In recent months, a major health care crisis hit Jerusalem following a plan by the director- general of Hadassah to increase hospital revenue by expanding medical tourism.The physicians of the only pediatric hematology- oncology department in the city felt compelled to resign out of concern that this move would seriously jeopardize the care the limited staff could provide to the children. A legitimate concern about how to finance health care was at odds with a professional duty to provide safe care.At its core, however, this tragic story represents a failure of leadership. Leaders create and sustain organizational culture through their management style. Hospital executives make difficult decisions every day. While finances are clearly a consideration, patient well-being and safety should be primary.Front line health care providers are often in the best position to assess what is necessary to ensure high quality and safe care. They will be more likely to raise concerns about patient care if leaders create a culture that invites respectful dialogue and encourages speaking up.Hadassah leadership missed an opportunity to genuinely engage the team in the decision- making process and created a culture of intimidation trying to silence concerns.Fear of speaking up about patient care concerns leads to underreporting of problems and perpetuates unsafe conditions. Extensive research indicates that psychological safety – the perception that the workplace is safe for speaking up – is a key factor for satisfaction, learning, productivity and profit. Strong leaders create this culture by encouraging and rewarding speaking up about problems.Prof. Mark Chassin, president of the Joint Commission for accreditation of hospitals in the US, explains: “High reliability organizations do not tolerate intimidating behaviors that suppress the reporting of safety concerns and perpetuate the existence of unsafe conditions.” An investigation into the Columbia space shuttle disaster that killed seven astronauts revealed that an engineer drafted, but did not send, an email saying it’s “wrong and bordering on irresponsible not to request additional imaging” for the damage to the wing of the shuttle. By contrast, the teamwork culture on nuclear submarines promotes the voicing of differing opinions: if at a staff meeting all agree, the commander has to explain why. This culture has been associated with a remarkable safety record: not a single accident despite a mileage equivalent to 265 flights to the moon.In health care, teams have the capacity to provide critical information – often missed by external reviews – for quality improvement and error prevention. Yet studies show that nurses and physicians often hesitate to report concerns on safety issues, which remain uncorrected, while they may endure moral distress and burnout. For instance, at one hospital, a nurse, too afraid to speak up and correct a surgeon, remained silent while the wrong leg was amputated. At a nursing home in Haifa, abuse of residents was missed by an external review board.Employees knew about it, but were either afraid to speak or no one listened.In order to promote safety, leaders need to foster a culture of openness where every team member can speak up. The government should allow movement of physicians who have lost trust in executives of their institution to other centers to foster free competition for quality of care mediated by good leadership.The budget for health care in Israel is insufficient to meet our growing demands.To increase revenues, institutions are tempted to promote private services and medical tourism, sometimes at the expense of local patients. Under conditions of scarce resources, who can guarantee timely and just access to safe care? How can we resolve the tension between financial stability and safe care to patients? The solution likely involves creating a culture of respect that invites dialogue and disagreement. Speaking up can save lives and the best leaders encourage it.Mayer Brezis is emeritus professor of medicine at the Hebrew University and former director of the Center for Clinical Quality & Safety at Hadassah Medical Center, Jerusalem.Lisa Soleymani Lehmann is associate professor of medicine and medical ethics at Harvard Medical School. The views expressed represent those of the authors and not those of any institution with which they are affiliated.