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The Fearless ICU
11 Plays4 years ago
The last 24 months have pushed ICU teams around the world to their limits. As we move forward, we need to heal and rebuild our critical care teams. Healthcare more than ever will require ICU teams to perform at the highest levels and to continuously innovate to deliver high-value care to the sickest of the sick. In today’s episode of the podcast, we will discuss the elements of The Fearless ICU. Our guest is Amy Edmondson (@AmyCEdmondson), the Novartis Professor of Leadership and Management at the Harvard Business School. For the last two decades, she has studied the elements of high-performing teams in complex environments.
Additional Resources:
Faculty page for Amy Edmondson. A great jumping point to her vast body of work: https://www.hbs.edu/faculty/AmyEdmondson
How to turn a group of strangers into a team. TED Talk by Amy Edmondson: https://bit.ly/3vaKwzA
The Fearless Organization. By Amy Edmondson: https://amzn.to/3v7JzrJ
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
Books Mentioned in this Episode:
Get Rid of the Performance Review! By Samuel Culbert: https://amzn.to/354mYl3
Mindset. By Carol Dweck: https://amzn.to/3LRR2B8
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
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Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
ICU Challenges and Rebuilding Post-COVID
00:00:32
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The last 24 months have pushed ICU teams around the world to their limits, often requiring heroics and ongoing improvisation during repeated surges of COVID-19 patients.
00:00:43
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As we move forward, we need to heal and rebuild our critical care teams.
00:00:47
Speaker
Healthcare more than ever will require ICU teams to perform at the highest levels and to continuously innovate to deliver high value care to the sickest of the sick.
00:00:57
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During the last years, we have covered a wide range of clinical topics related to critical care medicine.
Skills for Intensivists: Building a Fearless ICU
00:01:02
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Today, we will focus on perhaps the single most important skill intensivist need in the current healthcare environment, the skill to make an ICU team perform at their highest level, the skill to create and lead a fearless ICU.
Psychological Safety with Amy Edmondson
00:01:17
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Our guest is Amy Edmondson, the Novartis Professor of Leadership and Management at the Harvard Business School.
00:01:22
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For the last two decades, she has studied the elements of high-performing teams and complex environments.
00:01:28
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She has coined the term psychological safety and has made critical insights into teaming,
00:01:33
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learning from failure and innovation.
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She's the author of several books, multiple academic papers, and a regular contributor to the Harvard Business Review.
00:01:41
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I am truly honored and extremely grateful to have her on the podcast.
00:01:45
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Amy, welcome to Critical Matters.
00:01:47
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Sergio, thank you so much for having me.
00:01:50
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Such an important topic.
00:01:53
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Absolutely.
00:01:54
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And I would like to ask you to start, what would you define as a fearless ICU or a fearless intensive care unit?
00:02:02
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Well, maybe I'll first say what it's not.
00:02:04
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It would not be a reckless intensive care unit.
00:02:09
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It would be one, by fearless, I really mean that people honestly believe their voice is welcome, even when they're not sure.
00:02:18
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But if they have any doubt about what to do, they can ask a question, they can point out a possible error, they can raise an issue, and they just have no doubt
00:02:30
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that that's expected and welcomed.
00:02:35
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And I think that that is a perfect segue to start with really dissecting that concept and really digging a little bit deeper.
00:02:42
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And one of the things that I found very interesting is that when you started, I think you were a PhD at that time, you really came across a very counterintuitive finding that really propelled you to ask more questions.
00:02:56
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And I want you to explore that by answering a simple question.
00:03:00
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If all you knew about two ICUs was the following, ICU A reports five to eight safety events on a monthly basis, and ICU B reported two safety events in a whole year.
00:03:15
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Which one would you prefer to be part of or be a patient
The Role of Psychological Safety in High Performance ICUs
00:03:18
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at?
00:03:18
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I want to be a patient at the ICU that's reporting multiple events every week.
00:03:29
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And I know that's counterintuitive because you sort of would, you know, wouldn't we want to be in the one that's event free?
00:03:36
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Here's how I see it.
00:03:37
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I think that the work that goes on in an intensive care unit is by definition, complex, uncertain and interdependent.
00:03:46
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Now, in any workplace, whether that's health care or software or somewhere else where there's complex, uncertain, interdependent work, it's virtually a guarantee that things will go wrong.
00:03:57
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because you're often doing things that, at least in the exact manner you're doing them, hasn't been done before, where you're customizing based on the patient needs and so on.
00:04:09
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So it's just about a given that things will go wrong.
00:04:15
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The thing that's not a given is will you hear about them?
00:04:18
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So to me, the nature of the work that goes on in the ICU means that it's almost
00:04:24
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a fact.
00:04:24
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It's almost a given that things might be going wrong.
00:04:27
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So I want to hear about them because in the places where I'm hearing about them, then there's going to be opportunities to catch and correct and improve processes and make sure patients aren't harmed.
00:04:41
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And this is really based on what you originally called psychological safety.
00:04:46
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So could you define that for us, Amy?
00:04:49
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Yeah, psychological safety is a belief that
00:04:52
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the context, let's say the work environment in this case, is safe for interpersonal risks.
00:04:59
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Now, what's an interpersonal risk?
00:05:01
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So that means saying or doing something that might, that has the potential that someone might think less well of you, admitting a mistake, asking for help, offering an out-of-the-box idea.
00:05:13
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All of those behaviors are interpersonally risky, but in a psychologically safe environment, you know that
00:05:21
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It's welcome.
00:05:22
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You know that it's possible.
00:05:23
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And so you do it.
00:05:26
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And it seems that in medicine, we talk more about safety in the last couple of decades.
00:05:31
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But like we were talking before we started recording, this framework of psychological safety is still not disseminated as widely.
00:05:40
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But outside of medicine, this is also something that is growing.
00:05:43
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And I know that some years ago, there was a lot of noise with a Google study where they were trying to figure out the perfect team
00:05:51
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and came to the same conclusion that the single most important element is in a team to perform at a high level is psychological safety.
00:05:58
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Is that correct?
00:05:59
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That's right.
00:06:00
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And I'll just tell you, I wasn't involved with that study.
00:06:03
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So it was all the more exciting to me when I read about it in the New York Times, actually, and found that Google had studied 180 teams over a couple of years.
00:06:13
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They tested 200 different variables, I think.
00:06:16
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And the number one predictor of team performance is
00:06:21
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was psychological safety.
00:06:23
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Now you might find that surprising, but here's why it makes sense.
00:06:29
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Because the work that most teams at Google are doing is intense knowledge-based work.
00:06:36
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They're doing innovation, they're developing new products, they're coding software, they're listening to customers and trying to solve really tough problems for them.
00:06:50
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So that kind of work
00:06:51
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is the kind of work where if you don't have people feeling comfortable speaking up and offering their ideas and pushing back when something doesn't feel quite right, you're not going to perform as well.
00:07:05
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I would argue that is quite analogous to the work that's done in the ICU environment, where it's knowledge intensive, there's uncertainty, there's high stakes.
00:07:15
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And so in those kinds of work environments, it stands to reason that
00:07:21
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this factor, which I call psychological safety, which describes the interpersonal climate, really matters.
00:07:29
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And it's interesting that obviously Google is looking at performance from a business perspective, but there is, from what I understand, and you've studied some of this in literature to support the idea that in the healthcare environment, specifically as we talk in this podcast about the ICU, psychological safety is associated with perhaps even more important aspects
00:07:50
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of performance versus patient safety and patient outcomes.
00:07:53
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Could you comment on that?
00:07:55
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Well, yes.
00:07:56
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You know, in fact, one study in the ICU environment I did with Ingrid Nembhardt, who's a professor at Wharton, who was then a PhD student, and we were studying 23 NICUs, and all of them were actively engaged in quality improvement work.
00:08:16
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What we found was, and that, you know, as basic as hand hygiene to as complex as, you know, which lung surfactant should we use.
00:08:26
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And what we found was that based on the levels of psychological safety, the quality improvement projects had more uptake, right?
00:08:35
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They were more effective in changing the clinical practices in the teams in ways that had,
00:08:44
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real impact for patient safety.
00:08:46
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In fact, in a study that then Ingrid did with Anita Tucker, sort of continuing on with this work, they found that over a three-year period, the ICUs with the higher psychological safety had an 18% improvement compared to their counterparts in the study who had low psychological safety, 18% improvement in morbidity and mortality.
00:09:13
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And I think it's fascinating that this is such a powerful tool, yet it's one that we don't talk about or deliberately try to improve in our ICUs.
00:09:24
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And one of the things that I note a lot on a daily basis when I'm rounding or observing our clinicians is that creating a culture of psychological safety, it might be very difficult, it might have challenges.
00:09:39
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but destroying psychological safety seems to be awfully easy, and I see it every day.
00:09:44
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Yes, you're right.
00:09:45
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Can you give us some examples of how we can destroy psychological safety, and then maybe we can dig into more of a framework of how to promote it?
00:09:53
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Yeah, I mean, what you say is absolutely right.
00:09:56
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There's a huge asymmetry.
00:09:59
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It's, of course, a lot like trust, where it can be destroyed in a minute and take time to build back up.
00:10:05
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but you can certainly destroy psychological safety.
00:10:07
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If someone asks a question and you say, especially if you're the attending and the person asking, let's say they're a respiratory therapist in the unit, and you say, that's a stupid question, I guarantee you're not gonna hear some of the very important questions or observations that you depend on for quality care, again, for a while, right?
00:10:32
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That sends not only a message to the person
00:10:36
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who asked the question, but it sends a message to anyone in earshot that you will be humiliated or mocked for doing your job.
00:10:48
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And it's obviously, it puts you and the patients at great risk.
00:10:55
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I saw... Go ahead, sorry.
00:10:57
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I saw a tweet the other day of Dr. Jonathan Moffitt.
00:11:01
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Oh, sorry, excuse me.
00:11:03
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Dr. Jonathan Cohen, who's at Moffitt Cancer Center.
00:11:06
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He's an anesthesiologist.
00:11:08
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And he says in this tweet, he says, how does it feel when someone in the OR points out my error?
00:11:15
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And then he says, almost surprisingly, actually, it feels pretty good.
00:11:20
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And then he says, to be fair, it didn't always feel this way.
00:11:24
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but when that happens, I know the patient's getting better care.
00:11:29
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And then he also says, and I love this, he says, and it also means I've been doing something right.
00:11:36
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So it takes wisdom to get to that point, but that's essentially the mindset and the resulting behaviors that help create that kind of environment where of course people know that they are expected
00:11:51
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and even valued for pointing out an error.
00:11:54
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Yeah.
00:11:56
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And it's interesting because the converse of what Dr. Cohen is tweeting is the often publicized and very sad situation where, for example, somebody, a patient gets the wrong leg amputated or a very obvious mistake happens that somebody observed but felt unable because of where they feel they stand
00:12:20
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to point out to the people in charge.
00:12:22
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Exactly.
00:12:23
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And, you know, I'm pretty sure, you know, I think most people, not all certainly, but most people, if they were 100% certain that's the wrong leg, they'll say something, even though it's hard.
00:12:34
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But what happens is more often than not, I mean, there's very few times when we're 100% certain of anything in the critical care environment, for example.
00:12:43
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And so what you have to realize is that given
00:12:46
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you might be 30% confident that you're right, or you might be 50% or maybe even 80%.
00:12:52
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I don't know, but whatever it is, it's not a hundred very often.
00:12:55
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And that's where the risk happens, right?
00:13:01
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That's where people are, well, you know, I'm not going to speak up because I could be wrong.
00:13:05
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Well, so what, you know, you could be wrong, but you could be right.
00:13:09
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And that would save the patient's leg.
00:13:12
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But we don't think that way in the moment because there's a fundamental asymmetry between
00:13:17
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speaking up and staying silent.
00:13:19
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You know, if I'm speaking up the, you know, I might be wrong, I might be belittled, you know, but I might be helping the patient, but that's such a big might.
00:13:31
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And how confident am I?
00:13:33
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Well, not very.
00:13:34
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And when would that happen?
00:13:35
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Well, you know, a little bit down the road versus staying silent.
00:13:40
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I'm always saving myself from,
00:13:44
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whatever blowback would happen from my speaking up.
00:13:47
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So there's this asymmetry that always favors silence over voice.
00:13:51
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And we've got to, or good clinicians know that they need to flip that upside down.
00:13:56
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In order to make people feel more awkward staying silent than speaking up, you just do something very simple.
00:14:04
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Ask a question.
00:14:05
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If I asked you, Sergio, what are you seeing?
00:14:08
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You'd feel very awkward just staying silent.
00:14:12
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Exactly.
00:14:13
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So one of the things that, that, that is very common in the clinical world in the ICU is for clinicians to think of leadership as those who have a title.
00:14:23
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But the reality is that if you're an intensivist and you're rounding or you're leading a cardiac arrest team, or you're running down to the ED for assicitation, you are the leader.
00:14:34
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People are following your instruction.
00:14:36
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And like we said earlier, Amy, it's very easy for those clinical leaders to destroy psychological safety.
00:14:42
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But I know that you've talked about a framework of how to build a culture of psychological safety.
00:14:47
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Could we talk a little bit about that?
Building Psychological Safety Framework
00:14:50
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Sure.
00:14:50
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And I, I tend to think of it in terms of, this is oversimplifying, but before, during, and after, but before, during, and after happens, you know, in, in a moment, right?
00:15:02
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Before the moment, during the moment, after the moment.
00:15:05
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But, but the three types of behaviors, one type is, is,
00:15:11
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stage setting, framing the work.
00:15:13
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I mean, being the kind of leader, as I've seen many good clinical leaders do this, who will frequently say things like, healthcare is by its very nature, you know, complex and error prone.
00:15:25
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Or they'll say things like, we've never done a procedure like this on this type of person before.
00:15:31
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They're saying the kinds of things that just remind people, A, of what's at stake and B, that we should be humble,
00:15:39
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in terms of our own confidence about whether we, whether we have this, you know, with, so we, we're, we're setting the stage as the kind of stage where anyone's voice could be mission critical.
00:15:51
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The during is really the art of asking good questions early and often, right?
00:15:56
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Much like you're doing right now, but just asking a question, what are you seeing?
00:15:59
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What's happening?
00:16:01
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Who has a different point of view, right?
00:16:03
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Those kinds of questions invite voice.
00:16:07
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They invite,
00:16:08
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genuine speaking up about what people see.
00:16:13
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And then of course, and I think this is particularly important in healthcare, how you respond, how you respond when someone asks a question, let's say in your mind, you're thinking, Ooh, that's a dumb question.
00:16:24
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That's okay.
00:16:25
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Right.
00:16:25
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I forgive you.
00:16:27
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Don't say it aloud.
00:16:29
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You know, what, what do you say aloud?
00:16:30
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You say, thank you so much for asking always.
00:16:33
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Right.
00:16:33
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And, and why?
00:16:34
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because people need to be appreciated and you need to be forward facing.
00:16:40
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And forward facing means you're aware of the shadow of the future.
00:16:44
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If you bite someone's head off today, they're not going to speak up tomorrow.
00:16:49
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And tomorrow might be the day where what they said would have saved your day.
00:16:55
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Yeah.
00:16:57
Speaker
And I think that as a clinical leader and as a scientist, one of the things that I always try to emphasize to our
00:17:04
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colleagues is that there's so much more that we don't know than what we do know.
00:17:08
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And we have to really have that kind of humbleness of really wanting to learn and be genuinely curious about what, what we could be doing wrong or what we could be missing.
00:17:19
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And I think that's present in the three stages that you talked about.
00:17:23
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So I almost think like the, before setting the stage as a clinician, it's important for people to realize that you don't have all the answers, that just plenty of things that you just have no idea.
00:17:34
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when you invite participation, I think you've written about like humble inquiry and truly asking genuine questions and really giving people the opportunity to contribute.
00:17:44
Speaker
Could you give us maybe some pointers of what constitutes a good question, Amy?
00:17:48
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Sure.
00:17:49
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I like to say that a good question is one that focuses on something that matters, you know, the patient, the situation, you know, it's not just, hey, what's on your mind, right?
00:17:58
Speaker
It's a bit more focused than that.
00:18:00
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But it's not a yes, no question.
00:18:02
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It's a question that invites careful thought and gives people space to respond.
00:18:06
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So a good question might be, you know, how was the patient last night?
00:18:13
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Right now, I'm asking for a very, in that question, I'm asking for a report.
00:18:19
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I'm asking for you to tell me what you saw.
00:18:21
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Or, you know, who has a different perspective?
00:18:25
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You know, we're maybe doing morning rounds and we're asking people,
00:18:31
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we're trying to figure out a diagnostic path and what to try next and you, you know, who has a different view is a good question.
00:18:43
Speaker
Or the kind of question that asks people to elaborate their thinking.
00:18:49
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That's a good point.
00:18:50
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Can you tell us how you got there?
00:18:52
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What data were you looking to?
00:18:54
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So these are questions that show respect because they,
00:18:57
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They show that you actually are curious about what someone else is seeing and thinking, and you're giving them that opportunity to share it.
00:19:06
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And I find also that another area in terms of questions that's important is when you're deciding on a path as a group, the group think is very common.
00:19:16
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And especially when the first person to usually give a suggestion is the clinical leader or the leader or the more senior person in the team.
00:19:25
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So sometimes maybe challenging the team to think out of the box and say, this sounds like a great plan, but how could we go wrong here?
00:19:32
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Or how could we be on the wrong path?
00:19:35
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And really encourage people to think about what could we be missing?
00:19:40
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Right.
00:19:40
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You can call it the premortem.
00:19:43
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It's not the postmortem.
00:19:44
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It's the premortem.
00:19:45
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It's like, let's just say just for the sake of argument that this went wrong, what would have been the reason?
00:19:51
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Which invites people.
00:19:52
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not to be negative and critical and speaking up, but to be creative and smart because they're the ones who are able to go, ooh, we didn't maybe do this right or consider that fully.
00:20:05
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Absolutely.
00:20:06
Speaker
And the last section you talked about was after responding productively.
00:20:12
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What I find often, Amy, is that it's not so much that somebody thinks that it's a dumb question, is that the clinician feels threatened and becomes defensive.
00:20:21
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when, for example, a nurse is suggesting that maybe there's a better way of doing this, or maybe there's something else that they should be doing.
00:20:28
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And that is probably one of the most difficult tensions to manage, but is one that's very common.
00:20:34
Speaker
Could you talk about, I guess it's like almost welcoming the messenger of bad news, right?
00:20:39
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And embracing that bad news.
00:20:41
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Yeah, I mean, you know, it's the oldest phrase you can think of, which is don't shoot the messenger.
00:20:48
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And, um,
00:20:50
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If you think about it, that's a pretty low bar.
00:20:52
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I mean, but it's normal.
00:20:54
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I mean, we don't shoot messengers, but it's normal to get to express frustration or disappointment when someone is the messenger of bad news.
00:21:04
Speaker
And so we have to train ourselves to, in fact, appreciate messengers, right?
00:21:10
Speaker
It's like, wow, thank you so much for letting me know.
00:21:14
Speaker
Thank you for the clear line of sight.
00:21:16
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Thanks for asking.
00:21:17
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But it's the.
00:21:18
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It's just appreciate the messenger and then dig into the message to figure out where do we go from here?
00:21:25
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So it's the same idea of appreciative and forward looking.
00:21:31
Speaker
And in terms of responding productively, there's also an area that I wanted you to touch on because a lot of times people, when they hear the definition of psychological safety, might immediately think that it's a very lax culture that doesn't have high standards.
00:21:46
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And I think that part of responding productively is to recognize that some behaviors need to be dealt with in a way that's very firm.
00:21:55
Speaker
Absolutely.
00:21:56
Speaker
Thank you so much for asking that because it is psychological safety is not an anything goes environment.
00:22:05
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It's an environment where people feel able to speak up.
00:22:10
Speaker
I think you need to marry that to an environment that's committed to
00:22:14
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high standards for sure to get people into that really learning zone that's, you know, the agile zone where great work happens in an uncertain environment.
00:22:25
Speaker
But it's a little bit paradoxical, not intuitive to everybody that in fact, when you sanction problematic behavior, you don't make it less safe, you make it more safe, more psychologically safe and more patient safe.
00:22:42
Speaker
So when, if people behave,
00:22:44
Speaker
badly, if they are disruptive or belittling or bullying, that needs to be called out.
00:22:53
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And people actually feel more able to be candid and bring their full self forward when they appreciate that there are boundaries here, right?
00:23:03
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That there are things we don't do to each other and things we don't say.
00:23:08
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And I think that dealing with the bad apples is always important because it also
00:23:14
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I think reinforces that cultural psychological safety in terms that there are certain behaviors, like you said, that should not be allowed if the team is really trying to move forward and perform at a high level for our patients.
00:23:27
Speaker
Right.
00:23:28
Speaker
You know, it's so important to start with keep starting with keep coming back to the patient, right?
00:23:33
Speaker
This isn't at some level, it's not about us, right?
00:23:37
Speaker
It's about the patient.
00:23:38
Speaker
It's about, um,
00:23:41
Speaker
the why we're here, we're here to deliver the very best care that we can.
00:23:46
Speaker
And because of the context being critical care, that's a really hard thing to do because there will often be uncertainty.
00:23:55
Speaker
There will often be complexity, comorbidities and all of the rest and short staff nowadays, especially.
00:24:03
Speaker
So what you're, what you're all about is inherently challenging and what you don't want
00:24:09
Speaker
is for people to be tied up in knots and afraid to speak up because that just makes the very hard work you already do even harder.
00:24:20
Speaker
Absolutely.
00:24:21
Speaker
And Amy, it's interesting that as a critical care physician, obviously you have a long road that is really paved with individual accomplishment or praise for individual accomplishment.
00:24:35
Speaker
Yet once you're done, and I became an attending when I was 32 years old, all of a sudden what's required of me is to work in teams.
The Art of Teaming in ICUs
00:24:43
Speaker
Now, the reality today of that is that it's really the team is more important than the individual, but also what has occurred for the last several years, and I think it's been accelerated by COVID, is that even my team in the ICU seems to be a different team every day.
00:24:59
Speaker
And I have to now work with other teams in the hospital that are not my usual team as well.
00:25:06
Speaker
You've talked and written about teaming.
00:25:08
Speaker
What is teaming?
00:25:09
Speaker
The teaming is exactly, you know, my writing a book called Teaming was exactly a reaction to what you just described because I was doing research in the hospital setting and it didn't take long to realize that people aren't just on a team.
00:25:25
Speaker
They're on multiple teams and they're teaming across shifts and they're teaming across professions and subspecialties.
00:25:36
Speaker
with different people at different times based on the needs of the patient or the, the needs of the shift.
00:25:43
Speaker
And, and I realized that's a very different, like we need to provide slightly different advice for people who are teaming versus for people who are in stable teams.
00:25:54
Speaker
You know, in stable teams, we say, get, get the goal clear, make sure you've got the right skills on the team and good processes and off you go.
00:26:03
Speaker
But in teaming, there's this perpetual need to sort of get quickly up to speed with who are you, what are you up against, what are you trying to get done, what am I trying to get done, and how do we understand each other well enough to work together and then disband again?
00:26:20
Speaker
And it's a process that's even more dependent on some level of interpersonal sort of skill and sensitivity than regular teams.
00:26:33
Speaker
And from all that I see, this is not going away.
00:26:35
Speaker
It's just probably likely to increase over time, especially in medicine.
00:26:40
Speaker
I think that's right.
00:26:40
Speaker
In fact, we're seeing it's increasing over time in other industries as well, especially with remote work and global work.
00:26:50
Speaker
There's just a lot of boundaries we need to span.
00:26:54
Speaker
We talked about the three aspects of
00:26:57
Speaker
creating a culture of psychological safety and setting the stage, inviting people to participate and then responding productively.
00:27:03
Speaker
And I would imagine that you can take that in a very compressed way and on a daily basis when you meet up with your new team or when you're working with new people, introduce elements of that.
00:27:15
Speaker
Could you give us some pointers on how we can do better in teaming?
00:27:20
Speaker
You know, I like to say, yeah, I mean, for me, again, it does start with framing.
00:27:26
Speaker
I mean, I think being
00:27:27
Speaker
being very explicit up front that we're, we're doing something novel and challenging.
00:27:34
Speaker
So it's sort of being clear that, um, we haven't done this before.
00:27:40
Speaker
So let's be open.
00:27:42
Speaker
Let's be honest.
00:27:42
Speaker
That's why teaming really depends on psychological safety.
00:27:46
Speaker
Teaming depends on that framing about the novelty of what we're doing, psychological safety to invite voices in.
00:27:53
Speaker
Um, and I'd say just, um, frequent,
00:27:57
Speaker
kind of status updates.
00:27:58
Speaker
Like we've got to get in the habit of what I would call reflection in action, that it's not just the after action review that we care about.
00:28:07
Speaker
It's being almost a kind of working aloud that I tell you what I'm thinking, what I'm doing and why, and you're telling me the same and together we're providing great care in an unusual and maybe even unprecedented situation.
00:28:27
Speaker
And that kind of inaction reflection reminds me perhaps of the kindergarten kids in the marshmallow experiments where they were building those structures.
00:28:36
Speaker
Is that a good analogy?
00:28:39
Speaker
Well, maybe so because they spoke aloud about, they shared their thought patterns as they were building so they could understand what each other was doing
00:28:56
Speaker
And that allowed them to be sort of almost more creative and more responsive, I guess is the right word, more responsive to what was happening.
00:29:06
Speaker
And if you're referring to the same thing, I think it was they were able to build taller structures than the adults given the same task.
00:29:18
Speaker
And that's what I was thinking of.
00:29:19
Speaker
And also, I guess at that age,
00:29:22
Speaker
you still have not experienced all the things that in life make us lose that psychological safety, right?
00:29:28
Speaker
That's true.
00:29:28
Speaker
Too naive, yeah.
00:29:30
Speaker
That's true.
00:29:30
Speaker
You haven't been told, oh, you know, most people are pretty good with five-year-olds and they don't tell them, oh, that's a stupid question.
00:29:36
Speaker
They get a lot of positive feedback when they ask questions and they aren't told, oh, that's wrong.
00:29:42
Speaker
You've done that wrong, or at least we hope they aren't.
00:29:45
Speaker
And so they're more willing to take those risks and more open to what's going to happen.
00:29:51
Speaker
Ooh, I'm curious what's happening when I do this, you know, whoop, marshmallow is too heavy.
00:29:56
Speaker
I better not put it on there yet.
00:29:59
Speaker
Yeah, absolutely.
00:30:00
Speaker
Well, and I think that obviously the idea of creating the environment where people can feel safe, can give ideas, can ask questions is really something that we need to be deliberate about on a daily basis.
00:30:14
Speaker
But another area that I wanted to touch with you today, Amy, is failure.
00:30:20
Speaker
Unfortunately, as physicians, we don't tolerate failure very well.
00:30:27
Speaker
And we really measure all our decisions based on the outcome and not the process.
00:30:33
Speaker
And I think that really hinders our ability to learn because we have still not figured out that there's a lot to learn from failure and that there's different types of failure.
00:30:42
Speaker
Could you talk a little bit about
00:30:44
Speaker
this aversion to failure or a relationship with failure, why is it so difficult?
Learning from Failure in Healthcare
00:30:48
Speaker
Well, to begin with, you know, physicians are high achievers.
00:30:52
Speaker
They've done very well in school and they've gotten into medical schools and gotten into residency programs and so forth.
00:30:58
Speaker
So you're used to a lot of experience of success and that can create a kind of fear of, well, I don't want to be, you know, there's the imposter syndrome.
00:31:10
Speaker
I don't want to be caught out as there's not as, you know,
00:31:14
Speaker
not smart enough, not good enough.
00:31:16
Speaker
So people are naturally afraid of revealing that they're imperfect because we're all imperfect, but we'd rather not be caught being imperfect, of course.
00:31:26
Speaker
And our, you know, that's natural and our environment reinforces that.
00:31:30
Speaker
So to me, part of, you know, part of dealing effectively and in a learning oriented way with failure means
00:31:41
Speaker
rethinking, actually rethinking what success means, right?
00:31:45
Speaker
Success in a clinical environment doesn't mean you get everything right all the time and you're perfect.
00:31:51
Speaker
Success in a clinical environment means you are able to avoid, you know, the really basic failures, the, the, the, forgive me for this, but the stupid mistakes,
00:32:05
Speaker
you know, you're alert enough and you're listening enough to what other people are saying that the things that we should know in our sleep, we do.
00:32:13
Speaker
You're able to anticipate the Swiss cheese failures, you know, the complex failures, the lining up of a bunch of factors that never happened in that exact way before that, you know, let a problem go all the way through and actually impact a patient.
00:32:32
Speaker
If you're aware, you're alert, you're vigilant,
00:32:35
Speaker
you're teaming, you're talking to people and asking for them to be speaking as well, you are better positioned to catch and correct the things that go wrong.
00:32:46
Speaker
Because let's face it, things will go wrong.
00:32:49
Speaker
The only question is, do you catch and correct them?
00:32:51
Speaker
Do people speak up about them?
00:32:53
Speaker
So, and then the, you know, in the laboratory or in clinical trials, that other setting where we want to
00:33:01
Speaker
I mean, we embrace the necessity of failure when we're trying to develop new information, new therapeutics, you know, new knowledge.
00:33:09
Speaker
And so success isn't about being perfect and getting everything right all the time.
00:33:14
Speaker
Success is about minimizing basic failures to near zero, anticipating complex failures so that you can catch incorrect before patients are harmed.
00:33:23
Speaker
And then offline when we're, you know, we're not in a position to hurt somebody,
00:33:30
Speaker
experimenting in thoughtful ways to keep expanding our knowledge base.
00:33:35
Speaker
Yeah, and I think that that's what you've called intelligent failure, which obviously still applies to the ICU because we might be doing research or trying during COVID or trying to figure out new ways of taking care of patients.
00:33:49
Speaker
And there, I mean, the goal is to learn and improve, but you have to be able to learn from failure.
00:33:55
Speaker
But before we talked about learning, I guess, from failure,
00:33:59
Speaker
really it's about building that culture, which in medicine is very common, unfortunately, which is who did it, who's to blame versus understanding what really happened.
00:34:10
Speaker
Right.
00:34:11
Speaker
And that is something that is just, I mean, deeply ingrained in clinicians from the time they do their first morbidity and mortality report, where basically you do a mea culpa.
00:34:20
Speaker
And when I was a resident, the answer always was that we will all try harder next time.
00:34:25
Speaker
You didn't really learn that much.
00:34:27
Speaker
Could you talk about what we need to do to facilitate learning from failure?
00:34:33
Speaker
Just pause for a moment to think about the difference between those two questions.
00:34:38
Speaker
One is who did it?
00:34:40
Speaker
The other is what happened?
00:34:42
Speaker
It's a profound difference right there.
00:34:45
Speaker
And yet they're going to, you know, in theory, they're both intent upon getting to the bottom of the event
00:34:55
Speaker
so that we improve and don't ever have that exact same thing happen again, right?
00:35:01
Speaker
The intent was the same, but the impact is very different.
00:35:05
Speaker
And I think intuitively you can appreciate that the impact is different.
00:35:10
Speaker
Who did it immediately inspires defensiveness, makes it difficult and in some cases near impossible to speak up honestly, because if you speak up honestly,
00:35:24
Speaker
you're going to get blamed.
00:35:25
Speaker
You're going to be the culprit and nobody, no healthy human being wants to be that.
00:35:30
Speaker
Whereas if it's who did it, it's still not easy, but I mean, sorry, what happened, what happened says essentially, are you smart enough, aware enough, alert enough to be able to describe the events as they unfolded, right?
00:35:48
Speaker
It's a, yeah, I am right.
00:35:50
Speaker
I'm a good student.
00:35:50
Speaker
I can do that.
00:35:51
Speaker
So it's,
00:35:52
Speaker
It's just got a profoundly different implication and therefore is more likely to produce good data.
00:35:59
Speaker
And good data are the kinds that we would be able to learn from.
00:36:04
Speaker
It almost speaks to that basic understanding of a fixed mindset versus a growth mindset.
00:36:11
Speaker
It does.
00:36:12
Speaker
Absolutely.
00:36:13
Speaker
So Carol Dweck's wonderful work on growth mindset, she says most, you know, most of us, like it or not, have
00:36:20
Speaker
you know, a performance mindset or a fixed mindset where we think that our abilities are meant, you know, our cognitive abilities, our intelligence is fixed.
00:36:30
Speaker
And so how well we do in whatever tasks we're performing, whether it's medicine or something else, is a reflection on how good we are, right?
00:36:39
Speaker
How smart we are, how capable we are.
00:36:42
Speaker
Unfortunately, by the time most of us are working adults, we've kind of bought into that fixed mindset, that performance mindset.
00:36:50
Speaker
But some rare people, and we're able to help people adopt this, have what she calls a growth mindset, what you might also think of as a learner mindset, which essentially thinks, no, my capabilities are a function of how much I work at something, how much practice I get, how alert I am, how much I'm willing to stretch and grow and keep trying.
00:37:20
Speaker
So they don't think of themselves as being a sort of a fixed capable person.
00:37:24
Speaker
They think of themselves as being a person who through diligence and effort and curiosity and all the rest will get better, which of course is true.
00:37:34
Speaker
Our brain is a muscle.
00:37:36
Speaker
It is, I mean, not literally, but it is something that improves with diligence and effort and learning.
00:37:47
Speaker
Absolutely.
00:37:48
Speaker
And one of the things that obviously we've talked about and touched on and also recognized is that COVID has taught us this, but also as we move forward in healthcare and trying to really be patient-centered and create a value-based care, innovation will be required from our ICU teams.
Innovation in Post-COVID ICU Teams
00:38:06
Speaker
Yet most ICU teams, when they think of innovation, think of the latest drug, the new fancy ventilator.
00:38:13
Speaker
And I think it's much more than that.
00:38:15
Speaker
How do you think of innovation, Amy?
00:38:17
Speaker
That's such an important issue, Sergio.
00:38:21
Speaker
You know, innovation is not the latest gee whiz technology.
00:38:26
Speaker
Innovation is anything new and useful.
00:38:28
Speaker
And during COVID, you know, from afar for me, but from close up for you, we saw lots of innovation, right?
00:38:36
Speaker
In the early days, nobody knew.
00:38:38
Speaker
You didn't know quite how to treat people or how to set up your processes or where patients should go or
00:38:45
Speaker
you know, how in some cases how to quickly create an ICU out of a floor space or even a, you know, hallway space in some cases.
00:38:54
Speaker
So there was lots of innovation real time as we figured out what this disease was and what were the options.
00:39:01
Speaker
And as those experiments were unfolding, you were observant and you noticed what worked better than other things.
00:39:10
Speaker
And then after a while, that created a set of practices that
00:39:15
Speaker
people try to adhere to.
00:39:17
Speaker
And so innovation is the, and it's generally a team sport and it's something that anytime you are developing new and better ways of doing something you're innovating.
00:39:30
Speaker
Absolutely.
00:39:30
Speaker
And it seems that in order to innovate successfully, it starts with psychological safety in today's environment in the ICU, it required teaming and ultimately really trying to learn from failure.
00:39:43
Speaker
Yeah, and you don't, you know, you, we're not saying, or at least I'm not saying everybody should feel free to do every single thing they want to do.
00:39:51
Speaker
And I think everyone should feel free to raise a crazy idea, say, what about, right?
00:39:56
Speaker
And so, because one of the things that I can say about intelligent failures is that they're hypothesis driven, meaning you do your homework, you run the idea by other thoughtful people.
00:40:08
Speaker
You don't just sort of throw darts at the wall to see where they stick.
00:40:13
Speaker
You think about it a little and you carry out those experiments in as small a scale as you can to be meaningful enough to learn.
00:40:24
Speaker
But not so, you know, you don't throw lots of time and resources at something that might not work.
00:40:31
Speaker
You throw a little bit of time and resources at something that might not work.
00:40:36
Speaker
And in the post-COVID world, it seems that there's going to be a lot of growth required for critical care and for hospitals in general.
00:40:43
Speaker
You've written about learning from startups.
00:40:46
Speaker
And as we close, could you explain the S-curve applied to an ICU or a hospital?
Applying the S-Curve Model to Healthcare Evolution
00:40:52
Speaker
It's funny you should ask because I was just thinking about that from your prior question.
00:40:56
Speaker
But the S-curve is a famous model in business that says and particularly applies to startups, but it also could apply to any new project or something.
00:41:06
Speaker
But let's think of it from a startup perspective.
00:41:09
Speaker
Let's say you are an entrepreneur.
00:41:10
Speaker
You have an idea.
00:41:12
Speaker
you have some idea that you could offer some value that customers will pay for and get pull some colleagues together, right?
00:41:21
Speaker
You found a company and there's lots of energy, lots of experimentation.
00:41:26
Speaker
People are utterly unafraid, you know, to speak up and to experiment because everybody knows we don't know how to do this yet.
00:41:33
Speaker
So there's all this energy and all of this creativity.
00:41:36
Speaker
And if you're lucky,
00:41:38
Speaker
you eventually, and hopefully not too slowly, arrive at a repeatable formula, where you figure out how to offer that product or that service in an economical enough and repeatable enough way that you can start doing it.
00:41:56
Speaker
And then you've entered phase two of the S-curve.
00:41:58
Speaker
And phase two is all about growth.
00:42:00
Speaker
Because of that replicability, you now know how to do something, you know how to do it efficiently and well.
00:42:05
Speaker
You attract customers, and you get
00:42:08
Speaker
you're bringing in revenues that allows you to invest and get more customers.
00:42:11
Speaker
And so the company grows and the company grows into a company that makes, you know, that has its success because of its repeatable, viable process.
00:42:24
Speaker
But over time, markets change, customer preferences change, new technologies come along, whatever it is, all formulas for success eventually hit a wall where they're no longer
00:42:37
Speaker
working.
00:42:38
Speaker
And so then you have to recognize that.
00:42:41
Speaker
You have to recognize maybe customers are less enthusiastic or the growth is slowing down or what have you.
00:42:47
Speaker
And so then you enter or try to enter a phase three where you're innovating again, where you're saying, okay, you know, what's next and who out there wants something that we could provide that's new.
00:43:00
Speaker
And so you try to reinvigorate that sense of
00:43:04
Speaker
creativity and energy and possibility again, that you had back in phase one.
00:43:09
Speaker
Now let's apply that S curve thinking to healthcare under COVID sort of the early, in the early days, you know, the spring of 2020 critical care practitioners were trying to figure out what works, how do we treat these people?
00:43:25
Speaker
How, you know, how do we diagnose them?
00:43:26
Speaker
What's happening?
00:43:27
Speaker
And then, you know,
00:43:31
Speaker
Pretty soon we got a few things that worked.
00:43:33
Speaker
We figured out how to, how to set up protocols and how to set up our personal protective equipment and so forth.
00:43:41
Speaker
And, um, you know, we got, got somewhat good at it, but now, now I think you're entering the phase where, how do we go back or not back?
00:43:51
Speaker
How do we go forward to the new healthcare delivery environments?
00:43:56
Speaker
The sort of the post COVID, if you will, how do we keep
00:43:59
Speaker
How do we reintegrate some of the things, some of the elective procedures that we weren't doing?
00:44:07
Speaker
How do we keep people from burning out, given that everybody's been really stretched thin for all these months?
00:44:13
Speaker
And so it's sort of how do we enter a phase three that's going to work for the future?
00:44:22
Speaker
And I think the first answer to that question is recognize it for what it is, new territory.
00:44:30
Speaker
And I think it's also important, I mean, when we think of that phase three, Amy, to not want to return to normal, quote unquote, but really it's an evolution, right?
00:44:38
Speaker
There's things that should not return to normal because they were wrong to begin with.
00:44:42
Speaker
And how can we learn from this trip and this process?
00:44:46
Speaker
There's no going back.
00:44:49
Speaker
Absolutely.
00:44:49
Speaker
Well, and I think that as we close, and I know that I'm respectful of your time, just a reminder to our listeners that perhaps the greatest innovation that you can apply this year to your
00:44:59
Speaker
ICU is to create a culture of psychological safety and to really be deliberate about what are the actions and behaviors that on a daily basis as intensivist we are doing that can promote or detract from our team being the best it can be.
00:45:17
Speaker
And a lot of the topics that we talked about today, I think fall right into that area.
00:45:24
Speaker
Amy, we'd like to close the podcast with some questions that are unrelated to
00:45:29
Speaker
usually to the clinical topic or the topic that we were discussing, but just to kind of tap into the wisdom of our guests, would that be okay?
00:45:35
Speaker
Sure.
00:45:37
Speaker
So the first question is about books, and I know that you've written several, but it's about what book has influenced you the most or what books have you gifted to others often?
00:45:48
Speaker
You know, the one that comes to mind, and it's got a crazy title, so forgive me, but it is a absolutely spectacular book and I think quite relevant to our conversation, and it's called
00:45:59
Speaker
Get Rid of the Performance Review by Sam Culbert, who is an Emeritus at UCLA professor.
00:46:06
Speaker
And of course, he doesn't actually mean we shouldn't be giving people performance feedback.
00:46:13
Speaker
What he means and what two thirds of the book argues is that most of the time, most of the way this is done is very counterproductive, you know, in some cases almost, you know, downright harmful.
00:46:26
Speaker
And what
00:46:29
Speaker
he describes as the replacement is the performance preview, where essentially people who manage others or people who teach others, like attending physicians, should take a stance of looking forward and thinking about it in the following way.
00:46:47
Speaker
How do I help you develop and be great?
00:46:51
Speaker
What's it gonna take from me?
00:46:53
Speaker
What's it gonna take from you?
00:46:54
Speaker
Let's have honest conversations.
00:46:57
Speaker
about that and about what we're up against, rather than the rather artificial conversation where I'm all knowing and you have to just receive whatever message I give you and you may feel defensive, but you're not allowed to, you're not allowed to speak, push back or, or any of that.
00:47:15
Speaker
I'm not doing it justice, but the reason I love this book so much is that it actually represents at its very core what we know about human beings and our ability to learn
00:47:25
Speaker
especially in work environments.
00:47:27
Speaker
It represents that when you set up a defensive environment, you're gonna get defense, not learning.
00:47:33
Speaker
When you set up a learning environment, you'll get learning.
00:47:37
Speaker
Yeah, and I've not read this book, but definitely we'll pick it up, but I've had used that same phrase in discussions with our group that we should get rid of the performance review, thinking more that we should be coaches and really work together towards growth, right?
00:47:51
Speaker
It's like that whole idea
00:47:53
Speaker
that we talked about from Carol Dweck that becoming is more important than being.
00:47:57
Speaker
It's not about giving somebody a grade every year or every six months.
00:47:59
Speaker
It's more about thinking for the next six months, what are the things that you can do to really grow and help our purpose?
00:48:07
Speaker
Right.
00:48:07
Speaker
Because we're responsible for delivering something that really matters.
00:48:11
Speaker
And so it's much more about how do we do that well than about whether I'm right and you're wrong and vice versa.
00:48:19
Speaker
Excellent.
00:48:20
Speaker
The second question relates to something that you believe to be true that most people don't believe or don't act as they believe.
00:48:29
Speaker
Well, I believe that we are all fallible human beings, each and every one of us.
00:48:35
Speaker
And I guess, you know, at some level, we all, everyone knows that, but we act as if it's not true.
00:48:42
Speaker
I mean, we still act as if, and we, we often feel bad because of our infall, because of our fallibility and,
00:48:50
Speaker
And so in a sense, even just behind, you know, even privately, we feel so bad about being fallible human beings.
00:48:57
Speaker
And I think we shouldn't.
00:48:59
Speaker
I think that's just a given.
00:49:02
Speaker
And so how do we embrace the notion of our fallibility and then, you know, find ways to take a deep breath and enjoy the journey?
00:49:15
Speaker
Absolutely.
00:49:16
Speaker
And it just speaks to what you're saying speaks to me in terms of thinking of
00:49:20
Speaker
how can I be more vulnerable in front of people that I'm leading, right?
00:49:23
Speaker
And being able to say I was wrong or I just have no idea.
00:49:27
Speaker
Obviously, as a leader, you don't want to say that every day, but being able to say it at the right times has tremendous power.
00:49:34
Speaker
It sure does.
00:49:36
Speaker
It just casts a wonderful, long, happy shadow.
00:49:40
Speaker
I guess that's a mixed metaphor, but it really does make a difference.
00:49:43
Speaker
So keep it up.
00:49:45
Speaker
The last question is,
00:49:47
Speaker
What would you want every intensivist who's listening to us today to know?
00:49:51
Speaker
Could be a thought, a quote, or just a fact.
00:49:56
Speaker
Anyone's voice could be mission critical.
00:50:02
Speaker
And I think that that's a perfect place to stop.
00:50:04
Speaker
Amy, thank you so much for being generous with your time, for all the research that you put out to the world that I think really helps us to reflect and try to be better team members and team leaders.
00:50:17
Speaker
And I look forward to reading whatever's coming up next and having a chance to talk with you again.
00:50:22
Speaker
Well, thank you so very much.
00:50:24
Speaker
I really appreciate your desire to get these ideas out into your community.
00:50:30
Speaker
It matters so very much.
00:50:32
Speaker
Thanks.
00:50:34
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:50:38
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:50:44
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:50:48
Speaker
To learn more, visit www.soundphysicians.com.