Speaking Up and Teaming Up to build a better world (or at least a better organization)

Amy C. Edmondson Novartis Professor of Leadership and

Management, Harvard Business School

November 2016

Whom Can You Rely on at Work?

In a survey of nearly 8000 employees in over 250 companies, only 59% of respondents reported they can rely on people in other units all or most of the time to follow through on what they promised to do – not much more reliable than external partners such as suppliers. This compared to 84% reporting they can rely on people upward and downward within their chain of command.1 Industrial era mindsets in a knowledge era world 1 Sull et al, (HBR, March 2015) Why Strategy Execution Unravels—and What to Do About It.

Think of a Team

…Or this

Or this…

Or this?

How Work Gets Done

Teaming Work Teams Command & Control

Teaming is a Verb

Teaming is teamwork on the fly –coordinating and collaborating, across boundaries, without the luxury of stable team structures

team • ing (v.)

Teaming is especially needed when work is COMPLEX and UNPREDICTABLE

Teaming is a Verb

Teaming is teamwork on the fly–coordinating and collaborating, across boundaries, without the luxury of stable team structures

team • ing (v.)

Welcoming New Recruits

Adopting a Teaming Mindset

COMPETITIVE MINDSET:

OVERLEARNED

SUCCESS AS ZERO-SUM

FOCUS ON SELF

FOSTERS COMPARISONS

TEAMING MINDSET:

MUST BE ADOPTED ON PURPOSE

SUCCESS AS SHARED & EXPANSIVE

FOCUS ON THE WORK & THE CUSTOMER

FOSTERS RELATIONSHIPS

Building Relationships for Teaming

“Seek first to understand” (Inquiry) • Intentions: Other’s aspirations & goals • Resources: Skills, information, experiences • The Situation: What s/he is up against…

Then seek to be understood (Advocacy) • Your intentions • Your resources • What you’re up against…

In hospitals, do better teams make fewer medication errors?

WORK UNIT

MEMORIAL 1

UNIVERSITY 1

UNIVERSITY 3

MEMORIAL 2

MEMORIAL 4

MEMORIAL 5

UNIVERSITY 2

MEMORIAL 3

REPORTED ERRORS

23.68*

17.23

13.19

11.02

8.6

10.31

9.37

2.34 * preventable and potential adverse drug events (ADEs) per 1000 patient-days

Units Sorted by Observer Ratings of Psychological Safety Which is the Safest Unit?

Reporting Climates

“She treats you as guilty if you make a mistake... I was called into her office and made to feel like a 2-year old.“

“She gives you the silent treatment.”

“You get put on trial...”

“People get blamed for mistakes... you don’t want to have made them.”

“Nurses are too hard on themselves... they are harder on themselves than I would ever be.” (nurse manager)

“Mistakes [in this unit] are serious, because of the toxicity of the drugs—so you’re never afraid to tell the nurse manager.

NO ONE WANTS TO LOOK:

IGNORANT

INCOMPETENT

INTRUSIVE

NEGATIVE

IT’S EASY TO MANAGE!

DON’T ASK QUESTIONS

DON’T ADMIT WEAKNESS OR MISTAKE

DON’T OFFER IDEAS

DON’T CRITIQUE THE STATUS QUO

Impression Management is Second Nature

It’s not just front-line employees

The Social Psychology of Speaking Up

Speaking Up Who gains?

The organization (& the patient)

When? Delayed

(& uncertain)

The Social Psychology of Speaking Up

It’s not surprising is that speaking up is rare, but rather that it occurs at all!

Speaking Up Silence Who gains?

The organization (& the patient)

Self

When? Delayed (& uncertain)

Immediate (& a near certainty)

Make it Safe to Team (to Make it Safe for Patients)!

Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.

IT’S ESSENTIAL FOR PATIENT SAFETY

Does role status predict psychological safety?

Teaming Up To Improve Quality in the NICU

N=1100 clinicians

• Leaders who: • Are accessible • Proactively invite input • Acknowledge their own fallibility

• Inclusive leaders • lower the psychological costs of speaking up and • raise the psychological costs of silence

Inclusive Leadership

Is it a matter of finding the right point on a balance beam?

PSYCHOLOGICAL SAFETY

ACCOUNTABILITY

Psychological Safety vs. Accountability?

NO!

high

low low high

ACCOUNTABILITY

PSYC

HOLO

GIC

AL

SAFE

TY

Apathy Zone

Comfort Zone Learning Zone

Anxiety Zone

The Learning Organization – A Just Culture

high

low low high

ACCOUNTABILITY

PSYC

HOLO

GIC

AL

SAFE

TY

Apathy Zone

Comfort Zone High-Performance

Zone

Anxiety Zone

Facing Uncertainty & Interdependence

Recent Research at Google: Explaining Team Performance

“Psychological safety was far and away the most important of the five dynamics we found -- it’s the underpinning of the other four.”

When Rozovsky and her Google colleagues encountered the concept of psychological safety in academic papers, it was as if everything suddenly fell into place.

One engineer, for instance, had told researchers that his team leader was ‘‘direct and straightforward, which creates a safe space for you to take risks.’’ That team, researchers estimated, was among Google’s accomplished groups. By contrast, another engineer had told the researchers that his ‘‘team leader has poor emotional control.’’ He added: ‘‘He panics over small issues and keeps trying to grab control. I would hate to be driving with him being in the passenger seat, because he would keep trying to grab the steering wheel and crash the car.’’ That team…did not perform well.

What Google Learned From Its Quest to Build the Perfect Team New research reveals surprising truths about why some work groups thrive and others falter. By CHARLES DUHIGG Illustrations by JAMES GRAHAM

NYTimes Magazine, February 28, 2016

Does implementing “team scaffolds” in an Emergency Department facilitate teaming

among fluid clinical personnel?)

The Theoretical and Practical Challenge

Seamless Coordination among Clinical Roles

despite

Fluid Personnel

1. Language barriers and different mental models • Donchen et al 1995; Huber and Lewis 2010 )

2. Ambiguous accountability • (Hackman and Oldham 1980)

3. Role occupants may focus on their own role responsibilities at the expense of the overall task

• (Hackman 2011)

4. Role groups sometimes function as divisive in-groups • (Bates 1975; Rossides 1998; Ashforth, Kulik & Tomiuk 2008)

5. Role hierarchies create interpersonal barriers to voice • (Nembhard & Edmondson, 2003)

Challenges & Risks of Role-based Coordination

(

• Minimal team structures designed to help fluid teams act more like real teams

• Enable coordination behavior and reduce throughput time in a busy Emergency Dept.

Team Scaffolds

Valentine, M. and Edmondson, A.C. (2015). Team scaffolds: How Minimal Team Structures Support Role-Based Coordination. Organization Science: 26:2, 405-422.

Research Site

Urban “safety-net” Emergency Department 600 employees; 18 month study period Attending Physicians - 3 possible shifts Residents/Interns - 5 possible shifts Nurses - 12 possible shifts

Problems with overcrowding & poor teamwork

Decided to implement “pods” (team scaffolds)

Previous coordination structure (unstructured, role-based)

Nurses Residents Attendings Patients

New coordination structure - PODS The work (role task division), technology, staff, patient population are unchanged

Attending

Resident Resident

Nurse Nurse

Nurse

1. ROLE SET

2. BOUNDARY

3. COLLECTIVE RESPONSIBILITY Set of Patients owned

by whole role set

Pods as Scaffolds Pods embody the logic of role structures and team structures

No Stability “It is a totally different team most of the time” – Attending

No Team Launch “Involving the nurses in transitioning the new resident into the pod is really rare.” – Resident

No Training or Coaching “There was no teamwork training before we went live.” – Nurse manager

ED “Pods” as Minimal Team Structures

Minimal Team Structures: A Role Set “If you have clearly defined roles and plug somebody else in who know what they’re doing, it’s going to continue to function fine.” – Resident

A (Temporary) Boundary “[Within a single shift] I have a designated group of nurses [and] a faculty that’s assigned to me.” – Resident

A Whole Task “Patients are assigned to a pod, you own them, no ifs ands or buts” – Attending

Clear Metrics “You can look at the computer and see how many patients are in your queue.” – Nurse

What explains why teaming improved with this minimal structure?

•

Ad-hoc role-based coordination Teaming

“You throw it over the wall” –Nurse “You’re just like a monkey following orders…no idea of the end result” –Nurse “They were always like, ‘that’s not my patient’” – Resident

“I and the Pod Lead work very side-by-side, saying “I need this patient here. We need to do this. Let’s try to get this done…” -Resident “You know what’s going on [with the patient in your pod] and you’re drawing the blood, the doctor is right there, and if they need more stuff they’re asking you for it. And you can talk to them and say, “Hey what are we

Improvements in Coordinating Behavior

“It is the difference between a really active communication versus you have to go discover everything on your own.” – Nurse

What are the explanatory mechanisms?

Why it Worked: Ownership Before the Redesign After the Redesign Competition “There wasn’t really even individual competition before the pods. You just

sort of did your job.” (Resident) “Someone will say “Pod 4 is killing us!” and then the pace and intensity of communication will increase.” (Resident)

Ownership “Before there was a lack of ownership by faculty and a lack of correlated ownership between nurses and doctors.” (Nurse)

“Pod design solved the ownership problem because with one faculty, one resident in charge… there is built-in ownership.” (Nurse)

Belonging “Before, I had to say, “Which one is Doctor [Jones]?” I didn't know who I was dealing with.” (Nurse)

“Knowing who you’re accountable to that day and who’s accountable to you. It does keep things on track.” (Nurse)

Visibility “There was just this giant stack of orders, and you got to them when you got to them.” (Nurse)

“With a smaller group being responsible for the whole package, you know what’s going wrong that day.” (Nurse)

Proximity “You had to walk across the ED all timid, ‘Uh, excuse me? Now they’re in the trenches with us.” (Nurse)

“You say to yourself, “What’s going on [with that patient]?” and then you go to the doctor, who’s sitting very close to you and say, “What’s going on with this patient?” (Nurse)

Why it Worked: Belonging Before the Redesign After the Redesign Competition “There wasn’t really even individual competition before the pods. You just

sort of did your job.” (Resident) “Someone will say “Pod 4 is killing us!” and then the pace and intensity of communication will increase.” (Resident)

Ownership “Before there was a lack of ownership by faculty and a lack of correlated ownership between nurses and doctors.” (Nurse)

“Pod design solved the ownership problem because with one faculty, one resident in charge… there is built-in ownership.” (Nurse)

Belonging “Before, I had to say, “Which one is Doctor [Jones]?” I didn't know who I was dealing with.” (Nurse)

“Where are my doctors?” (Nurse) “Who are my nurses today?” (Doctor)

Visibility “There was just this giant stack of orders, and you got to them when you got to them.” (Nurse)

“With a smaller group being responsible for the whole package, you know what’s going wrong that day.” (Nurse)

Proximity “You had to walk across the ED all timid, ‘Uh, excuse me? Now they’re in the trenches with us.” (Nurse)

“You say to yourself, “What’s going on [with that patient]?” and then you go to the doctor, who’s sitting very close to you and say, “What’s going on with this patient?” (Nurse)

Why it Worked: Visibility Before the Redesign After the Redesign Competition “There wasn’t really even individual competition before the pods. You just

sort of did your job.” (Resident) “Someone will say “Pod 4 is killing us!” and then the pace and intensity of communication will increase.” (Resident)

Ownership “Before there was a lack of ownership by faculty and a lack of correlated ownership between nurses and doctors.” (Nurse)

“Pod design solved the ownership problem because with one faculty, one resident in charge… there is built-in ownership.” (Nurse)

Belonging “Before, I had to say, “Which one is Doctor [Jones]?” I didn't know who I was dealing with.” (Nurse)

“Knowing who you’re accountable to that day and who’s accountable to you. It does keep things on track.” (Nurse)

Visibility “There was just this giant stack of orders, and you got to them when you got to them.” (Nurse)

“With a smaller group being responsible for the whole package, you know what’s going wrong that day.” (Nurse)

Proximity “You had to walk across the ED all timid, ‘Uh, excuse me? Now they’re in the trenches with us.” (Nurse)

“You say to yourself, “What’s going on [with that patient]?” and then you go to the doctor, who’s sitting very close to you and say, “What’s going on with this patient?” (Nurse)

Why it Worked: Proximity Before the Redesign After the Redesign Competition “There wasn’t really even individual competition before the pods. You just

sort of did your job.” (Resident) “Someone will say “Pod 4 is killing us!” and then the pace and intensity of communication will increase.” (Resident)

Ownership “Before there was a lack of ownership by faculty and a lack of correlated ownership between nurses and doctors.” (Nurse)

“Pod design solved the ownership problem because with one faculty, one resident in charge… there is built-in ownership.” (Nurse)

Belonging “Before, I had to say, “Which one is Doctor [Jones]?” I didn't know who I was dealing with.” (Nurse)

“Knowing who you’re accountable to that day and who’s accountable to you. It does keep things on track.” (Nurse)

Visibility “There was just this giant stack of orders, and you got to them when you got to them.” (Nurse)

“With a smaller group being responsible for the whole package, you know what’s going wrong that day.” (Nurse)

Proximity “You had to walk across the ED all timid, ‘Uh, excuse me? Now they’re in the trenches with us.” (Nurse)

“You say to yourself, “What’s going on [with that patient]?” and then you go to the doctor, who’s sitting very close to you and say, “What’s going on with this patient?” (Nurse)

Quantitative Analyses Inputs • Repeat collaborations among clinicians increased

(chance of working with the same person again within a shift)

• On average people worked with 4.6 fewer different work partners per shift (down from 16.7 to 13.1)

Outcome • Throughput time was reduced by 3.7 hours (from

7.9 to 4.2) • No difference in clinical outcomes

sra

• Interpersonal risk is a powerful force at work, with major implications for patient safety. It’s natural to manage others’ impressions of us, especially in hierarchies, and silence is a natural and easy approach to doing so.

• But interpersonal fear is not universal. Significant variance exists across individuals and groups in speaking up and psychological safety – across and within organizations (even facing famously strong organizational cultures).

• These differences affect teaming and learning behaviors (speaking up, asking for help, coordinating, and admitting error).

• Minimal (low to no cost) enabling structures & leadership messages can make a big difference in psychological safety, patient safety, and clinical performance.

Closing Thoughts

Thank You!