to central line–associated bloodstream infection prevention, efforts to facilitate speaking up may be best implemented at the broader organizational level.


      Central line–associated bloodstream infections (CLABSIs) are associated with increased morbidity, mortality, and cost for U.S. hospitals, but many infections are preventable. Employees' willingness to speak up about errors or opportunities for improvement has been associated with a stronger safety culture in hospitals. However, the link between organizations' efforts to promote speaking up and prevent CLABSIs has not been studied.


      This exploratory, qualitative study included interviews with 158 key informants, including hospital executives, managers, and staff employees, in 6 hospitals that participated in the federally funded On the CUSP—Stop BSI initiative. Verbatim transcripts were analyzed to examine whether and how speaking up was addressed in CLABSI prevention efforts.


      Hospitals implementing evidence-based practices for CLABSI prevention facilitated employees' improvement-oriented speaking up by leveraging quality improvement and care management processes. Leader behavior, employee training, and error reporting systems also facilitated speaking up. Although the focus of this study was on CLABSI prevention, broader organizational practices to improve patient safety were salient in creating a nonpunitive, highly inclusive environment in which employees felt comfortable speaking up.


      These findings provide insight into the factors that may support speaking up to foster a safety culture and prevent health care–associated infection at unit and organization levels.

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