A chain of command is a formal, structured communication technique used to resolve patient safety issues. Through this process, care team members can escalate a concern through leadership levels until a resolution is reached. When appropriately utilized, the chain of command provides clear guidance to staff and enhances an organization’s culture of safety.
Elements vary by organization. However, the process usually begins with communication to an immediate supervisor that may then extend up the hierarchy to organizational leaders, medical executives, or even governing body members.
Typical situations in which the chain of command is invoked include:
- A lack of orders.
- Disagreements over patient care.
- A non-responsive practitioner.
- A practitioner who does not follow established policies and procedures.
Consider the following when implementing or reviewing your organization’s chain of command policy:
- Develop a well-defined, written policy that covers:
- Specific steps that are to be used, including the job titles (not names) of the persons that are to be included and the expected response times.
- When to invoke the process, including a decision-making algorithm.
- Who can invoke the process, including an open invitation to any staff member with a safety concern, regardless of their job title.
- Documentation expectations, addressing when process invocation should be documented in the organization’s incident/event reporting system.
- Eliminate cultural and organizational barriers, ensuring that the work environment is a safe place where staff feel empowered to question others for the benefit of patient safety.
- Educate all staff, coaching them on how to overcome barriers to the chain of command process such as fear of intimidation and retaliation, doubt in one’s own abilities and concern about confidentiality.
- Utilize structured, standardized communication techniques to decrease misconceptions and misunderstanding between health team members.
- Evaluate effectiveness, conducting regular audits to determine whether staff follow policies and procedures, as well as to determine whether the process resolves concerns in a timely fashion.
When patient safety is in jeopardy, failure to speak up can result in liability and patient harm. When used appropriately, the chain of command process is a powerful patient safety tool in an organization that embraces Just Culture principles and a patient safety philosophy.