Psychological safety and accountability in longitudinal integrated clerkships: a dual institution qualitative study.

BACKGROUND: Psychological safety and accountability are frameworks to describe relationships in the workplace. Psychological safety is a shared belief by members of a team that it is safe to take interpersonal risks. Accountability refers to being challenged and expected to meet expectations and goals. Psychological safety and accountability are supported by relational trust. Relational continuity is the educational construct underpinning longitudinal integrated clerkships. The workplace constructs of psychological safety and accountability may offer lenses to understand students' educational experiences in longitudinal integrated clerkships. METHODS: We performed a qualitative study of 9 years of longitudinal integrated clerkship graduates from two regionally diverse programs-at Harvard Medical School and the University of North Carolina School of Medicine. We used deductive content analysis to characterize psychological safety and accountability from semi-structured interviews of longitudinal integrated clerkship graduates. RESULTS: Analysis of 20 graduates' interview transcripts reached saturation. We identified 109 discrete excerpts describing psychological safety, accountability, or both. Excerpts with high psychological safety described trusting relationships and safe learning spaces. Low psychological safety included fear and frustration and perceptions of stressful learning environments. Excerpts characterizing high accountability involved increased learning and responsibility toward patients. Low accountability included students not feeling challenged. Graduates' descriptions with both high psychological safety and high accountability characterized optimized learning and performance. CONCLUSIONS: This study used the workplace-based frameworks of psychological safety and accountability to explore qualitatively longitudinal integrated clerkship graduates' experiences as students. Graduates described high and low psychological safety and accountability. Graduates' descriptions of high psychological safety and accountability involved positive learning experiences and responsibility toward patients. The relational lenses of psychological safety and accountability may inform faculty development and future educational research in clinical medical education.

The Dynamics of Team Learning: Harmony and Rhythm in Teamwork Arrangements for Innovation.

Innovation teams must navigate inherent tensions between different learning activities to produce high levels of performance. Yet, we know little about how teams combine these activities-notably reflexive, experimental, vicarious, and contextual learning-most effectively over time. In this article, we integrate research on teamwork episodes with insights from music theory to develop a new theoretical perspective on team dynamics, which explains how team activities can produce harmony, dissonance, or rhythm in teamwork arrangements that lead to either positive or negative effects on overall performance. We first tested our theory in a field study using longitudinal data from 102 innovation teams at a Fortune Global 500 company; then, we replicated and elaborated our theory in a study of 61 MBA project teams at an elite North American university. Results show that some learning activities can occur within the same teamwork episode to have harmonious positive effects on team performance, while other activities combine to have dissonant negative effects when occurring in the same episode. We argue that dissonant activities must be spread across teamwork episodes to help teams achieve a positive rhythm of team learning over time. Our findings contribute to theory on team dynamics, team learning, and ambidexterity.

Wicked Problem Solvers.

Companies today increasingly rely on teams that span many industries for radical innovation, especially to solve "wicked problems." So leaders have to understand how to promote collaboration when roles are uncertain, goals are shifting, expertise and organizational cultures are varied, and participants have clashing or even antagonistic perspectives. HBS professor Amy Edmondson has studied more than a dozen cross-industry innovation projects, among them the creation of a new city, a mango supply-chain transformation, and the design and construction of leading-edge buildings. She has identified the leadership practices that make successful cross-industry teams work: fostering an adaptable vision, promoting psychological safety, enabling knowledge sharing, and encouraging collaborative innovation. Though these practices are broadly familiar, their application within cross-industry teams calls for unique leadership approaches that combine flexibility, open-mindedness, humility, and fierce resolve.

Measuring teamwork in health care settings: a review of survey instruments.

BACKGROUND: Teamwork in health care settings is widely recognized as an important factor in providing high-quality patient care. However, the behaviors that comprise effective teamwork, the organizational factors that support teamwork, and the relationship between teamwork and patient outcomes remain empirical questions in need of rigorous study. OBJECTIVE: To identify and review survey instruments used to assess dimensions of teamwork so as to facilitate high-quality research on this topic. RESEARCH DESIGN: We conducted a systematic review of articles published before September 2012 to identify survey instruments used to measure teamwork and to assess their conceptual content, psychometric validity, and relationships to outcomes of interest. We searched the ISI Web of Knowledge database, and identified relevant articles using the search terms team, teamwork, or collaboration in combination with survey, scale, measure, or questionnaire. RESULTS: We found 39 surveys that measured teamwork. Surveys assessed different dimensions of teamwork. The most commonly assessed dimensions were communication, coordination, and respect. Of the 39 surveys, 10 met all of the criteria for psychometric validity, and 14 showed significant relationships to nonself-report outcomes. CONCLUSIONS: Evidence of psychometric validity is lacking for many teamwork survey instruments. However, several psychometrically valid instruments are available. Researchers aiming to advance research on teamwork in health care should consider using or adapting one of these instruments before creating a new one. Because instruments vary considerably in the behavioral processes and emergent states of teamwork that they capture, researchers must carefully evaluate the conceptual consistency between instrument, research question, and context.

Speaking Up and Taking Action: Psychological Safety and Joint Problem-Solving Orientation in Safety Improvement.

Healthcare organizations face stubborn challenges in ensuring patient safety and mitigating clinician turnover. This paper aims to advance theory and research on patient safety by elucidating how the role of psychological safety in patient safety can be enhanced with joint problem-solving orientation (JPS). We hypothesized and tested for an interaction between JPS and psychological safety in relation to safety improvement, leveraging longitudinal survey data from a sample of 14,943 patient-facing healthcare workers. We found a moderation effect, in which psychological safety was positively associated with safety improvement, and the relationship was stronger in the presence of JPS. Psychological safety and JPS also interacted positively in predicting clinicians' intent to stay with the organization. For theory and research, our findings point to JPS as a measurable factor that may enhance the value of psychological safety for patient safety improvement-perhaps because voiced concerns about patient safety often require joint problem-solving to produce meaningful change. For practice, our conceptual framework, viewing psychological safety and JPS as complementary factors, can help organizations adopt a more granular approach towards assessing the interpersonal aspect of their safety climate. This will enable organizations to obtain a more nuanced understanding of their safety climate and identify areas for improvement accordingly.

Leadership lessons from the Chilean mine rescue.

Three years ago, when a cave-in at the San José mine in Chile trapped 33 men under 700,000 metric tons of rock, experts estimated the probability of getting them out alive at less than 1%. Yet, after spending a record 69 days underground, all 33 were hoisted up to safety. The inspiring story of their rescue is a case study in how to lead in situations where the stakes, risk, and uncertainty are incredibly high and time pressure is intense. Today executives often find themselves in similar straits. When they do, many feel torn. Should they be directive, taking charge and commanding action? Or should they be empowering, enabling innovation and experimentation? As the successful example of André Sougarret, the chief of the mine rescue operation, shows, the answer is yes--to both. The choice is a false dichotomy. Implementing this dual approach involves three key tasks. Each has directive and enabling components. The first task is envisioning, which requires instilling both realism and hope. The second task is enrolling, which means setting clear boundaries for who is on and off the team, but inviting in helpful collaborators. The third task is engaging--leading disciplined execution while encouraging innovation and experimentation. The authors of this article describe how Sougarret ably juggled all of these tasks, orchestrating the efforts of hundreds of people from different organizations, areas of expertise, and countries in an extraordinary mission that overcame impossible odds.

Strategies of learning from failure.

Many executives believe that all failure is bad (although it usually provides Lessons) and that Learning from it is pretty straightforward. The author, a professor at Harvard Business School, thinks both beliefs are misguided. In organizational life, she says, some failures are inevitable and some are even good. And successful learning from failure is not simple: It requires context-specific strategies. But first leaders must understand how the blame game gets in the way and work to create an organizational culture in which employees feel safe admitting or reporting on failure. Failures fall into three categories: preventable ones in predictable operations, which usually involve deviations from spec; unavoidable ones in complex systems, which may arise from unique combinations of needs, people, and problems; and intelligent ones at the frontier, where "good" failures occur quickly and on a small scale, providing the most valuable information. Strong leadership can build a learning culture-one in which failures large and small are consistently reported and deeply analyzed, and opportunities to experiment are proactively sought. Executives commonly and understandably worry that taking a sympathetic stance toward failure will create an "anything goes" work environment. They should instead recognize that failure is inevitable in today's complex work organizations.

Missing the Near Miss: Recognizing Valuable Learning Opportunities in Radiation Oncology.

PURPOSE: "Near miss" events are valuable low-cost learning opportunities in radiation oncology as they do not result in patient harm and are more pervasive than adverse events that do. Near misses vary depending on the presence of a latent error of behavior or process, and the presence of an enabling condition predisposing the patient to harm. These nuanced distinctions across near miss types can elicit different cognitive biases affecting the recognition of near misses as learning opportunities. We define near miss types in radiation oncology and explore the differential perceptions among radiation oncology staff. METHODS AND MATERIALS: Six event types were defined based on attributes of latent error and enabling conditions: "hit," "potential hit," "almost happened," "fortuitous catch," "could have happened," and "process-based catch." These events were illustrated with an example of a patient receiving pacemaker cardiac clearance before radiation treatment. A survey assessing (1) success versus failure of an event and (2) willingness to report the event was administered to a radiation oncology department using the pacemaker example. Mean scores for each near miss type were compared. RESULTS: Ninety-five staff members (74%) completed the survey. Perceived success scores and willing-to-report scores significantly differed by near miss type (P = .042 for success ratings; P < .0001 for willingness to report). "Could have happened" events were viewed as less successful and were more likely to be reported than "almost happened" events (P < .0001). CONCLUSIONS: Cognitive biases appear to influence whether and how near miss types are recognized as report-worthy. Education of near miss types and engaging staff for quality improvement may improve recognition.

Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses with Varying Proximity to Harm in Radiation Oncology.

BACKGROUND: Psychological safety, a shared belief that interpersonal risk taking is safe, is an important determinant of incident reporting. However, how psychological safety affects near-miss reporting is unclear, as near misses contain contrasting cues that highlight both resilience ("we avoided failure") and vulnerability ("we nearly failed"). Near misses offer learning opportunities for addressing underlying causes of potential incidents, and it is crucial to understand what facilitates near-miss reporting. METHODS: A survey of radiation oncology department staff in an academic hospital assessed psychological safety and presented five scenarios with varying proximity to patient harm: "standard care" involving no harm, three near misses with varying proximity to harm ("could have happened," "fortuitous catch," "almost happened"), and one "hit" involving harm. Respondents evaluated each event as success or failure and reported willingness to report on a seven-point Likert scale. The analysis employed ordered logistic regression models. RESULTS: A total of 78 staff (61.4%) completed the survey. The odds of reporting "hit" (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.19-3.23), "almost happened" (OR: 1.60, 95% CI: 1.07-2.37), and "fortuitous catch" (OR: 1.60, 95% CI: 1.10-2.33) improved with an increase in psychological safety. The relationship of psychological safety to reporting "standard care" and "could have happened" was not statistically significant. The odds of reporting were higher when a near miss was discerned as failure (vs. success). CONCLUSION: Near misses are not processed and reported equally. The effect of psychological safety on reporting near misses becomes stronger with their increasing proximity to a negative outcome. Educating health care workers to properly identify near misses and fostering psychological safety may increase near-miss reporting and improve patient safety.

The competitive imperative of learning.

Most executives believe that relentless execution--efficient, timely, consistent production and delivery of goods or services--is the surefire path to customer satisfaction and positive financial results. But this is a myth in the knowledge economy, argues Edmondson, a Harvard Business School professor. She points to General Motors, which for years has remained wedded to a well-developed competency in centralized controls and efficient execution but has steadily lost ground, posting a record $38.7 billion loss in 2007. Such an execution-as-efficiency model results in employees who are exceedingly reluctant to offer ideas or voice questions and concerns. Placing value only on getting things right the first time, organizations are unable to take the risks necessary to improve and evolve. By contrast, firms that put a premium on what Edmondson calls execution-as-learning focus not so much on how a process should be carried out as on how it should evolve. Since 1980 General Electric, for instance, has continued to reinvent itself in every field from wind energy to medical diagnostics; and it enjoyed a $22.5 billion profit in 2007. Organizations that foster execution-as-learning provide employees with psychological safety. No one is penalized for asking for help or making a mistake. These companies also employ four distinct approaches to day-to-day work: They use the best available knowledge (which is understood to be a moving target) to inform the design of specific process guidelines. They encourage employee collaboration by making information available when and where it's needed. They routinely capture data on processes to discover how work really happens. Finally, they study these data in an effort to find ways to improve execution. Taken together, these practices form the basis of a learning infrastructure that makes continual learning part of business as usual.

Is yours a learning organization?

An organization with a strong learning culture faces the unpredictable deftly. However, a concrete method for understanding precisely how an institution learns and for identifying specific steps to help it learn better has remained elusive. A new survey instrument from professors Garvin and Edmondson of Harvard Business School and assistant professor Gino of Carnegie Mellon University allows you to ground your efforts in becoming a learning organization. The tool's conceptual foundation is what the authors call the three building blocks of a learning organization. The first, a supportive learning environment, comprises psychological safety, appreciation of differences, openness to new ideas, and time for reflection. The second, concrete learning processes and practices, includes experimentation, information collection and analysis, and education and training. These two complementary elements are fortified by the final building block: leadership that reinforces learning. The survey instrument enables a granular examination of all these particulars, scores each of them, and provides a framework for detailed, comparative analysis. You can make comparisons within and among your institution's functional areas, between your organization and others, and against benchmarks that the authors have derived from their surveys of hundreds of executives in many industries. After discussing how to use their tool, the authors share the insights they acquired as they developed it. Above all, they emphasize the importance of dialogue and diagnosis as you nurture your company and its processes with the aim of becoming a learning organization. The authors' goal--and the purpose of their tool--is to help you paint an honest picture of your firm's learning culture and of the leaders who set its tone.

Facing ambiguous threats.

On February 1, 2003, the world watched in horror as the Columbia space shuttle broke apart while reentering the earth's atmosphere, killing all seven astronauts. Some have argued that NASA's failure to respond with appropriate intensity to the so-called foam strike that led to the accident was evidence of irresponsible or incompetent management. The authors' research, however, suggests that NASA was exhibiting a natural, albeit unfortunate, pattern of behavior common in many organizations. The foam strike is a prime example of what the authors call an ambiguous threat-a signal that may or may not portend future harm. Ambiguous threats differ from threats with obvious causes-say, a fire in the building-for which the response is clear. They also differ from unmistakable threats that may lack straightforward response paths (such as the frightening oxygen-tank explosion aboard Apollo 13). However, when the warning sign is ambiguous and the threat's potential effect is unclear, managers may choose to ignore or discount the risk. Such an approach can be catastrophic. Firms that do a good job of dealing with ambiguous threats do not improvise during a crisis; rather, they apply a rigorous set of detection and response capabilities that they have developed and practiced beforehand. In this article, the authors outline how to put such capabilities in place long before a crisis strikes. First, companies need to hone their teamwork and rapid problem-solving skills through practice. Second, they must learn to recognize weak signals, amplify the threat, and encourage employees to ask disconcerting "what if" questions in a safe environment. Finally, they should explore possible responses to threats through quick, low-cost experimentation.

Informal Peer Interaction and Practice Type as Predictors of Physician Performance on Maintenance of Certification Examinations.

IMPORTANCE: Physicians can demonstrate mastery of the knowledge that supports continued clinical competence by passing a maintenance of certification examination (MOCEX). Performance depends on professional learning and development, which may be enhanced by informal routine interactions with colleagues. Some physicians, such as those in solo practice, may have less opportunity for peer interaction, thus negatively influencing their examination performance. OBJECTIVE: To determine the relationship among level of peer interaction, group and solo practice, and MOCEX performance. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal cohort study of 568 surgeons taking the 2008 MOCEX. Survey responses reporting the level of physicians' peer interactions and their practice type were related to MOCEX scores, controlling for initial qualifying examination scores, practice type, and personal characteristics. EXPOSURES: Solo practice and amount of peer interaction. MAIN OUTCOMES AND MEASURES: Scores on the MOCEX and pass-fail status. RESULTS: Of the 568 surgeons in the study sample, 557 (98.1%) passed the examination. Higher levels of peer interaction were associated with a higher score (ß = 0.91 [95% CI, 0.31-1.52]) and higher likelihood of passing the examination (odds ratio, 2.58 [1.08-6.16]). Physicians in solo (vs group) practice had fewer peer interactions (ß = -0.49 [95% CI, -0.64 to -0.33), received lower scores (ß = -1.82 [-2.94 to -0.82]), and were less likely to pass the examination (odds ratio, 0.22 [0.06-0.77]). Level of peer interaction moderated the relationship between solo practice and MOCEX score; solo practitioners with high levels of peer interaction achieved an MOCEX performance on a par with that of group practitioners. CONCLUSIONS AND RELEVANCE: Physicians in solo practice had poorer MOCEX performance. However, solo practitioners who reported high levels of peer interaction performed as well as those in group practice. Peer interaction is important for professional learning and quality of care.