Dr Alwin Tan, GAICD, MBBS, FRACS, EMBA (Melbourne Business School)

Senior Surgeon | Governance Leader | HealthTech Co-founder |
Harvard Medical School — AI in Healthcare |
Australian Institute of Company Directors — GAICD graduate |
University of Oxford — Sustainable Enterprise

Institute for Systems Integrity

Healthcare repeatedly tells practitioners to speak up.

Report unsafe care.
Challenge inappropriate pressure.
Question decisions that may harm patients.
Exercise independent professional judgement.
Put the patient first.

These expectations are entirely reasonable.

But they contain an assumption that healthcare rarely tests.

That the system will protect the practitioner who complies.

What happens when raising a concern changes how someone is perceived?

What happens when professional disagreement is reframed as disloyalty?

What happens when resistance to unsafe pressure becomes a performance problem?

What happens when an employment dispute, governance conflict or disagreement between colleagues intersects with a regulatory notification?

And what happens when clinicians begin to believe that telling the truth may cost them their reputations, appointments or careers?

Healthcare cannot demand professional courage from individuals while failing to govern the consequences of courage.

That contradiction may be one of the most significant—and least examined—risks in modern healthcare.

PROFESSIONAL JUDGEMENT DOES NOT EXIST IN ISOLATION

Healthcare often treats professional judgement as though it belongs entirely to the individual practitioner.

Yet judgement is never exercised in isolation.

It occurs inside an environment shaped by:

• workload
• hierarchy
• staffing
• information quality
• time pressure
• organisational culture
• leadership behaviour
• commercial expectations
• employment security
• regulatory processes
• professional relationships

The Medical Board of Australia's Good Medical Practice code recognises that doctors' professional judgement may be influenced by financial, professional and personal interests, including relationships with third parties, and that these interests must be recognised and managed transparently.

Improper influence rarely arrives as an explicit instruction.

Few executives say:

"Ignore the patient's interests."

Few managers write:

"Do not raise this safety concern."

Organisational influence may instead operate through mechanisms such as workload expectations, incentive structures, access to opportunities, performance metrics, resource constraints or cultural norms.

The most powerful organisational pressures are often the ones that never need to be written down.

THE MISSING GOVERNANCE VARIABLE

Healthcare traditionally asks:

• Was the practitioner competent?
• Did they follow policy?
• Did they document appropriately?

These questions matter.

But they are incomplete.

A mature safety system must also ask:

• What information was available?
• What pressures existed?
• Could the practitioner safely disagree?
• Did they have sufficient time to think?
• What organisational incentives surrounded the decision?
• Did leadership create conditions that supported independent judgement?

Organisations do not merely employ professional judgement. They create the conditions under which judgement succeeds—or progressively deteriorates.

ISI proposes the concept of the Judgement Environment to describe these conditions.

THE JUDGEMENT ENVIRONMENT

The Judgement Environment Framework™ is an ISI governance framework that synthesises evidence from psychological safety, speaking-up research, conflicts of interest, organisational culture, procedural fairness and governance.

It describes the organisational conditions influencing whether practitioners can:

• recognise what is clinically right;
• communicate concerns;
• resist inappropriate influence; and
• act in the patient's best interests.

1. REALITY INTEGRITY

Can practitioners see what is actually happening?

Professional judgement depends upon accurate information.

When information is delayed, fragmented, filtered or reduced to simplified performance metrics, judgement becomes progressively less reliable.

Before judgement fails, reality is often filtered.

Reality integrity is therefore a governance capability, not simply an information-management function.

2. COGNITIVE CAPACITY

Can practitioners still think well?

Fatigue, excessive workload, repeated interruption, understaffing and administrative burden can reduce the cognitive capacity available for complex clinical judgement.

The Medical Board also recognises that fatigue may affect a doctor's ability to provide safe care.

Efficiency therefore has limits.

A system that removes the capacity to think has already begun compromising the quality of judgement.

3. RESPONSIBLE PROFESSIONAL AUTONOMY

Professional autonomy is not unlimited independence.

It is the ability to make decisions according to:

• patient need
• clinical evidence
• professional standards
• ethical obligations

Commercial sustainability is legitimate.

Resource stewardship is necessary.

The governance challenge begins when commercial or operational priorities influence clinical decisions while professional responsibility remains assigned to the practitioner.

The organisation cannot direct the conditions of judgement while leaving the clinician to carry accountability alone.

4. VOICE SAFETY

Healthcare has invested heavily in speaking-up systems.

Policies.

Incident reporting.

Escalation pathways.

Whistleblower mechanisms.

These are important.

But they do not automatically create psychological safety.

Research consistently shows that speaking-up behaviour is influenced by hierarchy, leadership, anticipated consequences and organisational culture.

A reporting mechanism is not the same as a speaking-up environment.

Silence does not necessarily indicate safety. It may indicate that people have concluded the personal cost of honesty is too high.

5. PROCEDURAL INTEGRITY

Healthcare regulation is essential.

Patients deserve protection from unsafe practice.

Nothing in this framework diminishes that responsibility.

At the same time, public confidence also depends upon regulatory processes being fair, proportionate and trusted.

Ahpra defines a vexatious notification as one lacking substance and intended to cause distress, detriment or harassment.

Importantly, Ahpra reports that such notifications represent less than 1% of notifications received and also emphasises that the greater public risk is when genuine concerns are never reported.

Following recommendations from the National Health Practitioner Ombudsman, Ahpra has introduced reforms to strengthen the identification and management of vexatious notifications and improve procedural fairness.

This demonstrates that regulatory systems must achieve two goals simultaneously:

encourage genuine reporting of public risk;

and

minimise harm from inappropriate use of regulatory processes.

Not every notification arising during workplace conflict is inappropriate.

Equally, workplace conflict can complicate motive, evidence and proportionality.

The challenge is not to assume either conclusion.

The challenge is to distinguish them fairly, independently and promptly.

A complaint does not need to result in regulatory action to influence behaviour. The prospect of a prolonged or damaging process may itself create a chilling effect.

6. GOVERNANCE ACCOUNTABILITY

Boards routinely receive reports about:

• incidents
• complaints
• finances
• workforce
• compliance

They often receive much less information about the environment in which clinical decisions are actually made.

Boards should ask:

• Can practitioners safely disagree?
• Are financial incentives influencing care?
• What happens after someone raises a concern?
• Could a clinician safely refuse something they believed was not in the patient's interests?
• Does the board understand the pressures surrounding professional judgement?

Boards do not govern individual clinical decisions. They govern the environment in which those decisions are made.

THE NEW GOVERNANCE COMPACT

Healthcare needs:

• regulation;
• accountability;
• financial sustainability;
• professional standards.

It also needs organisations that actively protect independent professional judgement.

Systems accountability does not replace individual accountability.

It makes accountability more accurate.

It distinguishes between:

• misconduct;
• human error;
• system-induced behaviour;
• organisational pressure;
• contested professional judgement.

Patients deserve competent practitioners.

They also deserve organisations that do not make competent practice progressively harder.

When honesty repeatedly carries disproportionate personal risk, silence becomes an adaptive response.

The system demands professional courage.

It must also create environments worthy of that courage.

Harvard references

Australian Health Practitioner Regulation Agency 2020, A framework for identifying and dealing with vexatious notifications, Ahpra, Melbourne.

Australian Health Practitioner Regulation Agency 2024, Improving the vexatious notifications framework: response to the National Health Practitioner Ombudsman recommendations, Ahpra, Melbourne.

Australian Health Practitioner Regulation Agency 2026, 'Vexatious notifications', Ahpra.

Edmondson, AC 1999, 'Psychological safety and learning behavior in work teams', Administrative Science Quarterly, vol. 44, no. 2, pp. 350–383.

Medical Board of Australia 2020, Good medical practice: a code of conduct for doctors in Australia, Medical Board of Australia.

O'Donovan, R & McAuliffe, E 2020, 'A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour', BMC Health Services Research, vol. 20.

O'Donovan, R, De Brún, A & McAuliffe, E 2020, 'Exploring psychological safety in healthcare teams to inform the development of interventions', BMC Health Services Research, vol. 20.

van Dongen, D, Guldenmund, F, Grossmann, I & Groeneweg, J 2024, 'Classification of influencing factors of speaking-up behaviour in hospitals: a systematic review', BMC Health Services Research, vol. 24.