Building and Sustaining an Organizational Culture of Respect for People

Through the Respect for People program, staff receive mandatory training on these listening and collaboration behaviors, which are incorporated in VM’s leadership expectations; patient and team member experience efforts; diversity, equity and inclusion strategy; and process improvement work. How does this build trustworthiness? The Virginia Mason Medical Center Respect for People program builds trust by fostering an inclusive, psychologically safe workplace climate in which all team members foster respectful behavior (e.g., listening to understand, keeping one’s promises) during interactions with patients and each other, and where individuals feel safe to ask for help, discuss problems and admit errors as we work together toward our vision to be the quality leader and transform health care.

How It Works

Virginia Mason’s Respect for People strategy is the foundation of our organization’s culture of safety and a pillar of the Virginia Mason Production System. Our 10 respect behaviors enhance open communication, teamwork, recognition and trust among staff, providers and patients. This strategic initiative creates support and accountability for sustaining a culture of respect. The behaviors address concepts of diversity, equity, inclusion and belonging to help reinforce these outcomes for individuals, teams and the organization. The Respect for People vision encompasses two principles: “We believe in a culture in which everyone experiences respect,” and “we all have a role in sustaining a community where everyone feels valued, included and respected.”

The 10 behaviors are:

  1. Be a team player;
  2. Listen to understand;
  3. Share information;
  4. Keep your promises;
  5. Speak up;
  6. Connect with others;
  7. Walk in their shoes;
  8. Be encouraging;
  9. Express gratitude; and
  10. Grow and develop.

All staff and physicians, including new hires, receive mandatory training in these behaviors to help them build trust with colleagues and patients. Leaders strengthen trust among teams using discussion guides (e.g., respect and integrity, speaking up, psychological safety, inclusion, etc.). Respect for People is built into process improvement to ensure resulting changes address the impact on stakeholders. The focus is on how people feel. While positive intent is important, if the impact is not positive, it bears looking into to understand stakeholder experiences. This is how trust among staff – and between our employees and patients – can be reinforced and sustained.

Skills and Competencies

Trust-building in our Respect for People strategy relies on leadership skills: self- and situational awareness and social sensitivity to consider deeply how it feels for team members and patients to experience respect and disrespect. Leaders use listening, psychological safety and facilitation skills to build and support team members’ understanding and application of the 10 respect behaviors in patient care and non-patient care settings. Beginning in 2018, required employee training has included how to address extreme disrespect, such as racism and sexism. Team members rely on collaboration, flexibility and conscious inclusion to build trust with one another and with patients and their families.


In 2009, our culture of safety and staff engagement surveys showed organization-wide improvement was needed in communication, teamwork and respect. These results informed our strategy to build and sustain a culture of respect.

Our health care teams work in an environment with a risk of catastrophic errors. These errors carry direct economic costs as well as indirect costs related to loss of trust by patients and health care team members, strained teamwork and lost productivity. We aim to be a high-reliability organization (HRO) that cultivates an environment in which all workers are empowered to identify and report problems. We want to foster an organizational culture in which employees not only feel free to speak up with concerns, but also recognize that they must do so.

HROs rely on listening to those who are closest to the work rather than deferring to those in more senior roles. A culture of respect provides psychological safety for workers and supports team engagement in care delivery. Accordingly, creating and sustaining an environment in which respect and trust are the norm was not optional – it became a strategic imperative for us. [1]


We surveyed all staff to measure the effectiveness of the Respect for People initiative. Surveys were conducted before and after the 2018 training, and six months later, to determine if behavior change was sustained. Survey items addressed respondents’ feelings of psychological safety and whether respect had improved on their teams. We used a Likert-style scale to assess respondent agreement with four baseline items: adjusting one’s style; sharing feedback; saying thanks; and valuing and respecting others. For each question, a statistically significant improvement was sustained six months after the training. For the item addressing sharing feedback, survey responses improved by 18 percent (45% to 63%; P < .001). [1]

After the training, most respondents (76%; 958 of 1,258) reported experiencing improvements in at least one respect behavior on their team. [1] We also saw statistically significant improvement over baseline on the “Nurses Treat You with Respect” question on patient discharge surveys. Our all-staff AHRQ Culture of Safety Survey reflected similar results. For the question regarding staff members treating each other with respect, we saw an increase in positive responses from 76% (3,209 of 4,223) at baseline in 2010, to 84.5% (2,824 of 3,342) in 2018 (P < .01). [1]


Respect for People training, team-building toolkits and internal communications (i.e., intranet, spotlight articles, Town Halls) are widely implemented and available to staff at our hospital and all our locations. This includes nine regional medical centers, three administrative centers and a residential care facility. Respect for People is regularly addressed during process or program improvement efforts. Patient-family partners and other volunteers (many of whom helped co-design the respect behaviors, along with scores of team members) learn the behaviors in their orientation. Residents and interns also learn the respect behaviors to help ensure they speak up and strengthen our culture of safety.

[1] Chafetz LA, Forsythe AM, Kirby N, Blackmore CC, Kaplan GS. Building a Culture of Respect for People. NEJM Catalyst 2020;1(6). DOI: 10.1056/CAT.19.1110