On "speaking up"

Many of the people who've kindly spoken to me have been in leadership roles for many years. They attributed their success and longevity in the role to a many things - learning from mistakes, education and traing, keeping the patient at the centre of what they do, support from above, and very importantly, support from their peers and teams.
One aspect of this support is the willingness of team members to speak up when they are concerned that something is unsafe, or that a practice or process is inefficient, inappropriate or ineffective. In Denmark, one senior clinician manager laughingly said, "When I ask my team to do something, they don't ask 'When?' they ask 'Why?'." He relies on this questioning to help him to make good decisions and he sees this behaviour as evidence that "Danish people are the most democratic in the world".
I met with a clinical leadership teamat department level, consisting of doctors and nurses, also in Denmark. I asked about the relationships between different professional groups, both as leaders and followers. This team described their structure as being very flat, with nursing and medical co-directors. Speaking up to each other was commonplace, and none felt that there was likely to be any negative consequences from doing so. They agreed that bullying existed but it was not commonplace.
In Sweden, a radiology nurse told me about their Monday morning meetings in the Radiology Department. Nurses (the nurses are radiographers) and doctors discussed any issues from the week before and in preapration for the week ahead. It was also a time that nurses might raise a point of variability that they observed - why does Dr A use Xmg of a drug, while Dr B uses Ymg? The doctors present would then discuss the evidence available and agree to standardise practice. This form of continuous quality improvement was seen as a normal part of being a good department.
Finally, I spoke to the Vice-Director of a large hospital in Denmark who commented "Why wouldn't I listen to them? They're spending the money!" He quickly followed that his main concern wasn't money, but that those "below" him saw problems well before he did. Encouraging his clinicians to 'speak up' to him meant that he could mitigate or prevent serious consequences.