What does "patient safety" have to do with the catastrophic 2003 explosion of the space shuttle Columbia, killing all seven of its crew members?

A lot, according to patient-safety experts. They regularly discuss the Columbia disaster as a classic case study of the potential for silence to kill -- whether in an organization like the National Aeronautical Space Administration (NASA) or a large health care system like the VA. Silence, it's been shown repeatedly, can be deadly not only when individuals don't speak up about problems risking human safety, but also when organizations silence those who do.

The Columbia Accident Investigation Board, appointed by President George W. Bush, concluded in 2003 that NASA's organizational culture had as much to do with the accident as the breach in the thermal protection system on the shuttle's left wing.

It reported, "Cultural traits and organizational practices detrimental to safety were allowed to develop, including ... organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion."

Like NASA, health care systems are large, complex, socio-technical systems. To provide safe products and services, they must increasingly depend upon clear and robust communication among many different people working across many different boundaries within the organization -- administrative, professional, ideological, geographical, temporal and cultural.


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That is why, for the sake of patient safety, it's become critical for health care systems to take responsibility for creating and rectifying organizational cultures of silence that obstruct and distort communication channels. Patients live -- and die -- at the ends of those channels.

Within such systems, organizational silence can cause serious side effects for patients. For example, it's risky for patients who receive care in settings that discourage health care workers from speaking up when mistakes occur. Patients are placed in harm's way from unnecessary testing or procedures that are secretly incentivized by kickbacks to hospitals or physicians. A system that silences reporting of impaired or incompetent health providers compromises patient safety. And, as the VA scandal seems to show, silence can be deadly when employees can't speak out against fraudulent or unjust administrative practices.

Health care silence isn't confined to the VA. It is pervasive and entrenched. And because it is at once both personal and organizational, opportunities arise for patients and workers to minimize their contributions to it.

Still, it's often hard to break codes of silences within organizations on which we depend -- for health care as patients, for work as employees. Deeper still, on a more fundamental level of belonging, many of us join these organizations already acculturated to upholding codes of silence within our families or relationships.

You bring up a loved one's problematic drinking, infidelity, investment mistakes, snoring, religion or politics at your own peril. Depending on your views and values, you decide how much to accommodate these tribal conventions.

Yet these interpersonal communication challenges are magnified multifold when working for a large organization with its many members from many different private and social cultures. Furthermore, you must also find ways to adapt to a corporate culture with its unique hierarchical communication channels, corp-speak, and codes of silence.

You have to decide how much to accommodate this new culture for the sake of company unity, your job, your sanity and self-respect. And you may have learned that speaking out against the organizational norms could risk your career advancement or being labeled as troublemaker, whiner, a non-team player.

It took a whistle-blower in Phoenix to create enough noise for the nation to hear about the deadly organizational silence that pervades VA's system. We righteously expressed our outrage upon learning about the VA's attempts to conceal its fraudulent scheduling and appointment schemes to improve organizational "performance measures" and contingent bonuses for executives. We voiced our disapproval of its intimidation and retaliation against employees who spoke up against these unethical practices that compromised patient safety and care.

And yet these grievances are only surface responses to a deeper problem at the VA that, if left unfixed, will simply morph into a new form of misconduct, a different set of unsafe practices. Fundamentally, the thousands of harmed veterans and their families were victims of a more sustained, longer-standing cultural problem of organizational silence that has been evident at the VA all along. Our concerns about that should not have required yet another interval sacrifice of veterans' lives to spark our outrage.

The VA's problems with patient safety won't be resolved by mere piecemeal fixes to improve appointment wait-times or access. They won't be addressed by yet another commissioned report to appease another momentary outrage -- like the 1992 congressional report confirming the VA's culture of silence, or the 1999 follow-up study affirming more of the same.

Like the faulty left wing of the Columbia, recently reported flaws within the VA system need more than a technical fix, if we're serious about human safety. They require deeper critiques of the VA's organizational culture, which affects the real lives of patients and workers -- in a family sort of way. It should not take rocket science to recognize that.

Dr. Kate Scannell is a Bay Area physician and the author, most recently of the novel "Flood Stage."