The Doctor’s Advocate | Third Quarter 2022
Perspectives from the CMO

Building a Culture of Safety in Healthcare, Part One: Mutual Respect

David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors

Years ago, I witnessed something surprising. During a discussion of our then-new Code of Mutual Respect at Maimonides Medical Center, a surgeon stood and put up his hand: “I’m part of the problem—and I dedicate myself to getting better.” This surgeon modeled the honest reckoning that is required as we cultivate mutual respect in healthcare.

Creating a Safety Culture in Four Not-So-Easy Steps

By now, we all have a general idea of what “safety culture” means, but to progress, we need specifics. A culture of safety requires four elements:

  1. Mutual Respect: When mutual respect permeates the workplace, it fuels interactions expressing the value of professionalism. Such interactions increase patient safety and decrease burnout.1
  2. Teamwork Training: Healthcare is a team sport, as we recognize “considerable interdependence” among healthcare providers.2 Therefore, we cannot optimize patient outcomes without emphasizing communication and teamwork skills among healthcare professionals.
  3. System Design: When IV bags have unreadable labels or crash carts have different arrangements, we are not setting ourselves up to succeed. We can change that.
  4. Just Culture: A just culture finds the desirable midpoint between a blame-free culture at one extreme versus punishing people for any mistake at the other. A just culture recognizes the need to console those whose role in an event is best ascribed to human error, coach those who have drifted into at-risk behavior, and punish only the reckless.

Cultivating these elements is easier said than done, so I will devote one column to each of the four elements, starting with mutual respect in this issue.

Mutual Respect Is Learned Behavior

Anyone can learn to treat their coworkers with more respect, and doing so improves patient safety, mitigates risks of liability, and shields us from some burnout-provoking factors.3 As Lucian Leape, MD, a founder of the patient safety movement, says simply: “The key success factors in a safety effort are teamwork and respect, two basic ideas that are too often lacking in medicine. People have to be trained to work in teams and to respect others on the team.”4

Disrespectful Behavior Can Be Categorized

Disrespectful behavior, like respectful behavior, can become atmospheric. Like fumes, disrespect can permeate a setting, so that no one is sure anymore where it originated. Helpfully, Dr. Leape and colleagues have taxonomized the types of disrespect:5

  1. Disruptive behavior: Includes shouting, swearing, loud or inappropriate arguments, the use of force, and/or the threat of use of force. Classic operating room temper tantrum scenarios, sexual harassment, and/or other egregious episodes are also included.
  2. Humiliating, demeaning treatment of nurses, residents, and students: Not as showy as flat-out disruptive behavior, but much more common, so perhaps even more insidious.
  3. Passive-aggressive behavior: Includes hindering progress while feigning innocence, such as by delaying tasks—or completing tasks in a way designed to annoy others.
  4. Passive disrespect: Perpetually delayed responses, attitudes of noncollaboration with others. Perhaps rooted more in apathy or burnout than in anger.
  5. Dismissive treatment of patients: Includes showing annoyance at being required to answer patient questions or conspicuously talking about a patient but never to them.
  6. Systemic disrespect: Includes features of healthcare systems that convey disrespect to both providers and patients, such as scheduling many inadequately brief appointments close together, so that sufficient time with one patient means all subsequent patients must wait.

Disrespect Is Dangerous

Dr. Leape and other researchers who focus on patient safety and respect have spelled out what we intuitively sense: Disrespect is dangerous. In the short term, a person’s emotional reactions to a degrading work environment impede their ability to think clearly, which increases the likelihood of error. Over the long term, those on the receiving end of humiliating behavior will exhibit “a very rational response: Avoid the person inflicting the hurtful behavior. . . .For a nurse or resident, this may be expressed by reluctance to call a disrespectful attending physician with questions. . . .The loser is the patient, who may suffer from delayed or erroneous diagnoses or treatment.”5

One recent study found that patients whose surgeons’ behavior had prompted an unusual number of coworker complaints were at increased risk of surgical and medical complications.3

Crafting an Effective Code of Mutual Respect

When I led the effort for Maimonides Medical Center to create a formal, written, official Code of Mutual Respect, I knew we needed to set clear expectations that would apply to everyone. We also needed to recognize and address contributing issues within our system. Therefore, when investigating incidents, we included unbiased peers from other departments and took other steps to create a fair process that would help to relieve, not further entrench, certain longstanding zones of frustration. We also tied our Code of Mutual Respect to our TeamSTEPPS® training and otherwise thoroughly embedded it within our institution-wide patient safety and risk reduction efforts.

As you create or improve policies to foster mutual respect within your own institution, I recommend you follow Dr. Leape’s outline:6

  1. Fairness: The policy applies to everyone providing care, whether they are a physician, nurse, student, etc.
  2. Consistency: The policy is consistently enforced throughout the hierarchy.
  3. Graded response: Some complaints can be approached via collegial discussion over coffee, while some behaviors are egregious in the first instance or have persisted beyond first-level interventions. Therefore, establish how to escalate as needed through reviews and disciplinary actions of increasing severity if the pattern of disrespect persists.
  4. Restorative process: Some persistent patterns of disrespect clear up after the person views a video of their problematic behavior; others benefit from more formal interventions, such as sessions with a psychologist.
  5. Surveillance mechanisms: Employees need access to a reporting system that protects them from potential retaliation, like the Co-worker Observation Reporting System (CORS Program) implemented by Vanderbilt University.7

Over the first three years of implementing our Code of Mutual Respect at Maimonides Medical Center, we saw across-the-board improvements in our respect survey results from team members in perioperative services.8

Mutual respect is the foundation of patient safety, risk reduction, and professional satisfaction. To get started, listen to my interview with Michael Brodman, MD, a patient safety leader at Mount Sinai, or learn more through our open-source Maimonides Medical Center Code of Mutual Respect.2


  1. Rosen MA, DiazGranados D, Dietz AS, et al. Teamwork in healthcare: key discoveries enabling safer, high-quality care. Am Psychol. 2018;73(4):433-450. doi:10.1037/amp0000298
  2. Maimonides Medical Center. Code of Mutual Respect. Accessed June 14, 2022.
  3. Cooper WO, Spain DA, Guillamondegui O, et al. Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. JAMA Surg. 2019;154(9):828-834. doi:10.1001/jamasurg.2019.1738
  4. Interview with Lucian Leape, MD. J Healthc Manag. Mar-Apr 2008;53(2):73-77.
  5. Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7):845-852. doi:10.1097/ACM.0b013e318258338d
  6. Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med. 2012;87(7):853-858. doi:10.1097/ACM.0b013e3182583536
  7. Vanderbilt Center for Patient and Professional Advocacy. Co-worker Observation Reporting System (CORS Program). Accessed June 14, 2022.
  8. Kaplan K, Mestel P, Feldman DL. Creating a culture of mutual respect. AORN J. 2010;91(4):495-510. doi:10.1016/j.aorn.2009.09.031

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

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