Psychological Safety in the Medical Workplace

In the past, medical harm has not been given due attention in Ethiopia. There was very low accountability, even though errors resulted from the reckless acts of physicians. But now we have come across a lot of medical doctors being pursued by patients or family members who suffered harm. While it is crucial to hold people accountable for committing errors, it is very important not to ignore the role of psychological safety in increasing the level of commitment and dedication to the patient safety effort. A lack of psychological safety impacts team work as people shift blame on others, or onto surrounding circumstances. This in turn reduces team work and collaboration which are the basics for an effective health care system.

I recognize the fact that the existing law is controversial in the eyes of stakeholders including medical professional. This has triggered the need for a revision. We also heard that the government has embarked on a research project to take a deeper look and identify issues that cause a lot of problems along these lines. In this article, I am looking to share insights to policy makers as to what should be done to ensure the psychological safety of medical professionals.

Psychological Safety and Its Importance
The term psychological safety describes a climate in which people feel free to express relevant thoughts and feelings. It is a shared, tacit belief by the group members that well – intentioned actions will not lead to punishment or rejection by others. Research by the well – known Harvard psychologist Amy Edmondson has shown that management by fear even leads to errors and cover ups of mistakes. In psychologically safe environments, people are willing to offer ideas, questions, and concerns. They are even willing to fail, and when they do, they learn. Edmondson states that the need for psychological safety is based on the premise that no one can perform perfectly in every situation when knowledge and best practices are in flux.

One of the case studies that I analyzed while doing an Executive Education Program at Harvard was Children’s Hospital, in which I learned how blame free reporting helped the hospital to significantly reduce medical error. The newly appointed Director of Patient Safety reminds people of ‘’why what they do matters.’’ Besides, the hospital institutionalized blame free reporting such that medical staff would not be reprimanded for making mistakes. This in turn helped the hospital to build trust and to create a shared urgency about an opportunity or performance gaps. It does not mean that you are allowed to make the same mistake repeatedly.

Studies show that psychological safety allows for moderate risk-taking, speaking your mind, creativity, and sticking your neck out without fear of having it cut off — just the types of behavior that lead to market breakthroughs. Google also has done a two – year study on team performance, which revealed that the highest-performing teams have one thing in common, that is, psychological safety, the belief that you won’t be punished when you make a mistake.

Understanding Health Care
In health care, expert workers, such as physicians and nurses face tremendous uncertainty and challenges in delivering high quality services to those in significant need of their care. This context is enveloped by high – stakes accountability systems, professional norms and by organizational structures that make psychological safety especially relevant and yet, unfortunately, also especially elusive. Hospitals by their very nature are characterized by high stakes and challenging contexts in which the work affects patient health, sometimes in life or death circumstances. Professionals also value autonomy and a lot of space to exercise their expertise.

In health care, concerns about patient safety, along with the growing complexity of care delivery processes, make psychological safety relevant. It is well established that many patients are harmed each year by errors, and psychological safety has been shown to be a crucial element in organizational efforts to detect and prevent these problems.

Current estimates suggest that preventable adverse events occur in one third of patients who are hospitalized. To ensure the quality of care, especially for patients with multiple health conditions (“comorbidities”), diverse experts must coordinate their decisions and treatments. Further, health care professionals take psychological risks when they allow their performances to be watched and analyzed by peers and senior experts. Thus developing and maintaining a psychologically safe environment is important.

Managing Health Care Delivery
The health system produces health, but it also produces harm. Health care is a very complex system, and complex systems are, by their very nature, risk prone. The culture of health care must be one of everyone working together to understand safety, and report issues without fear of blame. This in turn requires a cultural change, among other things, in our hospital settings. To this end, instead of jumping to blaming medical experts for medical accidents, hospital settings should first create the psychological safety for the practitioners by executing actions outlined below:

Creating Culture that Welcome Open Communication
The famous saying: culture eats strategy for breakfast (I would like to add: even for lunch and dinner) resonates strongly across the spectrum. Thus, the Ethiopian health care system should set out to create a culture that welcomes open and frank communication about safety issues. It is imperative to establish an environment in which everyone focuses on learning from past mistakes, rather than ‘’ pointing fingers ‘’ when something goes wrong. To that end, it is highly commendable to institute a ‘’ blameless reporting ‘’ system to enable to discusses medical errors openly. The idea is to allow people to communicate confidentially and anonymously about medical accidents without being punished, so as to unearth as many of the problems as possible, and to determine the underlying causes of these accidents. Research has shown that blameless reporting helps to avoid blame and shame culture such that it encourages front line workers to use patient safety efforts to discover and eliminate breakdowns in hospital systems and processes.

Patient Safety Dialogues
Hospitals need to create learning sessions where by clinical staff and employees come together to learn about the current state of research on medical safety, as well as to discuss other safety related – issues that demand immediate attention and so on. I strongly recommend that clinical and administrative staff are trained in a health care management program where they emphasize opportunities for exploring breakthrough delivery models and practices; enhance their capabilities in strategy, operations, finance, and leadership—and improve their ability to drive change, manage people, and improve patient care. Because this health care management program focuses on developing strategies that address organizational challenges such as prevention and managing of medical errors, it will foster teamwork, but also will amplify the impact on health care delivery.

Infrastructure
It is imperative to establish several structures and processes to oversee and implement patient safety initiative. In particular, it is important to set up a patient safety steering committee responsible for leading the initiative and approving major policy changes such as a new patient safety reporting system as well as processes for examining serious accidents. Besides, the impact of facilities and equipment drives effective health care delivery. Hospitals need to have a forward-looking leadership to invest in maintenance and modernizing, but the quick survey that I have carried out across hospitals in Ethiopia, shows that though the overall condition of Ethiopia’s health care infrastructure varies widely, most hospitals are struggling and have been unable to keep up. This in turn would increase medical accidents because medical facilities may not be supporting physicians to make informed decision at the expected level , hence , the psychological safety of medical experts is compromised .

Accountability
Medical directors, unit managers and administrators might express concerns that the blameless reporting system undermines their ability to hold individuals accountable for poor performance. While the patient safety field emphasizes ‘systems thinking’ as its central theme, there is a need to balance this ‘no blame’ approach with the need for accountability in certain circumstances, such as failure to heed reasonable safety standards. Research has shown that clarity about punishment creates safety. Experts over three decades of research identify ‘Blameworthy’ acts such as reckless behavior, disruptive behavior, disrespectful behavior, knowingly violating standards, working way beyond your boundaries, and failure to learn over time as mistakes that call for punishment. Besides, there is a need to clarify personal versus institutional accountability. It is worth reflecting on errors that stem from system flaws in which case the physician should not be liable for the medical accident.

Moving Forward
Most errors are, in fact, committed by good people trying their very best. I very much hope that medical experts such as physicians and nurses recognize that a ‘no – blame culture ‘is neither feasible nor desirable. A small proportion of human unsafe acts is egregious and warrant sanctions, severe ones in some cases. A blanket amnesty on all unsafe acts would lack credibility in the eyes of the public. More importantly, it would be seen to oppose natural justice. What is needed is a just culture, an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information—but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. The health care policy makers in Ethiopia need to understand the fact that while it is important to hold people accountable for the medical errors that they have committed , having a low psychological safety would result in a lot of medical errors and prevent groups from collaborative analysis that might have revealed technical / performance risk early . It also negatively impacts the occurrence of collective learning. Thus, in the course of revising the existing law, there is a need for considering all the above to make patient safety initiatives successful.

8th Year • Feb.16 – Mar.15 2019 • No. 71