All teams go through the stages of “forming,” “storming,” “norming,” and “performing.” Anyone coaching teams on improvement should embrace the storming phase since getting to this point means staff are becoming more comfortable opening up and discussing how things are (or aren’t) working. They feel, in other words, psychologically safe.
For frontline staff, psychological safety means being accepted, heard, and understood without fear of retaliation. Psychological safety creates the conditions for the transformational dialogue necessary to make improvement.
For an improvement coach, creating the environment for psychological safety begins when you meet teams where they are, both emotionally and physically. Psychological safety grows as coaches go to the frontline, and encourage participants to come to quality improvement (QI) meetings as they are. As relationships are built over time, so too does trust. Trust is key for the development of local QI capacity and workflow innovation. Where people feel safe to innovate, the conditions of contribution are primed, and the possibilities are endless. When supporting cultures of psychological safety, patience is key. For example, one team I worked with was at first hesitant to talk about work surrounding a medication reconciliation workflow. They feared speaking up about problems.
There was a lot of silence at those first meetings, despite my best attempts at humble inquiry. However, I stuck with this team, and over time, we built relationships.
A defining point was when the team used a process map to document the current state medication reconciliation workflow. They laid out every step by simply asking and answering, “What happens next?” As they got everything on paper, I heard staff say things like, “I didn’t know you were involved in that step” or “I didn’t know you did that.”
By relying on this common quality improvement tool, they shared their collective knowledge, and shifted their focus from fear to improving the process. It probably helped that we employed a “Vegas-style” ground rule at our team meetings, i.e., what happened in that meeting, stayed in that meeting. After about a month, they developed new standard work and updated the medication reconciliation process so it was used and understood by staff, and reliable for patients. Coaches need to understand that developing better conditions takes time, especially when working with frontline staff who have not historically felt safe to speak openly. Psychological safety is best fostered through respectful discussion, open-ended questions (like those above to document the current state), and the development of mutual relationships that foster dignity.
True coaching requires reflection, and an openness to hear from the staff. It does not mean going in ahead of time with the problem “solved.” It may mean uncomfortable silence in some meetings as frontline staff members test the waters.
At times, it may be frustrating to a coach who worries the work isn’t moving fast enough, but quiet, slower moments provide opportunities to create and celebrate small wins. Completing a complex process map where staff learn about the work (and each other), using a fishbone diagram that elicits new ideas for potential testing, or testing a hunch to improve care are all momentum builders for larger wins. Health care workers are intrinsically motivated to make something better than they found it. A culture that supports psychological safety is primed not only for reflection and growth, but true process innovation, something most health care systems desperately need.
Health care workers care for the complexity of the human condition every day. Improvement coaches have a responsibility to ensure our frontline staff feel cared for, psychologically safe, and respected as we make care and processes better than the status quo.
Julianna Spranger is a graduate of the IHI Improvement Advisor Program and the Improvement Coach program. She is a Lean Value Consultant for American Family Insurance and can be reached at firstname.lastname@example.org.
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