LIVES 2017: Psychological safety vital to patient care

Amy C. Edmondson speaking at LIVES 2017
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Speaking up is vital to patient safety, but healthcare professionals need a climate of psychological safety to be able to do so, said Amy C. Edmondson, Novartis Professor of Leadership and Management, Harvard Business School. Edmondson was the keynote speaker at the 30th congress of the European Society of Intensive Care Medicine, meeting in Vienna this week.

Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. “Think of it as felt permission for candor”, said Edmondson. She gave the example of a nurse on a night shift in a busy urban hospital, who notices that the dose for a patient’s medication seems a bit high. She considers calling the attending physician at home, but recalls his disparaging comments about her abilities last time she called him at home in the middle of the night. So she doesn’t make the call.

Nobody wakes up in the morning because they want to look ignorant, incompetent, intrusive and negative, noted Edmondson. However, impression management is second nature. The right hand side of the table represents skilled incompetence.

Leaders need to make sure that others are not afraid to speak up. Psychological safety is not about being nice. It is fostered by explicit recognition of the complex, interdependent nature of the work. It “lives” at the group level, and so varies across groups within organisations.

A climate of psychological safety does not mean high standards cannot be maintained. Psychological safety enables learning behaviour in organisations, for error reporting (Edmondson 1996), quality improvement (Tucker et al. 2007), innovation and more (Edmondson and Li 2014).

Leaders need to create both psychological safety for voice and convey high standards for work. If leaders don’t do either, it’s the apathy zone. If all leaders care about is psychological safety, it’s the comfort zone, while the  anxiety zone is when you know what’s good, but are afraid to make that call. Too many are living in the anxiety zone, observed Edmondson, which is about being anxious about how a colleague may respond to a well meaning question or idea.

When Google looked at its teams, it found that psychological safety was by far the most important team dynamic, underpinning the other four dynamics (dependability, structure & clarity, meaning, and impact.

Edmondson explained the concept of “teaming”. This is teamwork on the fly - coordinating and collaborating across boundaries without the luxury of a stable team structure. Teaming is especially needed when work is complex and unpredictable. In emergency departments, patient care depends on coordination across clinical groups, and 24/7 operations consist of diverse and staggered shifts. It’s a huge operational challenge, and in this study they found hospitals that had addressed problems with overcrowding and ineffective teamwork by implementing “pods” (Valentine and Edmondson 2015). These pods included a preset mix of roles (such as an attending physician, three nurses, a resident, and an intern) into which clinicians slide when they come to work  Pods are hyper temporary teams with a role set, boundary and shared responsibility for a set of patients owned by the pod. After team scaffolds were implemented, clinicians worked with an average of 4.6 fewer partners per shift (from 16.7 to 13.1), repeat collaborations increased, and throughput time reduced by 3.7 hours (7.9 to 4.2) with no reduction in clinical quality. This was due to increased familiarity and proximity. Edmondson explained the implications of this thus. Roles do not provide enough structure for truly effective teaming among ‘strangers’ in fluid work environments. Team scaffolds enable coordination despite fluidity. By establishing shared accountability and making it psychologically safe, teaming effectiveness improved dramatically.

Frame the work accurately, advised Edmondson.  Is it routine and well-understood, variable, uncertain, and complex, or innovative, novel and unknown. Uncertainty goes up and failure rates go up as work moves from routine up to unknown.

Edmondson’s parting advice? “Acknowledge your limits” - it’s ok to say “I may miss something. I need to hear from you. “ “I’m new to this role. What are you seeing out there?  “ “I’m not an expert in X; I need your help.”

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Edmondson AC (1996) Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. Journal of Applied Behavioral Science, 21(1), 5-28.

Edmondson AC, Lei Z (2014) Psychological safety: the history, renaissance, and future of an interpersonal construct. Annual Review of Organizational
Psychology and Organizational Behavior, 1: 23–43.

Tucker AL, Nembhard Im, Edmondson AC (2007) Implementing new practices: an empirical study of organizational learning in hospital intensive care units. Management Science 53(6): 894-907.

Valentine M, Edmondson AC (2015) Team scaffolds: how mesolevel structures enable role-based coordination in temporary groups. Organization Science, 26(2): 405-22.

Published on : Mon, 25 Sep 2017

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patient safety, Teams, psychology Speaking up is vital to patient safety, but healthcare professionals need a climate of psychological safety to be able to do so, said Amy C. Edmondson, Novartis Professor of Leadership and Management, Harvard Business School. Edmondson was the keynote spe

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