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Improving Employee Voice About Transgressive or Disruptive Behavior

A Case Study

Dixon-Woods, Mary, DPhil; Campbell, Anne, PhD; Martin, Graham, PhD; Willars, Janet, PhD; Tarrant, Carolyn, PhD; Aveling, Emma-Louise, PhD; Sutcliffe, Kathleen, PhD; Clements, Janice, PhD; Carlstrom, Michelle, MSW; Pronovost, Peter, MD, PhD

doi: 10.1097/ACM.0000000000002447
Research Report: PDF Only

Purpose: Employee voice plays an important role in organizational intelligence about patient safety hazards and other influences on quality of patient care. The authors report a case study of an academic medical center that aimed to understand barriers to voice and make improvements in identifying and responding to transgressive or disruptive behaviors.

Method: The case study focuses on an improvement effort at Johns Hopkins Medicine that sought to improve employee voice using a two-phase approach of diagnosis and intervention. Confidential interviews with 67 individuals (20 senior leaders, 47 frontline personnel) were conducted during 2014 to diagnose causes of employee reluctance to give voice about behavioral concerns. A structured intervention program to encourage voice was implemented, 2014–2016, in response to the findings.

Results: The diagnostic interviews identified gaps between espoused policies of encouraging employee voice and what happened in practice. A culture of fear pervaded the organization that, together with widespread perceptions of futility, inhibited personnel from speaking up about concerns. The intervention phase involved four actions: sharing the interview findings; coordinating and formalizing mechanisms for identifying and dealing with disruptive behavior; training leaders in encouraging voice; and building capacity for difficult conversations.

Conclusions: The problems of giving voice are widely known across the organizational literature, but difficult to address. This case study offers an approach that includes diagnostic and intervention phases that may be helpful in remaking norms, facilitating employee voice, and improving organizational response. It highlights specific actions that are available for other organizations to adapt and test.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

M. Dixon-Woods is Health Foundation Professor of Healthcare Improvement Studies, and director, THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, United Kingdom.

A. Campbell is a research associate, Division of Infectious Diseases, Imperial College, London, United Kingdom.

G. Martin is director of research, THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, United Kingdom.

J. Willars is visiting research fellow, Department of Health Sciences, University of Leicester, Leicester, United Kingdom.

C. Tarrant is associate professor, Department of Health Sciences, University of Leicester, Leicester, United Kingdom.

E.L. Aveling is research scientist, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

K. Sutcliffe is Bloomberg Distinguished Professor of Business and Medicine, Johns Hopkins University, Baltimore, Maryland.

J. Clements is Mary Wallace Stanton Professor of Faculty Affairs, and vice dean of faculty, Johns Hopkins University School of Medicine, Baltimore, Maryland.

M. Carlstrom is founder, Safe at Hopkins, Johns Hopkins University, and principal consultant and executive coach, Build a Better Culture, Baltimore, Maryland

P. Pronovost is adjunct professor, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Acknowledgments: The authors thank the staff, faculty, and board of Johns Hopkins Health System.

Funding/Support: This study was funded by Mary Dixon-Woods’ Wellcome Trust Investigator award (WT097899) and by Johns Hopkins Medicine. Graham Martin acknowledges the support of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East Midlands (CLAHRC EM). THIS Institute is supported by the Health Foundation - an independent charity committed to bringing about better health and health care for people in the United Kingdom. Mary Dixon-Woods is a National Institute for Health Research (NIHR) Senior Investigator.

Other disclosures: Some of the authors (M.D.W., J.C., K.S., M.C., P.P.) have current or previous affiliations with Johns Hopkins. A contract was placed by this center with some of the other authors for conduct of the interview element of the case study.

Ethical approval: Study number NA_00089193 was submitted to Johns Hopkins institutional review board and deemed service evaluation (December 26, 2013).

Disclaimer: The views expressed are those of the authors and not necessarily those of the Wellcome Trust, Johns Hopkins University, Johns Hopkins Health System, the National Health Service, the NIHR, or the Department of Health.

Correspondence should be addressed to Mary Dixon-Woods, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge CB2 0AH, United Kingdom; email:

© 2019 by the Association of American Medical Colleges