What is really interesting is that Gawande has found that if team members don't actually speak their names alound (as opposed to being introduced) as the team assembles, they are much less likely to speak up if they have a concern during the operation. It is frightening to realize that medical staff would hesitate to raise a concern during surgery just because s/he may not have the "right" to speak up. Why is that?

Extensive research into group behavior has taught us that group norms--invisible rules about what is okay to do and what isn't--are powerful drivers of organizational behavior. When groups first form, the norms begin forming. So, in the hospital example, if the surgeon and his/her assistant immediately begin by giving directions and performing tasks as the group assembles, the rest of the staff may begin to believe that they should  keep quiet and listen to those "more important". Thus, an unwritten rule begins to form: Don't speak unless asked. If that rule is not tested by the surgeon asking for feedback or someone simply speaking up, then the norm becomes more solid and little or big concerns may not be raised during the operation. Frightening!

Interestingly this phenomenon occurs in all types of organizations, especially business. If your team or business is "stuck", you might want to begin investigating the your team's unwritten rules.

Sallie