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The Fearless ICU (Part 2)
13 Plays4 years ago
In a recent episode of the podcast, we had a wonderful conversation with Amy Edmondson (Twitter: @ AmyCEdmondson), on the elements of high-performing teams in complex environments. In this episode of the podcast, we examine psychological safety, teaming, and learning from failure within the context of building better ICU teams. The episode is a recording of a webinar I recently presented entitled “The Fearless ICU: Building a Culture of Healing and Transformation.”
Additional Resources:
Critical Matters podcast episode with Amy Edmondson – The Fearless ICU: https://bit.ly/365bjmv
Webinar- The Fearless ICU: Building a Culture of Healing and Transformation: https://bit.ly/3u2zlXs
What Google Learned in its Quest to Build the Perfect Team. New York Times: https://nyti.ms/3p84qHk
Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units. A. Edmondson et al. Management Science 2007: https://bit.ly/3JJXisP
Recommended
Transcript
Introduction to Critical Matters Podcast
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Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
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Sound provides comprehensive critical care programs to hospitals across the country.
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To learn more about our programs and career opportunities, visit www.soundphysicians.com.
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And now your host, Dr. Sergio Zanotti.
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During
Exploring Fearless ICU Culture
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a recent episode of the podcast, we had a wonderful conversation with Amy Edmondson from the Harvard Business School.
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Amy is one of the worldwide experts on team dynamics and she dedicated her research to studying high-performing teams.
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In today's episode of the podcast, we will continue with the same topic and we will revisit some of the topics that she discussed in the context of creating ICUs
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that perform at the highest level possible.
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What you'll hear today is a recording of a webinar I recently gave as part of the Sound Critical Care Leadership Week entitled The Fearless ICU, Creating a Culture of Healing and Transformation.
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I hope that this is useful for you and your teams and that you enjoy it.
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What we'll cover today
Impact of COVID-19 on ICUs
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includes an introduction or the current state or why this concept of a fearless ICU is something that I find super relevant and important.
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We'll set the stage obviously of why we need to talk about this.
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I'll show some data and introduce to you what I think are the key ingredients to a fearless ICU and also define what do I mean by a fearless ICU.
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And finally, I'll share with you
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some very actionable steps that we can all take as leaders which we all are at the bedside in terms of making our icus fearless and hopefully helping our teams heal but also very important and transform and innovate as we continue to provide high value care in icus around the country so the last 24 months have been obviously marked and that um
00:02:26
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almost emphasized by the COVID-19 pandemic.
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When we started talking
The Great Resignation in Healthcare
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about COVID back in March of 2020, we were talking about a couple thousand cases worldwide.
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Now we have surpassed the 440 million infected patients with almost 6 million deaths throughout the country.
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We have seen multiple waves throughout the United States that have impacted our ICUs.
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We seem to be obviously in the back end of our last Omicron wave with
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decreasing numbers and many of our ICUs today don't have COVID patients, which is obviously something that we all welcome.
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Regardless of what happens with COVID, I don't think it's going to go away, but I also think that we're going to be moving on and trying to reestablish a lot of the value, high value care that we need to do.
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We have to rebuild our teams and we really have to learn to move forward.
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And that's really what we're going to talk about today.
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But I wanted to start with just looking at what has been the impact of COVID-19 on the workforce.
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And we start with this concept of the great attrition or the great resignation.
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And this is something that has been published throughout the world, not only here in the United States, and it goes beyond healthcare.
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This is one interesting study done a couple months ago where in a large sample of employees from different business
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worlds, different arenas in the workforce were surveyed, and 40% actually stated that they were highly likely or somewhat likely to leave their jobs.
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40% said that they were probably going to change jobs in the next couple of months.
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And what's also very interesting when you look at this data is that many of the respondents did not have another job
Workforce Misalignment and Resignation
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lined up.
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So they were not just switching jobs from one job to another, but they actually were just quitting and figuring out what they were going to do later on.
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And that is something that we've also seen with critical care clinicians who are leaving and do not have another job lined up, and they're trying to figure out what they'll do as they move along.
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That is definitely a unique characteristic of this phenomenon.
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that was not very common in the past.
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Furthermore, when you look at other studies that have evaluated this, try to understand what are some of the key factors that are making people leave.
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And when you compare what are key factors for employees versus what the employers believe, what's very interesting is that there's a little bit of a misalignment.
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And this is important because if employers think that people are leaving
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for reasons that are not that important for the employees, we might miss the opportunity of making a difference and really denting this exodus.
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So when you look at what is most important for the employees, it's being valued by the manager and a sense of belonging.
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It being valued by the organization.
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So not only the people you work with, but the organization where you work at, that is top on employees who are leaving.
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When you look
Burnout Among Healthcare Workers
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at
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what employers think is most important.
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What you can see is that there's a lot about compensation, but that doesn't seem to be as important for the employees.
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So this is not only about money like a lot of people have proposed, but it's really about how people feel valued and how they feel a sense of belonging.
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And that's going to be very important as we talk about what a fearless ICU can do for our people.
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This is another study that was published recently that actually looked specifically at COVID-related stress and work intentions in a large sample of U.S. healthcare workers.
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This was thousands of healthcare workers, and what you can see here is that it's divided by different fields.
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So you have from physicians, APPs, nurses, other clerical members of the healthcare force, administrators, housekeeping, and others.
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And what you can see here is
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likelihood of reducing their clinical work hours in the next 12 months.
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Low likelihood is in orange and high likelihood is in blue.
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But when you look at physicians and APPs and nurses, up to a third, one in three, are thinking of reducing the number of hours they work clinically in the next 12 months.
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The likelihood of them leaving their current practice, again, seems to be highest for nurses at 40%.
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second highest for APPs at 33%.
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And then for physicians,
Importance of Psychological Safety in ICUs
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it's one in four.
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So 25% of physicians thinking of leaving their post in the next 24 months.
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So these obviously are very, very concerning.
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When you look a little bit, you dig a little bit deeper and try to understand why there's two factors that impact this likelihood of
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changing jobs in a different way.
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So burnout obviously is associated with an increased likelihood of leaving and feeling valued is associated with an increased likelihood of staying.
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So, and that is something that has been shown in multiple studies.
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And here again, when you look at the percent to reduce hours, those who are burnout are 69% likely to reduce hours and those who are valued,
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are only 35% to reduce their hours.
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So clearly feeling valued is a negative or has a positive impact on healthcare workers wanting to stay at their workplace.
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And then you can see there's a similar relationship with percent intent to leave.
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So people who are burned out, 73% are likely to leave.
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And people who feel valued, only 26% are likely to leave.
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So clearly, we're seeing another instance where the likelihood of people changing is high in healthcare worker or jobs, but it's also much higher than those who are burnout and can be much lower in those who really feel valued.
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And that can have obviously a general connotation, but it's valued by the people who they work with, but also valued by the organizations that they work on.
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One of the important aspects
COVID-19's Effect on Female Healthcare Workers
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of any ICU, as we all know, is our nurses.
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And perhaps one of the hardest hit groups in healthcare workers with COVID has been nursing.
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There's been a lot that has occurred day after day when I talk with our ICUs, I hear about nursing shortages.
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That is something that is not unique to any one of our ICUs, but something that we're seeing everywhere.
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And this has been studied.
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There's a lot of reasons why nurses leave.
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But in this one, what they found was
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that an important percent of nurses, up to 25%, are thinking of leaving or likely or very likely or definitely leaving.
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And in terms of what they were leaving for, insufficient staffing levels seems to be a big problem.
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Some of them are seeking higher paid positions.
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So that is what we're seeing, the dynamic of traveler nurses that can be paid twice or three times their hourly wages.
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And also,
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not being listened or supported at work is another thing that has really been a problem as the most important.
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And when you look again at some of the factors affecting their decision to stay or leave, the unmanageable workload is most likely to make them leave, 60%.
00:10:28
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But there's things like having caring and trusting teammates, doing meaningful work, feeling engaged at work, and a sense of belonging
00:10:37
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which when present are much more likely to impact favorably in nurses wanting to stay in their post.
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So these are important messages that the workforce and these studies are sending us.
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And I think that as you'll see a little bit later, will feed into this whole narrative of why we need a fearless ICU for our programs.
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Another
Building a Fearless ICU Environment
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area that I think is very important and something that we've obviously
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discussed within critical care, but also within sound in the context of disparities and increasing diversity, equity, and inclusion is the disproportionate impact that burnout stress and changing jobs has had on female leaders.
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So this is actually a study looking specifically at leaders, both senior and manager level.
00:11:35
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And what you can see here is that in terms of the impact of burned out, chronically stressed or exhausted, it is much more likely to be present in women for many reasons that relate to gender differences and lack of equity at the workplace.
00:11:52
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But it's something also that's impacting our female colleagues in a bigger way.
00:11:56
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And we can all understand why, but again, something that I think is very important for us to be aware.
00:12:04
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And again,
00:12:05
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factors into why it's important to build a culture that really has a fearless ICU as part of it.
00:12:14
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This is a very interesting study from Yale that looked at some socio-ecological predictors of mental health outcomes among health care during the COVID-19 pandemic.
00:12:24
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And what you can see in the table is that diagnoses or categories of mental health problems such as major depression,
00:12:33
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a general anxiety disorder, post-traumatic stress disorder, and alcohol use disorder were very common among healthcare workers during COVID at higher rates than expected.
00:12:44
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And what they did is they found a series of factors at the individual level, interpersonal level, institutional level, and community level that really, really have an impact either negatively or positively, but an independent impact
00:13:04
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on healthcare worker mental diagnosis.
00:13:07
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And one of the ones that came as the strongest predictor in a negative way, so it was protective, was team cohesion and how supportive people felt at their workplace by their colleagues.
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This study
Teaming and Innovation in ICUs
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was recently published out of the UK, and basically they looked at the impact of the winter surge, the last winter surge,
00:13:33
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which was 2020 to 2021 with diagnosis such as moderate depression, anxiety, severe depression, severe anxiety, probable PTSD and other anxiety disorders.
00:13:48
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And what they found, which is remarkable, is that on ICU healthcare workers, so ICU staff, the impact of COVID in terms of probable and determined PTSD
00:14:02
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was similar in terms of percent as what veterans suffered when they returned from the wars in Afghanistan.
00:14:10
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So clearly the impact of that surges that we took care of, that very high volume of death has had a similar toll on us in the ICU as war has had
00:14:26
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on veterans in recent conflicts.
00:14:28
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So clearly something to ponder, very sobering.
00:14:33
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And when you talk with people in the ICU, I mean, a lot of what I hear is that people are tired and tired of being tired.
00:14:40
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And we kind of, through these different waves, fell in this vicious circle of increased volumes, increased acuity, all sorts of either PPE, medication, or eventually personnel shortages,
00:14:56
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And we talked about this in previous meetings this week.
00:14:59
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There's been a change in the way the families and patients have interacted with us with all the misinformation, a lot of belligerent interactions.
00:15:09
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And that has really generated a tremendous amount of malaise that just seems to be going one after another.
00:15:15
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And with all these successive ways, it's been very difficult for us to recover.
00:15:20
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Not to mention that so many of our ICUs have seen an enormous amount of turnover with every day you come, there's new nurses, new RTs, maybe new team members.
00:15:31
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And that is also a big problem for us.
00:15:34
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And we'll talk about what that means.
00:15:37
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So clearly, the last 24 months have had an impact on all our ICUs.
00:15:46
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We have lost a lot of what
00:15:49
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made us strong in the past as teams.
00:15:52
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We have new teams.
00:15:54
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There's a lot of healing that needs to be done, but there's also an enormous amount of work to be done in terms of improving patient care.
00:16:02
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We have seen a deviation of our practice away from what we were doing with A to F bundles, with increased hospital-acquired infections.
00:16:11
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We probably have new challenges to deal with.
00:16:14
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There's still going to be COVID patients.
00:16:16
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There's probably higher acuity in non-COVID diagnoses because of the lack of or poor access to healthcare.
00:16:24
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And we're seeing over and over again that our volume and our acuity throughout our programs continues to increase.
00:16:31
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So we obviously need to find ways to provide that value and make a difference for the patients in our ICUs, but also for the people who work in our ICUs.
00:16:42
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So this is where the fearless ICU comes.
00:16:45
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I think it's a great way of thinking of how are we going to build up and how can we heal each other, but also prepare ourselves for a transformation that will lead us to innovation and better care.
00:16:57
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And the fearless ICU
Embracing Failure as a Learning Tool
00:16:59
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is defined, I define it as an ICU where every team member feels comfortable sharing concerns and mistakes without fear of embarrassment or retribution.
00:17:10
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Team members are confident that they can speak up and won't be humiliated
00:17:15
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won't be ignored or blamed.
00:17:17
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They know they can ask questions when they're unsure about something.
00:17:21
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Team members trust and respect each other.
00:17:23
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The fearless ICU has a growth mindset.
00:17:26
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It learns from mistakes and aims to perform at the highest level.
00:17:30
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The fearless ICU creates value and innovates in a complex changing environment.
00:17:35
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So one of the things that I've seen over and over throughout COVID is that when we were learning together,
00:17:42
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And when we were making a difference and moving the needle, people felt supported, felt engaged.
00:17:49
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And there are things that we can control within our own sphere of influence and things that are from outside.
00:17:56
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There's a lot that is broken in healthcare and perhaps in society.
00:18:00
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And we're all part of that solution.
00:18:02
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But today I want to talk about what are the things that we can do today in our ICU to move the needle towards a fearless ICU
00:18:10
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and to really create a better environment for everybody who is working there because every single person who's there wants to be heard, wants to be seen, wants to contribute, and wants to heal.
00:18:23
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And I think that by supporting each other and creating that culture, we have a better chance of achieving that.
00:18:28
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So let's look a little bit into the evidence and try to understand some of these key ingredients.
00:18:35
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So this is a very interesting study that was published almost 20 years ago.
00:18:40
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looking at teams,
Fostering Inclusive and Innovative ICU Culture
00:18:42
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healthcare teams adopting innovation in medicine.
00:18:45
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And this studied 16 high performing cardio surgical team, cardiothoracic or cardio surgical teams, trying to adopt a new technique of a minimally invasive cardiac surgery.
00:18:57
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And the study was on the success of implemented this new technology for the minimally invasive cardiac surgery.
00:19:04
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And what you can see here, the names are changed, but these are the actual hospitals that participated.
00:19:10
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And you can see that they have the annual number of cardiac bypass operations.
00:19:14
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You have the hospital type, academic versus community.
00:19:17
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You have the geographic region.
00:19:19
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And then you have the status of the adoptive surgeon.
00:19:21
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So some sent a department head.
00:19:23
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Others had a junior surgeon, senior surgeon.
00:19:26
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So different types of surgeons who were the leaders of those teams.
00:19:34
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Traditionally, the perception of the
00:19:38
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or the dogma would be that the department chair from an academic center that did a large number of cases, and depending where you would live, you would probably think that your area was even better, would be the ones that you would want your surgery or would be the best at implementing new technology.
00:19:56
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However, when you look at how these are ranked, and they're ranked in terms of their implementation success index, which is an objective way of measuring how well they implemented this new surgery,
00:20:08
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And what you can see is that in the top performers, there is a mix of high volume, low volume.
00:20:14
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There's a mix of academic and community.
00:20:16
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There's a mix of different regions.
00:20:19
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And there's also a nice mix of department head, junior surgeon and senior surgeon.
00:20:23
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So clearly none of those were associated or predicted who would perform the best.
00:20:29
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So the question is, what were the strongest predictors of success in implementing these new techniques?
00:20:38
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And the two things that were most important by far were coordination between clinical areas and psychological safety.
00:20:45
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And psychological safety is a topic or a term that was coined by Amy Edmondson.
00:20:52
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And we had a chance to talk with her for the podcast, and I'll share that at the end.
00:20:57
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And really the way this whole concept emerged is that she started studying hospitals and she realized that the safest ICUs
00:21:08
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were the ones that had the most reported safety events.
00:21:11
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And that didn't make sense to her.
Conclusion and Invitation to Further Learning
00:21:13
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But when you looked at who had the highest quality measures objectively, it usually correlated with who had the most reported adverse events.
00:21:21
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And that's when she realized that teams that have psychological safety are likely to report events.
00:21:29
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And when that happens, they are likely to learn.
00:21:32
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And when that happens, they are likely to have higher quality.
00:21:35
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So she published
00:21:38
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a series of studies in healthcare showing this idea of psychological safety.
00:21:43
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But I also want to take us now away from the healthcare arena to Google.
00:21:48
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And Google, a couple of years ago, was extremely interested in defining what makes the best teams or the perfect team.
00:21:57
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And they studied hundreds of teams at Google with literally millions of data points in a big data enterprise called Project Aristotle.
00:22:06
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And what they found
00:22:08
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without a doubt, was that the number one most important factor for a team at Google to be successful was psychological safety.
00:22:17
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Team members feel safe to take risks and be vulnerable in front of each other.
00:22:22
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And there's a link here, and we'll send the slides out to a very interesting article in New York Times that talked about this.
00:22:29
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But they basically came to the same conclusion that over and over Amy Edmondson at Harvard and her collaborators have found in hospitals.
00:22:37
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that psychological safety is what makes teams at work.
00:22:42
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It's what makes them perform at high levels, whether you are taking care of patients or trying to develop new software or new projects at a place like Google.
00:22:52
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So what is psychological safety?
00:22:54
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Psychological safety is a shared belief that the team is safe for interpersonal risk taking.
00:23:01
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So what we have in most places is psychological danger, right?
00:23:05
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There's fear of admitting mistakes.
00:23:07
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There's a lot of blame going around.
00:23:10
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We are less likely to share different views about what's best to do for a patient, for example.
00:23:15
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And there's this common knowledge effect where everybody assumes that everybody else knows what you know, or if you don't know something, you assume that you're the only one who doesn't know it.
00:23:24
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And that's a dangerous place for patients, but also it's a dangerous place for healthcare workers because especially when they're burned out, it does not lead to engagement.
00:23:34
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It does not lead to meaning.
00:23:35
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It does not lead to belonging.
00:23:37
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And what it leads to is to people leaving.
00:23:40
Speaker
Psychological safety, on the other hand, is when everybody feels safe and comfortable admitting a mistake.
00:23:46
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People are willing to learn from failure.
00:23:49
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Everyone openly shares ideas.
00:23:52
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And we are much better at innovating and making decisions, right?
00:23:55
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So if a nurse has an idea during a cardiac arrest or an idea during rounds, they feel that they're valued and that their opinion is important and they feel safe to share it.
00:24:07
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Even if we don't adopt that or it's not the best idea, people feel safe to contribute.
00:24:12
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People feel safe to ask questions.
00:24:15
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People feel safe to learn together.
00:24:17
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And that is really the key ingredient for a fearless ICU, as you'll see over and over again, and is a key ingredient for a high-performing team, but also is probably the one thing that a workplace could really do to keep people.
00:24:33
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There's four quadrants in terms of psychological safety.
00:24:36
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There's the
00:24:37
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whether the learner safety, the challenger safety, the collaborator safety, and the inclusion safety.
00:24:44
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So when you talk about psychological safety from a learning perspective, it's safe to discover, ask questions, experiment within certain limits, obviously.
00:24:55
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We're not talking about experimental drugs without official research.
00:24:58
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We're talking about what some people did during COVID is figured out that maybe if we put the IV pool outside the room,
00:25:05
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It would minimize the amount of PPE we required.
00:25:08
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We would learn from mistakes when something doesn't go well.
00:25:11
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We really try to understand why.
00:25:13
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When we do something, we evaluate the process.
00:25:15
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We look for new opportunities.
00:25:17
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In terms of safety for challengers and challenging, people feel comfortable speaking up.
00:25:23
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Why do we have over and over again seen in medicine that atrocious mistakes such as amputating the wrong length occurs?
00:25:31
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Because people don't feel safe to speak up.
00:25:34
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So we really need to make sure that everybody can express their ideas, people can expose problems, and that together we can figure out how to best address them.
00:25:44
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Finally, there's a collaborator safety, which is everybody feels safe to engage in making things better, interact with colleagues, maintain open dialogue, and really foster constructive debate.
00:25:57
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So for example, we have a psychological safety environment in our hospital,
00:26:01
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If we think somebody doesn't need to be in the ICU, but our hospitalist colleague or ED colleagues do, we can debate that in a very civilized way and find a way forward.
00:26:12
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Inclusion safety is about belonging, and that's, I think, what we've seen over and over again on these studies that I showed at the beginning, that people who feel valued, who feel that they're appreciated for what they do and what they bring to the table are less likely to leave.
00:26:31
Speaker
And you feel your experience and ideas matter.
00:26:33
Speaker
They make a difference.
00:26:34
Speaker
And that is something that we can all work, as you'll see a little bit later, towards creating a culture that fosters and really encourages this type of behavior.
00:26:44
Speaker
Now, what psychological safety is not is a lax environment where anything goes.
00:26:51
Speaker
We're not talking about that.
00:26:52
Speaker
So when you have low psychological safety and low accountability, what you have is an apathy zone.
00:26:59
Speaker
And that's, I think,
00:27:00
Speaker
where everybody's burnout.
00:27:02
Speaker
If you have high psychological safety and low accountability, people are in a comfort zone, it's very hard to improve.
00:27:09
Speaker
On the other hand, if it's pure accountability with no psychological safety, people get very anxious.
00:27:14
Speaker
And that is something that leads to burnout.
00:27:16
Speaker
And I think that we have to be careful as leaders with that because yes, we have to improve care and move forward, but we have to make sure that people feel safe to express their views, to express ways of doing things better,
00:27:30
Speaker
And ultimately, when we have a high psychological safety and a high accountability, we are in the learning zone.
00:27:36
Speaker
And that is the magic quadrant where a fearless ICU lives.
00:27:41
Speaker
Without the willingness to challenge a decision at all levels, the organization is at risk for failure.
00:27:47
Speaker
Without the ability or willingness to speak up about a mistake, quality outcomes cannot improve.
00:27:54
Speaker
And without the ability of our people to ask for help, our
00:27:58
Speaker
colleagues will underperform and won't learn.
00:28:01
Speaker
I was talking with one of our colleagues yesterday and sharing that we have ICUs that have very, very new nurses that might not be comfortable with a lot of the things that traditionally we have expected them to do.
00:28:13
Speaker
And if they can't ask for help, they'll never learn and then patients are placed at danger.
00:28:17
Speaker
So we really have to create that environment, as you'll see, to allow people to ask for help, to speak up about problems,
00:28:25
Speaker
and to challenge decisions at any level.
00:28:28
Speaker
And we should never feel upset when somebody challenges a recommendation we make.
00:28:32
Speaker
We should ask questions and seek the best answer possible.
00:28:39
Speaker
So it would be awesome to have the same team, well-trained, super safe forever.
00:28:45
Speaker
But the reality is that that type of team only exists in sports and not even, I mean, there's still a lot of trades in sports these days, but it's hard to have the same team day in and day out.
00:28:54
Speaker
It's something that we had valued for years in the ICU when we got to know our people very well.
00:28:59
Speaker
But the truth is that more and more we come to work and there's new people on our team.
00:29:05
Speaker
We have to work with teams within the hospital that are not our usual team.
00:29:10
Speaker
When we, for example, go to a cardiac arrest on the floor or go to help in the ED or have somebody on ECBON, there's a perfusion team that comes in.
00:29:18
Speaker
So a lot of this has happened in healthcare and it's been accelerated by COVID.
00:29:22
Speaker
These are all the travelers and all the things that we've discussed.
00:29:25
Speaker
But this concept is not unique to COVID and it's not unique to healthcare workers.
00:29:30
Speaker
This concept of teaming where you need to very quickly create an effective way of working
00:29:37
Speaker
with a new group of people on a regular basis.
00:29:40
Speaker
And this is the second big ingredient of a fearless ICU.
00:29:44
Speaker
A fearless ICU has to be very good at teaming because you're not gonna have the same people every day.
00:29:50
Speaker
And those characters or the people who are part of your team will change on a regular basis.
00:29:55
Speaker
There's some basic foundational principles that people have talked about teaming.
00:29:59
Speaker
There's the hardware and the software they say.
00:30:02
Speaker
So for hardware, it's really scoping out what is the team gonna be doing?
00:30:05
Speaker
There's different teams obviously.
00:30:06
Speaker
We're talking about our ICU team, how we structure that team, and how we sort the different tasks that people do.
00:30:14
Speaker
So there's tasks, for example, when you think about it in an ICU.
00:30:19
Speaker
Today, I'm working clinical, and I was just seeing a patient with GI.
00:30:23
Speaker
So they had their own team.
00:30:25
Speaker
They had to do an endoscopy.
00:30:26
Speaker
There's things that we need to do before they do the endoscopy.
00:30:29
Speaker
Then they do the endoscopy.
00:30:30
Speaker
So we have to sort out.
00:30:31
Speaker
what everybody's going to do, what's sequential, what can be done independently.
00:30:35
Speaker
And that's true for all sorts of work in the knowledge world, not only with patient care, but also with quality improvement projects and with other types of projects.
00:30:45
Speaker
And then we have the software, which is kind of the things we need to create in terms of the culture.
00:30:53
Speaker
And for effective teaming to work, we have to have a common purpose.
00:30:57
Speaker
So in our case, in the ICU, it's our patients.
00:31:00
Speaker
We have to create an environment of psychological safety where people can interact with each other, with new team members, feel welcome, feel they can ask questions.
00:31:10
Speaker
And we have to be able to embrace failure, not because we want to fail, but because it's the best way to learn.
00:31:17
Speaker
And we have to understand that when something goes wrong, it's much better to know about it and try to learn about it as opposed to ignore it and not share it, which is what happens in a non-psychological
00:31:29
Speaker
safe environment.
00:31:31
Speaker
So there are definitely some challenges related to teaming and this goes beyond, like I said, the healthcare arena.
00:31:39
Speaker
There's multiple functions that must work together.
00:31:42
Speaker
People are geographically dispersed, that's true for what we do in the ICU, around the hospital, but also what we do around sound.
00:31:49
Speaker
Relationships are temporary, right?
00:31:52
Speaker
I mean, there's people who are coming and going in our ICUs, but also you might work with people not on the same frequency,
00:31:58
Speaker
No two projects or no two patients are alike.
00:32:00
Speaker
So you're always trying to do something that might be a little bit different.
00:32:04
Speaker
And the work can be uncertain and chaotic at times.
00:32:07
Speaker
And certainly we've seen all that with COVID.
00:32:10
Speaker
So there's clearly challenges that this arises, but there's also tremendous benefits for those who get it well.
00:32:19
Speaker
When people can be part of different teams and can do teaming well, really our patients benefit
00:32:28
Speaker
but also the people who are working with us benefit significantly.
00:32:31
Speaker
So we'll talk a little bit more about this idea of teaming, but it's something that every single person who is working today is experiencing in the ICU.
00:32:40
Speaker
Every time you come to an ICU, there's different people, especially with all the travelers and all the new people.
00:32:46
Speaker
But also as soon as you step out of your ICU to take care of a patient, you might be involved with other people that you don't know as well.
00:32:54
Speaker
And the quicker you can create the right setting,
00:32:58
Speaker
or effective teaming, the more likely you are to not only achieve high outcomes, but to create an environment that makes people feel safe, appreciate it, and do meaningful work.
00:33:11
Speaker
So as we go on, the last thing I want to talk about as an ingredient is failure.
00:33:16
Speaker
And we have been taught, especially in medicine, that failure is always bad.
00:33:23
Speaker
We also sometimes believe that learning from failure
00:33:26
Speaker
is straightforward when it's not because we don't really understand sometimes that a process with a bad outcome was done well and a process with a good outcome was done poorly, right?
00:33:37
Speaker
But there's a lot of reasons why learning from failure is not as easy.
00:33:41
Speaker
And another thing that often we have been taught is that failure in high standards can't coexist, which is not true.
00:33:48
Speaker
Nobody wants to fail, but there are situations, as you'll see, in which you can learn tremendously from failure.
00:33:55
Speaker
And how you embrace failure as a learning and growth opportunity will define the culture of your ICU.
00:34:02
Speaker
Fearless ICUs embrace failure and learn from it, and they welcome bad news because they want to improve things.
00:34:09
Speaker
So there's three types of failures, and I think that this is very important to understand.
00:34:15
Speaker
First, you have preventable failures.
00:34:17
Speaker
So these are events that should not happen, that we have the right process and we stick to those processes.
00:34:25
Speaker
should not occur.
00:34:26
Speaker
So these are examples of following sterile technique for like a checklist for putting a central line, right?
00:34:33
Speaker
If we don't follow that checklist and we have an infection immediately, that was a preventable error.
00:34:37
Speaker
Amputating the wrong leg, an example that's very dramatic that I gave before, but that has happened in hospitals around the world.
00:34:44
Speaker
That is a preventable failure.
00:34:46
Speaker
And when preventable failures happen, those are usually need to be investigated.
00:34:52
Speaker
And those are the ones that you'll see that
00:34:54
Speaker
might require intervention to sanction people who are not following the rules because they should not occur.
00:35:02
Speaker
The second big category of failures is complexity-related failures.
00:35:05
Speaker
And just understanding that patients are very complex.
00:35:09
Speaker
We have patients who develop ARDS who get placed on ECMO who eventually die.
00:35:14
Speaker
And obviously we see that death as a failure, but there's a lot to learn there.
00:35:20
Speaker
But those are not blameworthy
00:35:23
Speaker
failures because there are so many factors that are impacting the outcome that we don't control that they're just, I mean, the nature of what we do within critical care.
00:35:35
Speaker
And then the third type of failure are intelligent failures, which are when we're trying to develop new protocols, if we do pilots with the idea that we want to learn as quickly as possible, and if we fail there, we know we don't need to do that.
00:35:50
Speaker
Like if we're trying new drugs for COVID,
00:35:52
Speaker
As soon as we can figure out that this doesn't work, that's an intelligent failure.
00:35:56
Speaker
So figuring out that certain things didn't work in failure very quickly with very well done randomized trials up front is an intelligent failure.
00:36:05
Speaker
What we've seen with ivermectin is not because we keep dragging and we still don't have an answer, right?
00:36:10
Speaker
But that has other problems.
00:36:12
Speaker
But I think there are times where if we design an experiment
00:36:16
Speaker
and we realize it doesn't work quickly, we can learn a lot and move on to the next thing.
00:36:21
Speaker
So those are intelligent failures, and those should be encouraged.
00:36:26
Speaker
Not maybe always in the clinical sense, but definitely in terms of trying to find new ways of doing things, intelligent failures should be welcome and they're part of innovation.
00:36:36
Speaker
So when you look at a more granular level in the terms of the reasons for failure and the whole spectrum, there are some
00:36:45
Speaker
they're blameworthy like when you have a deviance or inattention, right, from a process, that means that people are actively disengaged, right?
00:36:58
Speaker
That's a problem.
00:37:00
Speaker
Then you have in the middle processes like lack of ability, the process is not well designed, there's a task challenge, it's complex, and if people are not actively engaged,
00:37:12
Speaker
This is a fair that can occur more commonly, but we can work on engaging people and implementing the right things and trying to move the ball forward.
00:37:20
Speaker
And then there are people who are super engaged and they're trying to either find new drugs or new therapies or trying to try new processes, testing hypotheses.
00:37:30
Speaker
And these are praiseworthy failures because the quicker we fail, the quicker we can move on to something that might work and the more we can learn.
00:37:36
Speaker
So not our failure is bad, but we need to understand
00:37:41
Speaker
that these different types of failures have a different response, but some failure is valuable and that we should always be willing to hear when there's a problem, welcome that messenger of failure, but also learn from the things that we've done wrong.
00:38:01
Speaker
So the last portion of our talk today is moving to action.
00:38:05
Speaker
How can you as an individual in an ICU
00:38:10
Speaker
move your ICU towards a fearless ICU.
00:38:12
Speaker
And obviously it's a journey.
00:38:16
Speaker
Some ICUs are fearless and some are not, but all of us should strive for our ICUs to move in that direction.
00:38:23
Speaker
And really when you think about it, we're part of a large group of clinicians within Sound.
00:38:28
Speaker
Within Sound Critical Care, there are multiple programs that are very different.
00:38:34
Speaker
Within those programs,
00:38:35
Speaker
there's again different factions, right, or different groups, the nurses, the RTs, the clinicians that work with us.
00:38:43
Speaker
And within those, there might be, again, other groups that work together, like our sound colleagues, our APPs and our intensivists.
00:38:51
Speaker
There's also people who are part of other tribes, such as the critical matters tribes.
00:38:55
Speaker
But the idea is that there are groups within groups, and this is why we have so much teaming.
00:39:00
Speaker
And the point I want to make when we talk about action
00:39:03
Speaker
is that we need every single one of you to take action.
00:39:07
Speaker
The way I look at it is tribes need leadership.
00:39:12
Speaker
And there's a big difference between management and leadership.
00:39:15
Speaker
Management manipulates the resources to get a known job done.
00:39:20
Speaker
Leadership is about creating change that you believe in.
00:39:23
Speaker
Managers have employees, leaders have followers.
00:39:27
Speaker
Managers react, leaders initiate.
00:39:29
Speaker
Managers make widgets, leaders make change.
00:39:32
Speaker
And ultimately, managers are appointed, but leadership is a choice.
00:39:38
Speaker
And I truly believe that every person on this webinar, a clinician that works with us, is a leader in the ICU.
00:39:46
Speaker
When you are rounding, when you're taking care of a sick patient, when you are leading a cardiac arrest, you have people following what you're saying.
00:39:55
Speaker
You are the leader.
00:39:57
Speaker
And you perhaps don't realize, but you have an enormous, enormous,
00:40:03
Speaker
impact and responsibility to create a psychological safe environment.
00:40:08
Speaker
And we do that every single day by our actions.
00:40:13
Speaker
Before we talk about some of these actions, what I wanted to share with you is just this little chart of being aware, right?
00:40:21
Speaker
I always tell my kids that the biggest superpower in 2022 is being self-aware and being aware of other people's behaviors.
00:40:32
Speaker
If you can understand yourself and others, you'll do fine no matter what you do.
00:40:36
Speaker
But what's very interesting is that it's very risky for people sometimes to do certain things, right?
00:40:43
Speaker
None of us want to look ignorant.
00:40:45
Speaker
So the way we manage that is we don't ask questions, right?
00:40:49
Speaker
And it's happened to every single one of us.
00:40:51
Speaker
We've all been in a situation when we feel there's people who know something that we don't know and we don't want to ask because we don't want to look ignorant.
00:40:59
Speaker
Nobody wants to admit that they're incompetent.
00:41:02
Speaker
So nobody will admit a weakness or mistake, but if you don't seek help or admit it, how are you ever gonna improve, right?
00:41:10
Speaker
You might have difficulty with certain things and if you wanna learn, you wanna improve, you have to be able to identify that.
00:41:17
Speaker
Nobody wants to be intrusive into other people's thoughts sometimes, so they don't offer ideas.
00:41:23
Speaker
And nobody wants to be perceived as negative, especially these days, so they don't critique the status quo and they just go with the flow, right?
00:41:29
Speaker
It's a lot easier to just be quiet, move on,
00:41:33
Speaker
get your stuff done, and go home.
00:41:35
Speaker
But over time, there's a price to pay for that.
00:41:40
Speaker
And we need to be the first ones to step up and really help people.
00:41:45
Speaker
Studies have also shown that within healthcare environments, the role of each healthcare provider has a direct impact on how much they feel psychological safety.
00:42:00
Speaker
So there is a historical hierarchy, right?
00:42:04
Speaker
And unfortunately, and we need to be a lot more horizontal in terms of how we run our teams.
00:42:09
Speaker
But physicians are more likely to feel psychologically safe than nurses who are more likely to feel psychologically safe than respiratory therapists.
00:42:18
Speaker
This has been studied, and this is over a thousand clinicians in a study by Nembert and collaborators also from Harvard.
00:42:26
Speaker
And clearly what's interesting is that
00:42:28
Speaker
This correlation has been shown in other studies, but what's more important is that leader inclusiveness can move the needle.
00:42:37
Speaker
So here you have two graphs or two lines.
00:42:40
Speaker
The dotted line is low leader inclusiveness and the solid line is high leader inclusiveness.
00:42:47
Speaker
And again, psychological safety plotted against healthcare or a healthcare worker status or position.
00:42:54
Speaker
And what you can see is that those who are high inclusive leaders,
00:42:59
Speaker
can bend the needle, can flatten the curve, but also can make it a lot higher.
00:43:04
Speaker
So by being an inclusive leader, you can make a difference.
00:43:10
Speaker
And we'll talk about what an inclusive leader looks like and what are the actions you can take.
00:43:14
Speaker
But I have seen this too many times, unfortunately, when a nurse is afraid to ask a question in rounds or afraid to call a clinician at night, that means that they don't feel psychological safety.
00:43:26
Speaker
When a person fears pointing out a mistake, that means that they don't feel psychologically safe.
00:43:35
Speaker
When people don't contribute their ideas because they don't think they're going to be considered, that's a problem.
00:43:42
Speaker
And as the leader in your ICU, you can be more inclusive and you can help people feel much safer and contribute.
00:43:50
Speaker
So there's really four things that you need to do.
00:43:53
Speaker
Number one is frame the work accurately.
00:43:57
Speaker
What we do is hard.
00:43:58
Speaker
There's no question about that.
00:44:00
Speaker
And sometimes, like with COVID, we don't have all the answers.
00:44:03
Speaker
There's so much we didn't know and still don't know about what's best.
00:44:07
Speaker
So when we were deciding on what to do with some patients, I think framing that difficulty is very important, but also making sure that we always go back to our purpose.
00:44:15
Speaker
What are we trying to do?
00:44:16
Speaker
We're trying to create value for our patients and their families.
00:44:20
Speaker
When a family is belligerent because we don't give somebody ivermectin,
00:44:24
Speaker
It's important to remember that they are victims of misinformation and that we should be compassionate because our purpose is to help that patient and that family.
00:44:33
Speaker
It's very important as an inclusive leader to acknowledge limits.
00:44:37
Speaker
You don't have all the answers.
00:44:39
Speaker
You also make mistakes.
00:44:40
Speaker
And being able to show that vulnerability or saying when you run out of ideas and ask for ideas, I think is very valuable.
00:44:47
Speaker
As clinicians, we sometimes believe that we always have to have an answer.
00:44:51
Speaker
And it's okay to say, I don't know.
00:44:53
Speaker
It's also okay to say, hey, I made a mistake.
00:44:55
Speaker
We should change this because of this.
00:44:57
Speaker
And that allows other people to feel that they could do the same.
00:45:01
Speaker
We have to invite people to participate.
00:45:03
Speaker
And how do you do that?
00:45:05
Speaker
With what's called humble inquiry.
00:45:07
Speaker
You ask questions that you don't know the answer, that are beyond the yes or no, that really genuinely show curiosity about what somebody else can offer, right?
00:45:19
Speaker
And for example, is there anything we could do different?
00:45:21
Speaker
Maybe it's a yes or no question.
00:45:23
Speaker
So you would say, no, I think we did okay.
00:45:24
Speaker
But if you want to be more specific, you could ask, what's the one thing that you would do differently for your patient based on what we just did that could have changed the outcome or could improve things, right?
00:45:35
Speaker
And really try to get more people to speak, to contribute, invite them to participate.
00:45:42
Speaker
And in order for them to continue to do that, you have to respond productively.
00:45:46
Speaker
So there's no stupid questions.
00:45:48
Speaker
You should always answer questions without anything but trying to give people the best answer.
00:45:54
Speaker
You should always encourage people to point out mistakes.
00:45:58
Speaker
You should always welcome dissent.
00:46:01
Speaker
At the end of the day, it's your decision, but you should not feel that people are disrespecting you because they're suggesting something different.
00:46:07
Speaker
But I think that the other part of responding productively is that you should take care of the bad apples.
00:46:12
Speaker
So when there's behaviors that clearly go beyond what we have accepted as professional, as reasonable for our ICU, we should make sure that we take care of that and that we point that out.
00:46:25
Speaker
Because people don't want to be penalized for asking questions, but they also don't want to see people making gross
00:46:35
Speaker
growth and misconduct and not being sanctioned.
00:46:39
Speaker
I think it just deteriorates the culture.
00:46:41
Speaker
So responding productively goes on both ways.
00:46:44
Speaker
So be more inclusive, frame the work, focus on the purpose, acknowledge your own limitations, invite people to participate and respond productively to all suggestions.
00:46:58
Speaker
In terms of being successful in teaming, there's four behaviors that are important and they kind of go along the same lines.
00:47:05
Speaker
being able to speak up and making sure that everybody in the team has a word.
00:47:08
Speaker
So when you round, people should be able to contribute.
00:47:11
Speaker
We don't want to hear only one person talk throughout the whole rounds.
00:47:14
Speaker
Everybody should be able to speak up.
00:47:16
Speaker
And when there's a problem or somebody's uncomfortable, they should express that they're uncomfortable and why, and we should explore that.
00:47:22
Speaker
People should be willing to experiment sometimes.
00:47:24
Speaker
And again, when I say experiment, I mean, there's things that obviously fall within the range of what we call standard of care or best practices, but experiment is trying to figure out how can we do this a little bit better?
00:47:34
Speaker
How could we improve rounds?
00:47:35
Speaker
How could we improve our family meetings?
00:47:38
Speaker
How could we improve the way we follow certain processes?
00:47:42
Speaker
Whenever we finish an activity where it was a stressful intubation or a difficult conversation with a family, I think as a team, it's always good to reflect and kind of identify things that could be done better, things that were done well, things that we should learn, recognize what people have done well.
00:48:01
Speaker
And then I think ultimately we really have to have
00:48:04
Speaker
deliberate listening and intentionally listen to people to hear what they're saying and try to figure out how can what they're saying teach me?
00:48:13
Speaker
How can it help me take care of this patient?
00:48:15
Speaker
I think that too often we interrupt each other or at best we wait for somebody to finish just to tell them why they're wrong or why what we think is the best way to go.
00:48:24
Speaker
But if you are deliberate and listening to what people and patients say, I think you're much more likely to learn
00:48:31
Speaker
and also create that environment that leads to successful teaming.
00:48:34
Speaker
And this is all very important with our own team, but also when we're moving maybe to a different area in the hospital.
00:48:41
Speaker
How do we build that culture of learning?
00:48:43
Speaker
And it starts with our relationship with failure.
00:48:47
Speaker
So clearly, we need to stop blaming each other for things, right?
00:48:51
Speaker
This is something that comes from our M&M days.
00:48:54
Speaker
So when something goes wrong, it's always who did it.
00:48:56
Speaker
And this is something that is pervasive and impedes learning.
00:49:00
Speaker
What we really want to be is create a clear understanding of what happened.
00:49:05
Speaker
What happened and what needs to change.
00:49:08
Speaker
Now, as I showed earlier, there are mistakes or there are failures that are blameworthy.
00:49:15
Speaker
So when we have a very clear protocol of how we do certain things and people don't follow the protocol, that is something that needs to be taken care of, right?
00:49:23
Speaker
But most times we are involved with complex failures
00:49:28
Speaker
And there what's most important is to understand what happened.
00:49:30
Speaker
How can we improve our system and our process and our team to learn from that?
00:49:35
Speaker
And we learn from failure as a group by detecting failure and problems.
00:49:41
Speaker
So if people don't feel safe to report problems, we can't identify them.
00:49:46
Speaker
We have to analyze and reflect on them as a team and be able to learn from patterns and what can we do different.
00:49:53
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And then we have to be willing to experiment new ways of doing things.
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And that's how we move forward.
00:49:59
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That's how products are created.
00:50:01
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That's how new processes are created.
00:50:03
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And that's what we need to do in an environment where we're trying to create innovation and improve care with the idea of this fearless ICU.
00:50:13
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So we talked about the current state post-COVID and clearly a lot of strong headwinds against our workforce, our clinicians, our nurses, our APPs, a lot of trauma post-COVID.
00:50:27
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a lot of movement within healthcare.
00:50:30
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But we also have learned that what people really care about is being valued, purpose, and being able to contribute.
00:50:39
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Feeling safe that they can come to work, be their best selves, and do meaningful work.
00:50:45
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And that is something that we should not ignore.
00:50:49
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So if we work on our teams on a daily basis, if every one of us works on identifying these key ingredients of
00:50:58
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psychological safety, this concept of teaming, which is just a reality, it's not going to go away, and the idea of how we deal with failure, I think that we can all start moving in the right direction.
00:51:10
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And this is not something that your program medical director alone has responsibility or sound has responsibility or the CEO of your hospital.
00:51:18
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I think that we all, as leaders at the ICU, can start moving this in the right direction.
00:51:24
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So I really ask all of you to implement some of these
00:51:27
Speaker
ideas today or tomorrow when you're back on shift and see how you can slowly build a culture that's more inclusive, that allows people to ask questions, to bring up problems, and to learn together, which is ultimately, I think, what we need to heal as we move forward, but also what we need to be able to innovate and provide better care.
00:51:50
Speaker
So I just wanted to share with you, this week we released, last week we released an episode of the
00:51:57
Speaker
of the podcast where I speak with Amy Edmondson.
00:52:00
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She's from the Harvard Business School.
00:52:03
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And she really has been a pioneer in studying psychological safety.
00:52:06
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She coined the term psychological safety and coined the term teaming, all based on her studies in healthcare.
00:52:13
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So there's a lot more there for you to not only listen, but you can share this with your teams, with your nurses.
00:52:20
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That QR code would get you to the episode.
00:52:23
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And finally,
00:52:24
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just thank everybody for their time, for everything that you do.
00:52:28
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And if there's any questions, please put them in the chat box and I'd be happy to try to answer them.
00:52:34
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Thank you again for your time.
00:52:39
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So there's several comments and there's a question about AMD and the graph with mental illness, and that was an anxiety medical disorder.
00:52:47
Speaker
So it's just an abbreviation for severe anxiety disorder.
00:52:51
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There's also a comment about
00:52:55
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how it's hard to balance or how do you balance where people are and what we're talking about of improving our teams in terms of the burnout that people have.
00:53:06
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And I think that that's a great question, but ultimately it's a complex solution that involves multiple levels.
00:53:15
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What I'm trying to present today is what I think would be one step forward, which is trying ourselves as clinical leaders at the bedside
00:53:24
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to create a fearless ICU or an ICU where we have people feel comfortable asking questions, especially with all the new nurses and RTs we have.
00:53:33
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People feel comfortable giving their opinions, contributing, and that together we're learning to really improve care.
00:53:39
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What we've seen over and over again in all these attrition and healthcare, mental health studies is that people who are valued
00:53:49
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because of what they bring to the table to appreciate it, are the people who are less likely to be burned out, are the people who are less likely to seek another position.
00:53:59
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So I do think that there's something there positive for us to work on.
00:54:05
Speaker
And I think that we all have a responsibility.
00:54:09
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:54:13
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:54:19
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:54:23
Speaker
To learn more, visit www.soundphysicians.com.