Blogs

In the high-stakes environment of inpatient psychiatric care, safety isn't just a protocol—it's a culture. And in a culture that strives for High Reliability, we must challenge the assumption that authority alone dictates insight. True safety, as every frontline worker knows, emerges not from top-down policies but from the lived realities of those closest to risk.

One policy in particular—cell phone access for psychiatric inpatients— on a unit became a flashpoint for patient agitation, yet the voices most attuned to the issue had gone unheard for too long. This blog post makes the case for change, not from the top, but from the ground up.

The Policy Gap: Disconnected from Reality

The policy allowed patients to access their personal cell phones only with a provider’s order, and even then, only to retrieve phone numbers for use on hospital landlines. Social media and direct phone use were strictly prohibited. While this may seem cautious, the reality was more complex—and more dangerous.

Patients reported feeling cut off from their support networks, unable to manage essential life tasks like banking or medical appointments. In response, the facility observed a notable spike in safety incidents, including agitation, verbal aggression, and even attempted elopements.

Who raised the alarm? Not administrators. Not policymakers. But the public safety staff—those who walk the halls, respond to calls, and de-escalate crises daily.

Deference to Expertise: Trust the People Closest to the Work

The public safety team, composed of security officers and behavioral health technicians, consistently flagged one common thread in patient unrest: frustration over restricted phone access. Approximately 50% of daily safety incidents were linked to phone-related frustrations. Patients reported feeling isolated, especially those with family abroad who relied on WhatsApp or other encrypted messaging platforms. One officer recounted an incident where a patient denied access to WhatsApp attempted to elope, citing isolation as the primary trigger.

These observations were not anecdotal noise—they were critical data. In an HRO environment, data from the front lines is gold.

A Smarter, Safer Approach: Technology with Supervision

Informed by frontline insights, the quality team proposed a new model to inform a policy change —balancing safety with dignity and patient agency. First, they proposed supervised digital access. This allowed access to key apps (e.g., WhatsApp, banking, appointment scheduling) under staff supervision in a designated area. In addition, they proposed the use of device management software to restrict usage to only approved apps, blocking access to public social media or unsafe content.

Next, they advocated for task-specific access. This permitted staff-supervised use of phones for essential functions: paying bills, scheduling appointments, or managing subscriptions.

This was followed by patient education and communication planning. The facility implemented a clear, written policy discussed at admission. They also collaborated with patients to create individualized communication plans, managing expectations and reducing resentment.

Implementation with Accountability

This was not a free-for-all. It was a structured pilot, with checks and balances: notably a 3-month trial in a controlled environment, public safety staff trained in device supervision and software protocols, monthly feedback loop with public safety voices at the table and metrics tracked on incident reports, patient satisfaction, and staff feedback.

Results – Deference to Expertise

The new policy resulted in a 25–40% reduction in safety incidents linked to phone access, and improved patient-staff relationships, built on empathy and shared goals. A collaborative safety culture ensued due to the HRO principle of Deference to Expertise. The facility listened to those who experience patient behavior by honoring their expertise.  

In the bustling heart of an inner-city hospital, where acute inpatient services and post-rehabilitation care hum with activity, Steve, a dedicated housekeeper, begins his day. It’s a routine morning—parking his car, hurrying to his workstation to clock in, ready to contribute to the hospital’s mission. But today, something catches his eye, a moment that transforms an ordinary shift into a quiet act of heroism.

As Steve strides toward the entrance, he notices an elderly man in a wheelchair, his partner struggling to push him across uneven terrain. The man’s weight and the bumpy surface conspire to make the journey arduous. The couple’s exertion is palpable sweat on their brows, strain in their movements. For a fleeting second, Steve could have kept walking, chalking it up to someone else’s responsibility. But he doesn’t. Instead, he pauses, observes, and steps in.

This is where Steve’s actions align beautifully with the principles of a High Reliability Organization (HRO), a framework that guides the hospital system he serves. HROs thrive on a reluctance to simplify—the understanding that every situation carries layers of complexity worth noticing. Steve doesn’t dismiss the couple’s struggle as just another day at the hospital. He sees the physical toll it’s taking, the potential for exhaustion or even injury. He knows that preoccupation with failure—another HRO tenet—means catching problems before they escalate into something worse. A fall, a missed appointment, a cascade of stress for this vulnerable pair—it’s all on his mind as he decides to act.

Steve’s choice reflects something deeper, too: a culture of psychological safety woven into the fabric of his workplace. He knows the hospital values its patients above all, and he feels secure in prioritizing their needs, even if it means arriving late to clock in. In a system that champions sensitivity to operations—awareness of how every role and moment interconnects—Steve understands his part in the bigger picture. He’s not just a housekeeper; he’s a guardian of care. Confident that his team will support his decision, he approaches the couple with a warm offer of help.

With steady hands and a kind word, Steve takes over, pushing the wheelchair to the appointment location. He doesn’t stop there. After checking the patient in, he shares what he witnessed with the staff—the uneven walkway, the partner’s own mobility struggles, the near-miss of a situation that could have spiraled. His voice, calm and clear, ensures the patient’s challenges are heard. Because of Steve’s compassion and attention, the hospital acts. The elderly man is assessed, referred for a mobility scooter, and later enrolled in patient transport services. No longer will he or his wife—herself grappling with mobility issues—face the daunting task of navigating that terrain alone. Future appointments will be safer, smoother, and less burdensome.

This story isn’t just about one man’s kindness; it’s about a system that empowers such acts. Steve felt psychologically safe to step outside his routine because he works in a culture that values people—patients and staff alike—over rigid rules. His actions ripple outward, improving not just one day but an entire future for this couple.