Introduction: Transplant listing decisions are determined by a multidisciplinary team as mandated by regulatory bodies. Given the range of disciplines represented at selection committee meetings, the presence of a power gradient may prevent some members from expressing concerns about listing decisions, thus promoting an environment that limits psychological safety.
Methods: We surveyed the members of our hospital’s Pediatric Transplant Center (PTC) to understanding how listing decisions are made and to assess staff comfort level in speaking up during these meetings. The survey focused on the process of the listing decision itself, factors related to members’ comfort in sharing opinions, and perception of power dynamics during meetings. We surveyed all members of the PTC who participate in selection criteria meetings. Rather than asking for titles, we asked members to identify themselves as MDs or “other” to preserve anonymity. The hospital’s quality and safety analytics team conducted the survey and analyzed the data given the concern of non-response because of being queried by one’s direct supervisors.
Results: We received 41 responses (67% response rate) including 16 MDs and 25 from other disciplines. 90% of respondents agreed that the current selection process is working well. In some programs each discipline was asked to present at patient selection meetings,  while in others it was only done if desired. 85% felt comfortable speaking out during the meeting if they disagreed with a listing decision, including 94% of MDs and 80% of others. When asked whether they felt team members would support their decision about not listing a patient if they had concerns, 68% agreed including 94% of MDs and 52% of others (p=0.005 for difference). 58% felt that their discipline has equal weight in the selection process, including 88% of MDs and 40% of others (p=0.003). 71% felt that there was not a power dynamic/medical hierarchy present in the patient selection process making it difficult to voice opinions, including 88% of MDs and 60% of others (p=0.07). 91% felt that race, gender, religion, or sexual preference did not affect how others heard their opinions during the selection process.
While the majority of respondents felt the current selection process is working well, there were differences between MDs and other disciplines. MDs felt more supported in their decisions and felt that they have equal weight in the process compared to non-MDs. The perceived difference regarding a power dynamic within the selection process of MDs vs. others suggests a lack of awareness by MDs of the presence of a power gradient. A new process was put into place to improve the patient selection meetings. This includes a notification process for meetings, a safety statement at the beginning of meetings and an order of when each discipline will speak.  
Conclusion: We identified concerns by non-MDs in our patient selection process regarding psychological safety.