The Institute for Healthcare Improvement (IHI) and Safe & Reliable Healthcare have collaborated over 15 years to develop the Framework for Safe, Reliable, and Effective Care highlighted in a new white paper. The Framework comprises two foundational domains — culture and the learning system — along with nine interrelated components: leadership, psychological safety, accountability, teamwork and communication, negotiation, transparency, reliability, improvement and measurement, and continuous learning.

In other words, the paper is about creating a system of safety. Core to that system is something called psychological safety. What is it? How can you create it at your organization? This excerpt from the new white paper will help:

The concept of psychological safety originated with James Reason’s book, Managing the Risks of Organizational Accidents, and was popularized by Amy Edmondson in her early writings and in her book, Teaming.

Although thought of colloquially as “I can speak up about concerns,” the specific elements of psychological safety are much more nuanced and entail the following four attributes:

• Anyone can ask questions without looking stupid.
• Anyone can ask for feedback without looking incompetent.
• Anyone can be respectfully critical without appearing negative.
• Anyone can suggest innovative ideas without being perceived as disruptive.

Each attribute emerges in different places and times within work settings and is supported by different activities. For example, asking questions without looking stupid relates to learning in the clinical environment, whereas asking for feedback without looking incompetent is a major component of how frontline staff relate to the person they report to.

Unfortunately, many common social settings, even in our schools or with family and friends, reinforce the opposite of psychological safety and don’t support the value of asking questions, seeking feedback, or suggesting innovations. An environment of psychological safety breaks the cycle; such activities are not only welcomed but expected.

How can you move psychological safety from concept to reality?

Achieving psychological safety requires a flat hierarchy and a solid learning system that create an environment in which people can comfortably make suggestions, even somewhat outlandish ideas that might not fit at the time, but that others can mold to be useful. Leaders, in a coaching role, must be role models for applying learning judiciously and judgment sparingly, and admitting to their own failures and mistakes. These types of coaching and feedback are the primary mechanisms for achieving psychological safety. Regular one-on-one meetings with staff offer a prime setting for this work. Managers should meet individually with the people who report to them — at least 10 minutes per month — and ask pointed questions, such as the following:

• What’s working well?
• What’s not working well that makes it difficult to do the job?
• How am I doing in managing the environment?
• Who are the people that we should be highlighting for excellent work?
• What improvement suggestions do you have?

As mentioned before, responding to feedback is key. Staff members need to see that their concerns and comments are being heard and addressed.

In addition to individual meetings, leaders should conduct huddles — brief meetings where groups come together to quickly share information, and people are encouraged to speak up. Before the first huddle, a leader may want to ask specific people to bring up issues so other team members can see that it is okay to suggest ideas and provide constructive criticism. Once team members realize that feedback and input are welcome, it will become more natural.

To lay the groundwork for psychological safety, organizations need to clearly convey to all staff and leaders that it is an expectation. Everyone must create and support psychological safety as part of their job. Frontline staff may not realize they should expect this, and thus do not watch for these supportive behaviors in their leaders and colleagues.

Editor’s Note: Read the full white paper.