Can Questions About Patient Safety Feel Psychologically Unsafe?

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I think that working to reduce patient harm (to improve patient safety) is one of the most important (and most noble) applications of Lean.

Daily huddles can be an effective way to engage staff and improve communication. Sometimes, they are sadly just that 10-minute block of time where people look at their shoes or their watches.

But, when we have effective huddles, the leader asks questions to help draw out issues, problems, risks, opportunities for improvement, or the like.

If we're asking staff to speak, we have to make it “psychological safe” for them to do so. Psychological safety has been my theme this week, and you might want to check out my podcast with an expert on the subject, Amy C. Edmondson, PhD.

There are many different words and phrases that we could use to ask staff about risks or incidents related to patient safety.

“Any safety problems?”

I don't like this approach for a number of reasons. For one, it's a closed-ended question. Depending on the tone use and the history or culture in the department, this might seem like a question that is demanding “no” as an answer. It might seem like the leader doesn't really want to hear what's going on, even if they truly do. That question might seem unsafe.

A better way to phrase it might be:

“What safety risks or problems exist today?”

It's an open-ended question. Granted, it's a leading question. But, the field of “Motivational Interviewing” says that's OK at times — in the context of counseling or helping people.

The question presumes that there are risks. That is probably an accurate assumption in healthcare. If the leading question is incorrect, somebody can say so.

But, I think a question like this recognizes the real reality (there very likely are risks) and that seems to make it safer for people to speak up.

As Toyota leaders famously say:

“No problems is a problem.”

Maybe we only have a slight risk of minor harm, but it's still there. We probably can't eliminate all risk in a healthcare environment.

Toyota leaders also like to ask:

“What are your top three problems?”

That's an open-ended leading question that presumes there are problems (and the leader is probably correct). The implication is that if somebody replies, “We don't have any” (risks or problems), then it's possible that they aren't doing a good job of being aware of risks that are present… or they aren't feeling safe about speaking up (which is a cultural problem, not a problem with the individuals).

In her outstanding book, The Fearless Organization, Edmondson suggests this question:

“Was everything as safe as you would like it to have been this week with your patients?”

This question presumes that we all want things to be safe. We might debate whether the question means “as safe as possible” — and what is “possible?” As safe as reasonably possible in this environment? Or safe meaning zero harm and near-zero risk?

Edmondson says leaders need to “invite participation” after “setting the stage.”

She says about that question, asked by a healthcare leader to their staff:

“The question – genuine, curious, direct – was respectful and concrete: “this week,” “your patients.” Its very wording conveys genuine interest. Curiosity. It makes you think. Interestingly, she did not ask, “did you see lots of mistakes or harm?” Rather, she invited people to think in aspirational terms: “Was everything as safe as you would like it to be?” Sure enough, psychological safety started to take hold. People began to bring up incidents that they had seen and even contributed to.

Edmondson, Amy C.. The Fearless Organization (Kindle Locations 3683-3687). Wiley. Kindle Edition.

She says the question was effective in that context, so that's what really matters. I can't tell you exactly what to say, but I'd hope you would experiment with questions to see what engages people most.

It's a closed-ended question — triggering a yes or no answer. But maybe it sparks more discussion than that if it's a psychologically safe setting.

Maybe could modify the question to be something like:

“What was preventing us from providing the safest care to our patients yesterday?”

It's an open-ended question. It presumes that care was not as safe as possible and that something was preventing us. I'd try to ask the question in a way that focuses on systemic factors and not blame.

Maybe “What were the barriers to providing the safest care yesterday?” would be another variation.

I don't know what the answer is. I'd probably go test questions like the last iteration. Again, what matters is what works. I don't know if there is a “best practice” question phrasing that everybody should use or copy.

Plan, Do, Study, Adjust. I think that's still good advice. What do you think? What have you seen in practice?

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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

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