Have you ever seen a problem at work but decided not to say anything? Maybe you were worried about the reaction (fear). Or maybe you thought nothing would change anyway (futility).
Organizational psychologist Ethan Burris has researched these as two of the most common reasons people don't speak up. When I read his work years later, I realized I had been writing about these same barriers back in the 2008 first edition of Lean Hospitals–just without using those exact terms.
I also didn't use the phrase “psychological safety” in the book, which wasn't yet a widely used term in leadership or healthcare improvement circles, at least as I recall. But the concepts were there: creating an environment where people feel safe to raise concerns, share ideas, and point out problems without fear or futility.
One of the most enduring lessons from my work in healthcare is this: if people are afraid to speak up, or if they believe nothing will change when they do, improvement stops.
As I wrote in the book:
“If employees fear being punished for speaking up, they will remain silent about problems, even when those problems can lead to patient harm. If they believe that leadership will not act on their concerns, they will stop offering suggestions. Both fear and futility drive disengagement.”
Fear: “What will happen if I speak up?”
Healthcare is complex and high-stakes. A nurse who spots a near miss, a tech who notices a broken process, or a physician who sees a safety risk may hesitate to raise the issue if experience tells them it will lead to blame, criticism, or retaliation.
This is where Lean's “Respect for People” principle must be more than a poster on the wall. Respect means:
- Not blaming individuals for systemic errors.
- Making sure people have what they need to do the work.
- Creating an environment where concerns are welcomed, not punished.
Example – Reducing Fear at Virginia Mason Medical Center
At Virginia Mason, leaders recognized that fear was keeping staff from reporting problems. They implemented a Patient Safety Alert system where any employee could stop the line–literally halting care processes–if they saw a potential safety risk. Crucially, alerts triggered process reviews, not punishment. Over time, reporting skyrocketed, showing that fear had been replaced by trust in the system.
A Just Culture approach reinforces this–differentiating between human error, risky choices, and reckless behavior, and focusing on fixing processes rather than punishing people.
Futility: “Why bother? Nothing will change.”
Even when fear is low, futility can creep in. Staff might feel safe speaking up, but they stop trying because they believe “nothing ever happens” after raising a concern.
“If leaders ignore staff ideas, participation in Kaizen quickly drops. Employees need to see that their input matters–that leaders will listen, act, and provide feedback.”
Example – Overcoming Futility at Allina Health
At Allina Health, staff were encouraged to submit ideas to fix everyday frustrations–like a nurse having to walk to three different locations to gather supplies for starting an IV. Under their Kaizen program, managers worked with staff to reorganize supplies so that everything needed was in one place. The change saved minutes for each patient and showed employees that their suggestions could lead to meaningful improvements, reducing the sense of futility.
One antidote to futility is visible, timely action. In Kaizen, it's often the small improvements that rebuild belief. Quickly testing and implementing a staff idea sends a signal: “Your voice matters. Change is possible.”
Example – A Frontline Idea That Improved Patient Safety
In Lean Hospitals, I shared the story of a frontline nurse who noticed that patient wristbands were sometimes difficult to read because of how the information was printed. Instead of quietly working around the issue, she raised the concern through her hospital's improvement process.
Rather than dismissing it as “just the way things are,” leaders worked with her to test a revised print layout and font choice. The change was quick, inexpensive, and eliminated a potential source of patient identification errors. That improvement never would have happened if she'd been afraid to speak up–or if she thought it wouldn't matter.
Leader Behaviors That Reduce Fear and Futility
- Respond with curiosity, not criticism when problems are raised–ask “What happened?” instead of “Who messed up?”
- Follow up quickly on staff ideas, even if the first step is a small test.
- Recognize contributions publicly when people speak up or make improvements.
- Be visible at the gemba to hear concerns firsthand and show that you care.
- Close the loop by letting people know what happened with each idea.
- Model vulnerability by admitting when you've made a mistake or don't have an answer.
- Protect staff from blame when systemic issues cause problems.
- Make contributing easy with visual idea boards or simple submission methods.
Lean as the Antidote
Tools like 5S or value stream mapping help, but Lean is ultimately about trust and engagement. When fear and futility are replaced with psychological safety and shared purpose, staff energy goes into solving problems instead of hiding them.
“Lean is not a quick fix or program of the month–it's a management system and a culture. Without respect for people, without engaging them in meaningful work, Lean will not take root.”
If we want safer, better, more humane healthcare, we must eliminate not only waste in processes, but also the waste of human potential caused by fear and futility.
If you see fear or futility holding your organization back, it doesn't have to stay that way.
I work with healthcare leaders and teams to build cultures where speaking up is safe, ideas matter, and improvement is part of daily work.
If you'd like to explore how we could do that together–through a workshop, keynote, or ongoing coaching–contact me and let's start the conversation.
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Let’s build a culture of continuous improvement and psychological safety—together. If you're a leader aiming for lasting change (not just more projects), I help organizations:
- Engage people at all levels in sustainable improvement
- Shift from fear of mistakes to learning from them
- Apply Lean thinking in practical, people-centered ways
Interested in coaching or a keynote talk? Let’s talk.
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