Embedding speaking up at scale: a mixed methods evaluation of enablers, barriers, and pathways to sustain cultural improvement

Speaking up by health care staff is a critical component of patient safety culture (PSC) and a key mechanism for identifying and mitigating patient safety risks. Despite its importance, embedding and sustaining speaking up at scale in hospitals remains challenging. Empirical evidence examining how hospital-wide PSC interventions are embedded and sustained over time is limited.

The objective of this study was to examine how a hospital-wide speaking-up program, Speaking Up For SafetyTM (SUFS), was embedded and how associated improvements were sustained 4 years after implementation.

A mixed methods case study was conducted using routine staff survey data capturing PSC indicators (n>4,000), analyzed using t-tests, correlations, and regression analyses, alongside 17 one-on-one semi-structured interviews. Qualitative data were analyzed thematically and mapped to a sustainability framework. Findings were integrated to examine organizational, leadership, and contextual influences on sustaining improvement.

Early gains from SUFS were supported by strong initial executive sponsorship and committed trainers. However, hospital-wide embedding was uneven. Operational pressures, resource constraints, and program discontinuities limited integration into routine practice. Managers reported consistently more favorable and stable perceptions of PSC than frontline staff, whose perceptions deteriorated over time. Speaking up was associated with authority openness and leadership responsiveness, while unit-level PSC reflected reciprocal influences between local environments and perceived organizational priorities. Qualitative findings highlighted enablers and barriers across organizational culture and resourcing, leadership capacity, and implementation processes that shaped SUFS sustainment.

SUFS generated localized cultural improvement but has not yet achieved consistent organizational embedding. Strengthening leadership coherence, resourcing, and continuous participatory evaluation will be critical for sustaining speaking-up practices and realizing enduring, patient-centered safety improvements.

https://links.lww.com/IJEBH/A722.