Tag Archive for: leadership

Psychological Safety: A Missing Ingredient for Effective Teams

The manager has an open office policy. He involves staff in decision making, asks for feedback about new programs and initiatives, and helps out on the floor often. Still, he frequently finds staff are hesitant to speak openly about problems they see and challenges they face in their everyday work. He oftentimes doesn’t find out about issues until they become big problems, and there is a steady stream of bickering among many of the staff members.

The manager has held meetings to talk with staff about his desire for everyone to communicate openly and proactively. He assures staff they can drop by his office anytime—he almost always arrives early and leaves late. He walks the halls to check in with staff and asks how he can help. Still, the fundamental challenges remain. So what is missing? Why are his staff still reluctant to engage?

A key ingredient to high functioning teams is “psychological safety,” a term that describes individuals’ perceptions about the risks of their actions on interpersonal relationships. Amy Edmundson, a professor at Harvard Business School, has researched psychological safety and its impact on team performance extensively: “It consists of taken-for-granted beliefs about how others will respond when one puts oneself on the line, such as by asking a question, seeking feedback, reporting a mistake, or proposing a new idea. One weighs each potential action against a particular interpersonal climate, as in, ‘If I do this here, will I be hurt, embarrassed or criticized?’” (An excellent read is Edmundson’s recent book, “Teaming:How Organizations Learn, Innovate, and Compete in the Knowledge Economy“.)

This is crucial to understand. An open-door policy may sound great from a leader’s perspective; they just have to sit back and wait for staff to come talk. But if individual staff members worry about being judged for “going to the boss’ office,” or believe that their boss will overreact—or, worse, do nothing—they may be reluctant to risk the effort.

Psychological safety may sound like a familiar concept, especially if you work with one of the many organizations that has invested in developing a strong culture of trust and respect. Psychological safety is related to trust, as both involve perceptions about risk and vulnerability. But the differences between the two are important, too: trust involves perceptions about another’s future actions towards you, and generally considers a longer-term timeframe across many interactions, whereas psychological safety is an internal calculation about how others will perceive a specific action in the relatively immediate future.

These differences are important, in two key respects. First, the focus of psychological safety’s effect is a near-term calculation. This means a person may choose a course of action with negative long-term consequences to avoid a short-term embarrassment or reprisal. Consider the all-too-common example of a CNA who observes an unsafe condition but fails to speak up because she is fearful of being labeled “a troublemaker.” The long-term potential for harm should outweigh the short-term risk of standing out—but often it doesn’t. Second, trust involves holding a belief about how another person will treat you in the future, whereas psychological safety involves an assumption about how your own actions will be perceived by others. Individuals with lower self-esteem and self-confidence may struggle to take risks even in environments where there is trust. In addition, the experience of the group tends to influence psychological safety much more than trust; if you witness a team member being criticized or embarrassed, you are much more likely to censor your own actions in defense.

A lack of psychological safety manifests itself in myriad ways: employees are less likely to speak up if they have concerns or reservations; co-workers may observe mistakes, but fail to call attention to them; managers stick to the status quo, rather than attempt a risky innovation or improvement effort; teams are less capable of achieving goals that require communication and interpersonal interaction.

So, how can a leader combat these tendencies within their organization? Here are 3 practices to promote a culture of psychological safety.

  1. Be vulnerable and take risks. A secure leader can model vulnerability for the team. Embrace weakness, admit mistakes openly, and demonstrate a willingness to take interpersonal risks. Pay particular attention to actions you are hesitant to take: are you worried about another person’s reaction? The company’s response? Your reputation? Confronting these fears head-on can help you identify places where other team members may be struggling, too.In addition to taking appropriate risks, explain the context around your actions openly. Leaders often unwittingly harm psychological safety by making decisions without describing context or alternatives; by doing so, they create an illusion that every action should be “certain,” which reduces risk-taking confidence in staff. Similarly, make sure that you don’t unwittingly punish staff for failures that come from prudent risk-taking. When handled appropriately, failures and mistakes should be celebrated for the learning opportunities they provide. Doing so helps to normalize imperfection and lowers the risks for others to make mistakes. (A commitment to Just Culture helps balance accountability with support.)
  2. Develop team competencies that contribute to psychological safety. As noted earlier, psychological safety is related to trust, but also has some important distinctions. Typical trust-building exercises focus on peer-to-peer or employee-to-supervisor relationships. By contrast, building psychological safety involves whole team discussion about the barriers and roadblocks to speaking and acting openly, and requires diligence in establishing and maintaining norms for acceptable and desired behavior (which should include making mistakes). In this regard, leaders must also be mindful about cliques that exist within departments or units, as these tend to normalize behavior in ways that limit risk-taking. Calling attention to appropriate instances where individuals took risks to speak up or take action helps to reinforce expectations and build support.Practice is also important: sometimes team members may come to an administrator to share something “confidentially” or “off the record”— rarely, however, do these concerns really involve a confidential matter; rather, they are a symptom of a lack of psychological safety in the team. Take the opportunity to prepare the individual, and then gather the team for the individual to raise the concern directly to the group. Show your support for this type of behavior, and use the instance in an upcoming staff meeting to highlight the risk individuals face, the benefits of speaking up (to both the team and to the residents being served), and the commitment the team can expect from leadership.
  3. Identify your True North. Purpose-directed organizations build safety by creating a shared vision of what is trying to be achieved. The Cleveland Clinic, for instance, identified “Patients First” as their true north, and constantly asks team members at all levels of the organization to focus on “what matters most.” By striving for a shared purpose, staff are freer to take risks because they can mediate discomfort or conflict with someone else by appealing to that overall goal instead of focusing on a specific action or behavior.

Increasing the psychology safety in an organization takes time, commitment and courage. But the benefits– improved patient safety, increased employee engagement, and strong, more resilient teams are well worth the struggle.

Using Lean and PDSA to Reduce Employee Injuries


For many aging services providers, employee injuries are a costly reality of the workplace. In addition to workers compensation costs, however, employee injuries can cause scheduling challenges and lower worker morale. Lakeville Management, a small regional provider of assisted living and memory care communities, decided to tackle employee injuries as part of their commitment to deepening their respect towards employees.

To begin, administrators held several small focus groups to solicit information about the current safety culture, the employee injury reporting process, and barriers to implementing changes. With this initial information, the leadership team was able to construct a company-wide survey and identify opportunities to improve their processes.



The company safety committee (composed of multi-disciplinary representatives from each member community) first examined their current incident reporting process, which was used to report both actual injuries and near misses. Staff reported that the process was somewhat difficult, and, as a result, very few employees bothered to submit near misses. In addition, by examining the type of injuries that occurred most frequently, the committee decided to focus education and interventions on muscle strains, which accounted for almost 60% of all employee injuries.

The committee began by mapping out the incident reporting process. By dialoguing with supervisors tasked with completing parts of the process, the committee identified pain points, unclear forms, and burdensome back-and-forths. Using this knowledge, the committee tested several process and form updates, refining methods after 30 day trials in a single community.

The organization also created a temporary contest to build awareness about the value of near-miss reporting, including incentives for reporting near-misses and a transparent process in each community where near misses and interventions were displayed on a visual control board located in the staff break room. Staff were able see the results of reporting dangers before they led to injuries and could weigh in on interventions to help ensure that proposed changes were realistic within work routines.



After six months of work and four rounds of the PDSA process, Lakeville reevaluated the incident reporting process ease and short-term results. Supervisors reported that the updated processes were much easier to follow, and the leadership team noted a strong increase in the number of near miss reports. After twelve months, the results were dramatic: almost $200,000 in avoided worker compensation costs, 63% fewer lost days, and 15% fewer modified work days. In addition, managers at Lakeville became accustomed to including a review of staff injuries and near misses as part of their daily work, increasing accountability and awareness for the importance of worker safety to the organization.


Learn more about how Lean can help your organization improve performance, including reducing the number and severity of costly employee injuries, here.











Five Qualities of Role-Based Leadership

An important piece of adaptive leadership is the ability to apply different skill-sets to address different types of problems. Just as you (hopefully) wouldn’t use a hammer to fix a leaking pipe, you shouldn’t rely on one style or approach of leadership to meet every challenge. This complex understanding is oftentimes overlooked in leadership literature, where many authors propose more static models of “what a leader looks like.” In contrast, Ester Cameron and Mike Green, in Making Sense of Leadership: Exploring the Five Key Roles Used By Effective Leaders, propose a five quality leadership model that I find very helpful in understanding adaptive approaches. The five qualities they propose are:

  • The Edgy Catalyzer: Creates discomfort to promote change

    This quality is crucial when the status quo is an impediment to change or when an organization has become too complacent with its current structure and processes. By asking uncomfortable questions and pushing employees to examine held beliefs, the edgy catalyzer can help create a sense of unease that leads to a desire for change.

  • The Visionary Motivator: Focuses on engagement and buy-in to energize people

    A great deal of leadership literature focuses on the role of the visionary motivator in leading teams. This quality builds engagement and participation from team members and helps to create a coalition capable of moving change forward. Communication and positivity are essential traits of this quality.

  • The Measured Connector: Promotes a sense of purpose and connectivity between people

    Measured connectors work to align people with stated goals and targets. At times change can move uncomfortably fast, and this quality focuses on keeping team members together and committed. As organizations and care delivery systems become more complex, the importance of aligning not only internal employees but also external stakeholders grows.

  • The Tenacious Implementer: Focuses on projects, timelines, deliverables and targets

    In the article “What Leaders Really Do,” John Kotter creates a useful distinction between management work and leadership work. One common trap that leaders fall into, however—especially those skilled at building visionary coalitions– is failing to stick around and ensure that goals and projects are actually implemented. The quality of tenacious implementer is particularly important when managing the change required to implement regulatory fixes and large-scale IT projects, like EHRs.

  • The Thoughtful Architect: Envisions frameworks and system design to support needed change

    When working on system change or long-term strategic planning, leaders need to understand how to construct structural and process-oriented objectives to bring into existence an engaged vision. Indeed, many thought leaders are exceptional at building a strong coalition around a hopeful vision for the future, but then struggle to actually redesign an organizational structure or business line that brings this vision to life. The thoughtful architect quality is the most introverted of the qualities, and benefits from time to reflect and consider.

Cameron and Green constructed the following chart around some basic questions to highlight the differences between the qualities:

In considering the challenges facing your organization, different qualities of leadership are necessary in differing amounts to enable the organization to deliver the best results. Like many models of leadership, these five qualities are all considered “positive,” in the sense that they are all necessary to accomplish goals, though, as shown above, the amounts of each quality can vary considerably based on the specific aim. Put into the context of aging services, I’ve offered a visual depiction of the relative amounts of each quality useful in responding to the following challenges:

For each quality, too, there is a risk of using too much or too little of it, and it’s for this reason that I find the model most useful. The problems and challenges facing healthcare organizations today are myriad and diverse, and a one-size-fits-all model of leadership risks sacrificing the particular advantages of skills that might be necessary on one project but not on another. By understanding and embracing this complexity, adaptive leaders are much more effective in responding to a wide assortment of challenges and much more successful in leading a diverse range of change initiatives.

Using Plan-Do-Study-Act to Remove Alarms from a Skilled Nursing Home


Since the late 1980’s, nursing homes nationwide have taken dramatic steps to reduce the use of physical restraints among their residents. For many, this meant replacing lap belts and limb ties with bed and pull-tab alarms. These alarms attempt to alert staff to a resident about to fall, although studies of their effectiveness are inconclusive, at best. Many professionals now consider alarms to be unneeded, anachronistic, and disruptive to a resident’s wellbeing and quality of life—although removing them can be challenging, as Greenville Manor discovered.


When administrators at Greenville first proposed the idea of removing alarms, staff, family members and even some residents worried about the effect on resident safety and security. Although they were excited about eliminating the alarms to improve the atmosphere in the nursing home, the administrative team decied to utlize a Plan-Do-Study-Act (PDSA) cycle to test whether alarms could safely be removed without jeopardizing residents. A small, interdisciplinary team convened to work on the problem. By talking with staff and residents, and conducting online research, the team determined a number of root causes behind resident falls. The team also examined the process by which a nurse added an alarm to a resident’s care plan, and noted that very little investigation typically occurred. By organizing fall causes in a Pareto chart, the team was able to target the top 3 reasons and develop an education program to address those causes.


The team developed a test plan to remove an alarm from one resident and measure the results. After two weeks of no increased falls, the test was expanded to include seven additional residents (one nursing section). The team met frequently to analyze fall data and check in with staff involved in the test pilot. During the test, an alarm was discovered on one of the residents. The team quickly investigated and discovered that one of the night shift employees had been absent from a recent team meeting and did not receive the pilot notice in her mailbox. After correcting the issue, the team made a note to follow-up with a night shift focus group to talk about communication challenges and ways to better communicate between shifts.


After one month, the team determined that removing the alarms had actually resulted in a slight decrease in the number of falls in that section. (Later, the team learned that this result was not uncommon in communities that were successful in removing alarms.) The team decided to move forward with expanding the pilot, but to adjust the communication plan to ensure all staff and other stakeholders received adequate notice of the change.


At the next all-staff meeting, the team shared the results of the test, and solicited reactions from other team members. Staff who were involved in the pilot, along with the project team, responded to questions and helped to allay remaining fears about removing alarms throughout the community. Over the next three months, successive neighborhoods removed alarms while staff carefully monitored fall data. A community-wide party celebrated the removal of alarms, and a record of the before and after fall data was prominently displayed in the staff conference room.

The CMS Nursing Home Compare Five Star Update

Nursing Home Compare Five Star Rating

Since the Nursing Home Compare Five Star rating program was first launched in 2008, providers have approached it with a mix of trepidation, envy and awe. Using a set of complex statistical models, CMS awards between one and five stars to every nursing facility, with the goal of helping consumers make more informed and better care decisions. Unfortunately, its reliability is somewhat suspect, as most providers experience fluctuation in their star rating. According to a five-year analysis prepared by Abt Associates, only 3% of providers had the same star rating over the entire period, although 28% ended up with the same rating as when the program started. Almost 40% moved up or down one star over the five year period, while 20% moved two stars. Recently, CMS announced changes to the quality measure content and scoring methodology, costing about 8% of nursing facilities their five-star rating and creating unhappiness in the provider ranks:

LeadingAge Supports Transparency, But Still Finds Flaws in the CMS 5-Star Nursing Home Rating System
New Government Rating System Forces Nearly 1 in 3 Skilled Nursing Centers to Lose Coveted Quality Star
CMS’s confusing kick in the teeth

To understand what happened, first we need to understand how the score is calculated. You can read the CMS Technical Users Guide, or just follow along:

Health Inspections Five Star Rating

The health inspection rating is calculated from the number, severity and scope of deficiencies in the past 3 annual surveys, along with deficiencies from the last 36 months of complaint surveys. There is an aging component, as well, so that more recent surveys are weighted more than older ones. CMS then stratifies the star rating so that the lower 20% of nursing homes in each state receive one star, the middle 70% receive between 2 and 4 stars, and only the top 10% receive 5 stars. The actual state-by-state distribution looks like this:

Nursing Home Compare Five Star Rating

Staffing Five Star Rating

The staffing rating is based on reported staffing during the more recent annual survey, and looks at RN staffing and total nursing personnel (licensed nurses and nurse aides) adjusted by case-mix based on the RUG-III group. The star rating is determined according to the grid below:

Star ratings based on nurse staffing

And the state-by-state distribution looks like this:

Nursing Home Compare Staffing Star Rating

Alaska is excluded from the chart above. Why? Because 100% of Alaskan facilities received five stars for staffing.

Quality Measures Five Star Rating

The quality measure star rating is based on how the facility performs during the previous 3 quarters (9 months) on 11 of the 18 quality measures currently calculated by CMS:

Long-Stay Residents:
• Percent of residents whose need for help with activities of daily living has increased
• Percent of high risk residents with pressure ulcers (sores)
• Percent of residents who have/had a catheter inserted and left in their bladder*
• Percent of residents who were physically restrained
• Percent of residents with a urinary tract infection
• Percent of residents who self-report moderate to severe pain*
• Percent of residents experiencing one or more falls with major injury
• Percent of residents who received an antipsychotic medication

Short-stay residents:
• Percent of residents with pressure ulcers (sores) that are new or worsened*
• Percent of residents who self-report moderate to severe pain
• Percent of residents who newly received an antipsychotic medication

* Risk adjusted

The scoring methodology is somewhat complex, but essentially point values are assigned for each measure based on the nursing home’s performance compared to other nursing homes in the same state. Each quality measure is given equal weight, so the individual scores are simply summed. The total score is then applied to a scale to determine the star rating.

The current star distribution for quality measures, by state, looks like this:


Overall Five Star Rating

With the complicated math behind, calculating the overall star score is easy. Begin with the health inspection rating. Next, add one star if the staffing rating is a four or five stars *and* the staffing rating is higher than the health inspection rating. Subtract one star if the staffing rating is one star. Finally, add one star if the quality measure rating is five stars,  or subtract one star if the QM rating is one star.

Special note: If a facility has a one star health inspection rating, its maximum overall rating is limited to two stars. Also, if the facility is in the Special Focus Program, its overall star rating cannot be more than three stars.

Why was the Recent Rebasing Done and Why are Providers Unhappy?

Since the fundamental methodology is intended to stratify facilities relatively evenly, but the actual scoring is based on a known point system, a gradual drift towards higher star ratings occurred over the past five years. Part of this is probably due to overall care improvements, and part of this is probably due to providers gaming (or at least selectively improving) parts of the system.

There is also a slight issue of state imbalance. Consider the District of Columbia:



More than 50% of DC facilities hold a five star rating. Does this mean that DC providers provide phenomenal care? Perhaps, though it’s unlikely they provide significantly better care overall than providers in many other states. So how did so many providers get this coveted rating? As you can see above, the majority of DC providers received either four or five stars for staffing and five stars for QMs, which would lead to either one or two stars added to the health inspection rating. This points to a core problem with the five star system: CMS selectively stratifies measures by state, attempting to account for differences in state Medicaid policy and surveyor quirks, but this ends up causing some parts of the measure to reflect best-in-a-state results and others to reflect best-in-the-country results. Since the methodology isn’t standardized, it creates a real problem when comparing the five star rating of facilities located in different states.

What Does This Mean for Providers

CMS has clearly stated that it will continue to update measures and rebase scoring to promote continual improvement in nursing homes. While providers are understandably frustrated, this is simply the reality of healthcare today. Complaining about being ‘kicked in the teeth’ only furthers the perception that the nursing home field is behind the times. Instead, providers should see this as an opportunity to excel, not only in Nursing Home Compare rankings, but in service and care as well.

Understanding the methodology behind the five star rating system, as well as the state-level distribution, is a crucial first step to responding to this recent change. It should be clear that the health inspection score is the biggest driver of the overall score, and to reach a five star rating, a provider must be at or below the state average for survey deficiencies. Thus, it is critical, now more than ever, to build effective systems that embed quality processes into daily work. Customer service is also key, as most complaint surveys begin from unhappy residents or family members. Second, staffing hour cutoffs make it easy to compare current staffing metrics to the star rating system. For some facilities, adding slightly more staffing hours is an easy way to improve the star rating. Third, since quality measures are equally weighted, facilities can determine what measures are close to a higher point cut-off and work to improve those specific measures.


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