Risk Management Tools & Resources


Speaking Up for Patient Safety: Techniques to Support Assertiveness

Laura M. Cascella, MA

Speaking Up for Patient Safety: Techniques to Support Assertiveness

Speaking up about risks, concerns, and errors in patient care is an essential component of patient safety. Although voicing concerns may seem like a reflexive response for healthcare providers and staff, barriers can prevent it from happening. Fear, intimidation, lack of confidence, power structures, and other factors can thwart individuals’ efforts to assert concerns. These issues can permeate healthcare organizations that permit or do not constructively address disruptive behavior, bullying, retaliation, and blame.

To combat a toxic environment in which healthcare providers and staff do not feel empowered to raise concerns, healthcare leaders, providers, and staff must establish and support a culture of safety. This crucial effort is particularly important as healthcare delivery models expand to include more types of providers and providers who are working more closely together.

An effective culture of safety should support an environment in which advocating for patients is not only accepted, but also encouraged. In theory, supporting speaking up behavior seems fairly straightforward; however, the barriers mentioned above can create a complex dynamic that makes the actual practice of speaking up difficult. The Agency for Healthcare Research and Quality’s (AHRQ’s) 2016 Hospital Survey on Patient Safety Culture showed that less than half of respondents (49 percent) felt empowered to question the decisions or actions of those with more authority, and more than two-thirds (65 percent) were afraid to ask questions when something did not seem right.1

To address these roadblocks, AHRQ has developed several techniques that healthcare organizations can incorporate into their safety strategies to help providers and staff advocate on behalf of their patients, assert safety concerns, and resolve conflicts of interest in a professional manner:

  • CUS: This technique is designed to use when a conflict of information is identified that warrants a team member voicing his/her Concern, that he/she is Uncomfortable, and a Safety issue exists. AHRQ notes that the CUS method is helpful when a team member is trying to raise a concern, but it seems like no one is paying attention. CUS should be used sparingly and reserved for urgent situations.2
  • Two-Rule Challenge: This technique can be used when a conflict of information is identified that warrants a team member speaking up, alerting, and/or questioning other team members before proceeding any further with a task or intervention. The two-rule challenge provides a framework for asserting concern if a clarification has been requested, but a response is not forthcoming or does not address the concern. This method also triggers next steps for elevating safety concerns if they are not resolved.3
  • DESC Script: This technique is designed to help resolve various types of conflict, including interpersonal conflict and situations involving hostile behavior. The person initiating the discussion should Describe the specific situation (using concrete data when possible), Express his/her concerns about the action or situation, Suggest other alternatives and seek agreement, and state Consequences (in terms of team goals, while striving for consensus).4

Implementing these techniques can help empower healthcare providers and staff, regardless of their position in a team hierarchy, to raise concerns that might ultimately impact patient safety and quality of care. CUS, the two-rule challenge, and DESC script offer valuable frameworks for assertive communication; however, to realize their full potential, these techniques must be part of an overall culture of safety that emphasizes teamwork, sets forth standards for professionalism and conduct, effectively addresses disruptive and hostile behavior, and takes a nonpunitive approach to managing errors and near-misses.

To learn more about the techniques in this article and building a culture of safety, see AHRQ’s TeamSTEPPS®website and MedPro’s Risk Resources: Culture of Safety. Additionally, MedPro’s booklet Simulation Training: Sample Scenarios describes how to incorporate these techniques, as well as other TeamSTEPPS® methods, into patient safety training.

1 Famolaro, T., Yount, N., Burns, W., et al. (2016, March). Hospital survey on patient safety culture 2016 user comparative database report (AHRQ Publication No. 16-0021-EF). Rockville, MD: Agency for Healthcare Research and Quality.

2 Agency for Healthcare Research and Quality. (2014, March). TeamSTEPPS Fundamentals Course: Module 6. Mutual Support. Retrieved from www.ahrq.gov/teamstepps/instructor/fundamentals/module6/igmutualsupp.html#cus

3 Ibid., retrieved from www.ahrq.gov/teamstepps/instructor/fundamentals/module6/igmutualsupp.html#two

4 Agency for Healthcare Research and Quality. (2013, December). Pocket Guide: TeamSTEPPS. Retrieved from www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html#descscript

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