Psychological Safety in Healthcare | E. 94

The Healthcare Leadership Experience

Workplaces are only as safe as the experience of the least safe person. CEO and Founder of Iterum Tom Geraghty, discusses the need for psychological safety in every organization with Jim Cagliostro.

Episode Introduction

Tom outlines the evolution of psychological safety, why diversity will remain ‘’on paper’’ without inclusion, and why high-performing teams possess high degrees of psychological safety. He also explains the principle of the Andon Cord and how behaviors, practices and leadership are the three keys to creating psychologically safe working environments.

Show Topics

• Why psychological safety matters

• The role of the aviation sector and Google’s Project Aristotle

• Psychologically safe workplaces are more inclusive

• The unique challenges of psychological safety in healthcare

• Three keys to creating psychologically safe organizations

• The Andon Cord principle

05:38 Why psychological safety matters

Tom explained why psychological safety is a belief that one will not be punished for speaking out.

‘’So psychological safety has been recognized across multiple studies, a vast array of studies as the foundation, the core necessary but not sufficient element for high performing teams. And it has got a long history. It first emerged in the literature maybe in the 1950s or so, but it wasn't really until the 90s where Amy Edmondson was studying clinical teams, and she was looking at the mistakes that these teams made, and she was separating high performing and low performing clinical teams and looking at the dynamics between them. And she defined and codified psychological safety at that point in her research. That is to say psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. It's essentially a belief that the team is safe for interpersonal risk taking. That means being able to ask questions, to be able to admit your mistakes and ask for help and all that other stuff. But it also means being able to do it in a way that is safe and works for you. So for example, if you have a stutter or a stammer, or if you have a tick, or if you communicate by a sign language or by a written format, that it's safe and okay to do so in the way that resonates and fits you.’’

08:02 The role of the aviation sector and Google’s Project Aristotle

Tom outlined the evolution and impact of psychological safety.

‘’I think if you look back at domains like aviation, back in the 70s and 80s, aviation was probably one of the first industries to really recognize that as a result of analyzing disasters, they recognized that either poor communication or lack of communication or miscommunication was a primary, if not the primary causal factor in loads of disasters, including things like the Tenerife air disaster and things like that. So aviation has got on board, if you like. Then with cockpit resource management turned into crew resource management, and then we skip forward to the nineties with Amy Edmonton's work. And then in 2013, Google Project Aristotle came up. Julia Rosovsky's team did a bunch of research on teams inside Google and were able to show that psychological safety was the foundation for all high-performing teams in Google. That is to say that all high-performing teams possess high degrees of psychological safety and low-performing teams possessed low levels of psychological safety. There’s a clear correlation.’’

12:34 Psychologically safe workplaces are more inclusive

Tom said if we don’t practice inclusion, we will only have diversity on paper, not in reality.

‘’…we talk a lot about diversity on teams, diversity in organizations, but fundamentally, if we're not practicing, and psychological safety is about the practice of inclusion, if we're not practicing inclusion, then we might have diversity on paper, but we won't in reality. We might have a very diverse group of people who don't feel safe to suggest their ideas or ask for help or ask questions, and that's not true diversity. So I guess that's what I really mean by inclusion, and that's where we're coming from. …..And I should say as well, because that also leans directly into high-performing teams, right? Because a high-performing team is one where we surface all the best ideas or we surface all the ideas, and the best ones come to the surface and get made into reality. And it's also the ones where people are safe to challenge some ideas or some ways of working if we think there's a problem with it or there's a risk to it. And of course, it's through those multitudes of diverse backgrounds and diverse experiences that we can surface that range of ideas and that range of challenges.’’

15:01 The unique challenges of psychological safety in healthcare

Tom said the potential for serious consequences makes healthcare unique.

‘’ It is certainly unique. In healthcare, we're dealing with grave consequences of failure, patient safety, patient outcomes, life and death situations where, as we were saying earlier, where if an anesthetist or a nurse in an operating theater it doesn't feel safe to point out, "You've left something in the patient or that's the wrong leg", or there's some other concern, then that's going to result in a very bad outcome, which is not necessarily the case in other industries. There are also aspects of sheer demand on people's time, the cognitive load and the physical load and the time burden on people working in healthcare is great, is incredibly high. And what may be even more challenging is that it can be unpredictably high and low. So we go through periods where it's incredibly busy and then maybe less busy later on. We don't necessarily have the luxury as other industries do. We don't necessarily have the luxury of managing how much work we're doing at any one time. And that can result in, as we often see, the patient outcomes are worse when those peaks of workload are at the highest because people are more likely to miss an important step in a process or misread a signal or misread an alarm.’’

18:23 Three keys to creating psychologically safe organizations

Tom explained why behaviors, practices and leadership involvement are vital to create safe organizations.

‘’ This is the big question, isn't it? So I'm not even sure where to start because there's a few things we'd like to suggest, and we work with organizations to do. First of all is that for the people at the sharp end, for the people at the sharp end of work, we need to talk about behaviors and practices. And we like to separate behaviors and practices. So practices might be things like after-action reviews, debriefs, Schwartz Rounds and things like that. Things that you can name and begin doing and get better at creating feedback loops and things like that to continuously improve. And those practices and those rituals and those ceremonies, and whether creating team charters and social contracts, they can help foster and build psychological safety within our teams, within our organizations. There's also behaviors, and behaviors are the way we do things, those little interactions and the way we communicate, the way we work with each other. And that might mean improving the way we listen. So active listening. It might be non-violent communication. It might mean framing work in different ways. It might mean checking your body language and the way we communicate. All those sorts of micro dynamics and the way we interact with other people. So we can work on behaviors, we can work on practices, and we can do that at the sharp end of work. What we also need to do is speak to leadership and convince leadership that this is something worth doing. This is something worth putting effort into. And that means speaking the language of leadership. That means speaking to their desires, their goals, their objectives, and their fears as well. And in healthcare, the fears are patient deaths and poor patient outcomes and whatever that means for the organization.’’

22:49 The Andon Cord principle

Tom said thanking people for pulling the Andon cord is the most important part of the process.

‘’The Andon cord is a principle, a part of the Toyota production system that... is a mechanism for someone who's working on the production line to pull a cord or pull a metaphorical cord nowadays and request help. Stop the line, stop work, request help, because either there's a problem to address, which indicates some upstream fault or some process issue or something else going wrong, or there's simply an opportunity for improvement that they need help with implementing and it's important to address right now. And there are a number of amazing things about the Andon cord. One is that whenever it gets pulled, people are thanked for doing so. And that's probably the most important part of the whole thing, because ….this takes away that interpersonal risk. Well, it doesn't take it away completely, but it mitigates it. So it means that it's a praiseworthy thing to do, and it gets embedded within the culture. And so every time you pull the cord, something gets improved, even if actually it was a false alarm. Because even if there was a false alarm, you're learning about the signals that created that false alarm. What do we need to do to make sure that it’s not going to happen again? And it's fantastic. The Andon cord is such a powerful idea that almost every organization we work with adopts the Andon cord in some way, whether it's language or an actual tool or a real physical thing.’’

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You’ll also hear:

Tom’s personal experience of dyspraxia and his career history: ‘’….at some point during that process, maybe about a decade ago, I came across the term psychological safety. And for me, that was the light bulb moment.’’

How psychological safety has finally come of age: ‘’You’ve got this conflux of factors coming together with a topic, a field, a phenomenon that is of its time and the need for the growing recognition for psychological safety in … healthcare, in technology, in manufacturing, in aviation, and everywhere else.’’

A team or group is only as safe as the least safe person in the group: ‘’In a group of 10 people, you might have… eight people who feel really psychologically safe …. but two people in the group who don't for whatever reason…that group is not what we would call a psychologically safe group.’’

Everything is an experiment and a learning opportunity: ‘’The outcome of work should be learning how to do it better next time. And if we reframe work like that, we're almost taking failure off the table because the only experiment that fails is the one we didn't learn from.’’

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