Margaret Curtin talks about the importance of fostering a culture of psychological safety and teamwork to help organizations create a safer and more effective healthcare environment.
Several years ago, a hospital requested a Clinical Risk Assessment due to a high frequency trend of adverse events and claims in the OB unit. The risk department only became aware of these events when litigation occurred. They were eager to improve their OB outcomes and reverse this trend.
The assessment process began with collecting data to understand the organizations’ culture. This involved an anonymous staff culture survey and interviews. The findings revealed a collegial yet passive culture that lacked accountability. Nurses were fearful of speaking up, often hesitant to call physicians and were uncomfortable with the chain of command process. Subsequent chart audits to identify risk mitigation and patient safety opportunities uncovered several events that were not reported to risk management, which aligned with the described culture of fear.
One significant event involved a shoulder dystocia after an attempted forceps extraction, where the provider used the Zavanelli maneuver (a rarely used obstetric maneuver in which the fetal head is pushed back into the birth canal in anticipation of a cesarean section), followed by a stat cesarean section which took 52 minutes from decision to incision (accepted standard is 30 minutes or less). The patient had multiple known risks for shoulder dystocia, including large for gestational age with estimated fetal weight at the 90th percentile, over 9 pounds, postdate gestation, and a high body mass index. The risks were documented as discussed with the patient. The infant initially had no signs of injury; however, on day one of life, there was concern for brachial plexus injury which was not reported to risk management, nor peer reviewed. Several emergency cesarean section charts were reviewed showing unreported delays in performing emergency cesarean sections, ranging from 64 minutes to 95 minutes. Staff interviews revealed that while they sometimes report events to risk management, they often avoided reporting due to fear of bullying and retaliation from physicians.
Unfortunately, toxic/bullying cultures or incivility in hospital departments as well as outpatient group practice settings are identified during risk consulting assessments across the U.S. Conducting assessments that incorporate anonymous surveys and interviews reveal these issues because staff feel safer speaking to an independent third party who is there to listen, advise and educate when opportunities to improve both care and service to patients is identified. Addressing these problems is crucial, as a lack of psychological safety prevents open discussions about errors, depriving organizations of opportunities to prevent harm and mitigate risks.
Amy Edmondson, Harvard Professor and Author, discusses psychological safety, in her book, The Fearless Organization. She describes several scenarios where a culture of silence and fear contributed to errors and missed prevention opportunities. For instance, a NICU nurse’s fear of annoying a physician prevented her from reporting a medication error, and trained clinicians at a leading medical facility failed to question a fatal chemotherapy dosing regimen (full stories are on pages 3-8 and pages 83-86).
To build a team-based culture that supports psychological safety, consider the following steps:
- Identify Issues: Determine if there are known behaviors that hinder teamwork and whether errors are reported via litigation or complaints rather than through timely internal reporting.
- Develop a Plan: Create a corrective plan that includes training and coaching, potentially with external expertise to facilitate improvement.
- Measure Psychological Safety: Use anonymous surveys to assess psychological safety with statements like:
- On this team, I understand what is expected of me.
- I feel my ideas are valued and feel safe in suggesting them.
- If I make a mistake, it is never held against me.
- When something goes wrong, we work together to find the systemic causes.
- I feel able to bring up problems and concerns.
- All members of this team are included, and no one is rejected for being different.
- It is safe for me to take an intelligent risk on this team.
- It is easy for me to ask other members of this team for help.
- Nobody on this team would deliberately undermine my efforts.
- Working with members of this team, my unique skills and talents are valued and utilized.
(Adapted from Amy Edmondson. 1999, “Psychological Safety and Learning Behavior in Work Teams,” Administrative Science Quarterly 44 (2): 350-383)
- Utilize Resources: Refer to Chapter 7 of The Fearless Organization for the Leader’s Toolkit, which covers:
- Setting the stage for psychological safety, inviting participation, and responding productively.
- Creating an environment of candor through active learning.
- Leaders model behaviors that support psychological safety. Use the Leadership Self-Assessment (pg. 181)
- Practice Key Behaviors:
1. Open Communication: Leaders should encourage sharing ideas and opinions.
2. Humility: Leaders should admit their own mistakes and learn from them.
3. Empathy: Leaders should understand and support their team members’ feelings.
4. Setting an Example: Leaders should demonstrate kindness, respect, and openness.
Fostering a culture of psychological safety and teamwork can significantly reduce medical errors and improve patient outcomes. By addressing cultural issues, encouraging open communication, and supporting staff through effective leadership, organizations can create a safer and more effective healthcare environment.
Want to dive in a bit deeper into this topic? Check out these two helpful resources:
- https://haas.berkeley.edu/culture/culture-kit-podcast/posts/bonus-episode-4-amy-edmondson-steve-brass-on-psychological-safety/
- www.psychsafetyday.com
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