Reflections

In the beginning, it was difficult to find a capstone project. Several topics were explored, such as utilization of Artificial Intelligence in quality and safety as well as transitioning surgical follow-ups to telemedicine. I reached out to several teams, but nothing materialized. I observed that nurse practitioners are usually not involved in quality and safety initiatives, especially not in academic medical centers, though the reasons for this were unclear. This challenge lit the fire to explore why nurse practitioners and other advanced practice providers (APPs) aren’t more included in quality and safety initiatives at some institutions.

Through experience, I noticed this problem in my home institution. I subsequently reached out to my mentor and we decided to meet with the Advanced Practice Providers Leadership Council. APPs include nurse practitioners, physician assistants, certified registered nurse anesthetists, and certified nurse midwives. As result of this meeting, the problem of psychological safety among APPs was identified as a priority and it was decided I should investigate reasons for potentially low psychological safety in this group as well as avenues to drive improvement.

One of the experts in the field of psychological safety is Professor Amy Edmondson from Harvard Business School. I reached out to her and she agreed to help study this problem. Her team from The Fearless Organization offered to survey the APPs at MGH to identify if psychological safety is a problem and provide a sub-analysis of the aggregate score. The sub-analysis includes open conversations, attitude to risk and failure, willingness to help, and diversity. Each of these would have a specific score and through this we would be able to identify the biggest problem area(s). This is a validated survey that has been utilized by various organizations for the past 20 years. After an intervention is designed and implemented, the survey will be re-administered to measure changes. This process required buy-in from key stakeholders, especially because all APP emails had to be shared with The Fearless Organization for survey purposes.

As part of the “Going to Gemba” process, I shadowed multiple APP teams, both from in-patient and out-patient settings. One of the themes which surfaced is that APPs do not feel valued and integrated in the organizational structure. As a result, they are not included in various projects. This struck a chord as it reminded me of my struggles in joining a team to help with a quality and safety project. APPs felt that there was a mismatch between the organizational messaging and real-life actions involving their inclusion.

The survey has been sent out and will be open until January 15th. The team from The Fearless Organization noted that a low level of response is also an indication of very low psychological safety among employees. So far that seems to be the case, but we will remind APPs every two weeks that the survey is open and encourage responses. Once the survey is closed, we will analyze the aggregate data and determine the most pressing problem area. Solutions can then be identified and interventions designed.

The survey closed January 15th with a final response rate of 35%. While this remains a low response rate, it is similar to or slightly better than the yearly AHRQ safety survey. The paper discusses the results in detail but essentially 3 of the 4 themes had adequate psychological safety on average, but the “attitude to risk and failure” theme was very low. People are afraid to report mistakes because they perceive this as being held against them. Each APP member “tackles risks and errors individually or not at all”.

In order to better understand the scores, I looked at the number of safety events submitted by APPs in 2019 and 2020. Professor Edmondson correlates a low number of events submitted with low psychological safety. I also compared this to the total number of events submitted by all of MGH and it was low. During my interviews with various experts from different organizations, I identified that Virginia Mason Hospital had a very high patient safety profile. Subsequently I reached out to them and indeed their size is 1/4 to 1/3 the size of MGH however when we compare the number of submitted reports, MGH reaches barely 40% of what Virginia Mason has. This comparison is based on the number of safety events reported and the average daily capacity of each institution. One would argue that MGH, as an academic medical center with extensive research/innovation, large number of trainees, and various subspecialties would inherently have a higher number of safety events reported. This is not the case. Overall, when we place the attitude to risk and failure scores in this context, they seem to correlate to the low number of safety events reported.

One surprising element in the survey was the results of the CRNAs’ responses. When I compared interview notes with their overall score, they did not align. The interviews denoted a high psychological safety profile yet the scores indicated otherwise. After discussing this with the directory of APPs, I identified that this group had this problem last year and an intervention was implemented. Nonetheless, it appears that it was not effective. This suggests that appropriate QI science needs to be utilized when developing interventions.

Unfortunately, due to the timeframe, the implementation will likely not happen so those steps in the paper will be hypothetical. Regardless, I still advised with the Q&S department on the possible interventions.

This capstone project has been rewarding yet challenging in many ways. I was able to work with world-renowned leaders in quality and safety, which helped me develop intuition on when there may be quality and safety concerns. From a combination of classroom instruction along with lessons from this capstone project, I have a greater appreciation for the importance and difficult job that quality and safety leaders have in making positive changes. For the project, I interviewed and collaborated with leaders from Karolinska Institute (Sweden), UCLA, Cleveland Clinic, Mayo Clinic, Virginia Mason Hospital, and Professor Charles Vincent from Oxford University. It was a privilege to learn from them and hear their perspectives on what makes a good quality and safety culture. A common pattern in these institutions was their effort to flatten hierarchical structures since it greatly reduces fear experienced by employees. This has come full circle for me as our first class started with Deming’s 14 Points for Management, which includes “Driving Fear Out”.

I have seen that improving psychological safety can be successful in many cultural and organizational contexts. For example, Karolinska Institute is a highly socialized organization, to the extent that their hierarchical structures are almost nonexistent, and nurses drive quality and safety initiatives. It was great to see how psychological safety is taken very seriously and how the organization includes it in their leadership training. They correlate this not only with quality improvement and patient safety but also employee turnover rates. For them, a 12% turnover rate is considered very high and the executive leadership becomes directly involved when they get close to this threshold (M. Savage PhD, personal communication). Meanwhile at Mayo Clinic, they were successful by bringing in an outside organization to develop workshops and training programs to lower hierarchical structures. It’s clear to me that thoughtful leaders are acutely aware of the importance of psychological safety. At Virginia Mason Hospital, this was clearly illustrated by their transparent, prompt, and detailed responses to probing psychological safety questions.

One of the challenges I experienced was in navigating the MGH system as an advanced practice provider in order to find a mentor, find an appropriate project, and being supported in the process. It took almost a year to just find a mentor who would be willing to guide me at my home institution. The norm at other organizations is to support their employees when they want to expand and better their knowledge, but at MGH I ran into steep hierarchical structures and highly patriarchal systems which made it difficult to find a mentor and a project that I could implement.

Another challenge was that, once a project was identified, I needed to administer a survey to establish the current state of psychological safety and identify the problem areas that could be focused on. It took an excessive amount of time and effort to get approval for the survey, which cut into the implementation time. In addition, once the survey was approved, I learned how difficult it can be for people to complete a survey when there are psychological safety problems at baseline, which the survey results and going to Gemba revealed. Despite extending the deadline for the survey and even providing monetary incentives from personal resources, the response rate was still only 35%. However, this did align with the APP response rate for MGH’s annual AHRQ Hospital Survey on Patient Safety Culture of 30%.

Based on the current literature, contextual observations, and thoughtful interviews, I believe psychological safety should be a measure required by the Center for Medicare and Medicaid, accrediting bodies such as the Joint Commission, and ranking organizations such as US News and World Report. Psychological safety has knock-on effects to many parts of an organization and is a barometer for their health.