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“Pain points” can be thought of as the concerns and challenges each of us face which get in the way of accomplishing what is most important to us.

Research in psychological safety and intrinsic motivation indicates that the extent to which conversations at work elicit and explore these factors — what is important to each of us and our pain points — significantly impacts learning, innovation, and performance.

Psychological safety is present when people feel they can talk about difficult issues and trust what they say will be heard and explored rather than ignored, discounted, or criticized. Repeated psychologically safe conversations help people develop intrinsic motivation. In other words, they do things out of a sense of personal importance as opposed to compliance.

Over many years of serving as a leader and improvement advisor in innovation initiatives, I have repeatedly been surprised at how often managers and clinicians who are experiencing pain points have not brought them up with their supervising leaders. Or, when they have, the discussion was not helpful or — even worse — made them feel discounted or criticized.

Even more surprising, all too many times I have discovered that managers and clinicians either rarely meet with their supervising leaders or do so less than monthly.

To explore these observations further, at the 2019 IHI Summit, I asked 200 participants in a leadership workshop to complete a survey about their meetings with their supervising leaders, i.e., the leaders to whom they directly report. Of the 41 who did so, 86 percent reported that meetings with supervisors occur at least monthly. About half of all meetings with their supervisors lasted longer than 30 minutes.

In these meetings with direct supervisors:

• 42 percent indicated their major pain points are addressed never, rarely or sometimes as opposed to often or very often.
• 48 percent indicated that, when their pain points are addressed in meetings, the discussions are never, rarely, or sometimes helpful.
• Only 22 percent indicated that these pain points discussions are very often helpful.

While this small survey is just a rough indicator of how often and how well pain points of managers and clinicians are addressed in meetings with their supervising leaders, the results are consistent with my impressions that these communication gaps are common.

This is not surprising given the considerable barriers to speaking up about concerns. Research has shown that there is a strong, automatic tendency to stay silent about concerns even in the face of imminent threats to patient safety.

In addition, power differentials, as in the case of conversations between leaders and their direct reports, magnify this tendency. It is also nearly automatic for leaders to assume that high-powered, competent professionals should be able to just speak up as needed. Research, however, indicates that repeated invitations to speak up are required.

The high pressure, stress, and complexity of the health care environment further magnify these intrinsic human tendencies. So, we are all at high risk for not having conversations about the things that matter most to us right now and the pain points which impede desired outcomes.

Given these powerful and tenacious aspects of human nature, improving and sustaining psychological safety and intrinsic motivation depends on conversations between leaders and their direct reports in which there are consistent invitations to speak up and consistent efforts to address concerns and challenges.

As the ones with more power, leaders must carry the burden of responsibility to do the following to promote psychological safety:

• Schedule regular (no less than monthly) one-to-one meetings with their direct reports.
• Make repeated invitations in each of your meetings to bring up and explore what is important, of concern, and challenging.
• Set aside time to problem solve about pain points. (Consider using the IHI tool "What Matters to You?" Conversation Guide for Improving Joy in Work to use improvement science to do this collaboratively.)
• Ask for feedback from direct reports in each conversation to learn if problem solving has been helpful.
• Consistently follow up to track and assure progress.

Quality and safety in health care is supported by elegant and powerful concepts, methods, and tools to improve our work processes. But, our best efforts to change things for the better are at risk unless we also address our conversation processes so that we develop and sustain psychological safety and intrinsic motivation.

Neil J. Baker, MD, is IHI faculty and principal, Neil Baker Consulting and Coaching, LLC. He will be a presenter for “Managing the Risks of Power in Shaping Culture” at the IHI National Forum (December 8–11, 2019 in Orlando, FL, USA).

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