Published: 27/03/2003, Volume II3, No. 5848 Page 23

'Staff infections' anywhere in the human culture of our organisations are as potentially lethal and costly as 'staph infections' in the treatment room. When healthcare professionals do not afford one another careful treatment, interpersonal toxicity begins to breed. When doctors are allowed to verbally abuse nursing colleagues, when managers are put down for disagreeing with the boss, managerial malpractice is taking place.

Research evidence documents the fact that unless patients are kept safe from interpersonal toxicity anywhere in the organisation, the results can be no less lethal than accidentally administering the wrong drug. Missing from most safety protocols is the focus on protecting patients from the consequences of 'staff ' infections.

The quality of communication between staff and of interactions between doctors and nurses is correlated with patient outcomes. The process by which this happens is simple and direct. Senior management interactions create unwritten organisational norms, rules of behaviour that others follow and thereby pass on. By design, organisational culture is the consequence of the choices every individual makes in how to behave and react to one another. The task, therefore, as a manager responsible for enabling a caring and healing environment is to manage skilfully and carefully the quality of day-to-day relationships. Doing so is, in theory, as simple as ABC:

(A) I increase awareness by seeking face-to-face non-anonymous feedback on specific examples of what I could be doing more or less of to improve the quality of each of my important day-to-day relationships;

(B) I try to deliver the behaviours asked for, and, where need be, I get training and coaching support to learn how to do so;

(C) I monitor the consequences by asking for regular feedback on how I am doing.

Senior managers who choose not to improve the quality of their day-to-day relationships may find themselves accountable for the organisation's diseased health. To accept the responsibility and accountability for the impact one's interpersonal behaviour has on the quality of patient care requires courage and integrity - and a commitment to continuous quality improvement at the level of individual excellence, itself a pre-requisite to organisational excellence.

How many NHS organisations' boards are ready, willing and able to be held accountable for the documented impact of how their day-to-day treatment of one another and their colleagues has on the quality of care a patient receives in the treatment room.

Dr Irv Rubin President Temenos Inc Hawaii, Professor Sarah Fraser Independent consultant Visiting professor Middlesex University