I think we started the morning with a very important discussion on conflict management, a lot of engagement in the tables, I think that's what we really want. We're going to have a series now, two presentations I'll make, and then we'll have another presentation working with the tables. But I think that for the next one, which is lifting those around me, case number four is a perfect segue to what we're going to talk about, which is about creating the right environment and helping our team members when they are struggling and when maybe things like what happened to our ORT happened with that anesthesia colleague. So I think that this is obviously a very timely topic. As we mentioned before, we believe that every single one of you is a leader. It's not based on position, but it's based on an attitude of trying to change things around us for the best, and we are all responsible for lifting those around us and for creating the right environment. I'm Sergio Sanotti. I'm an intensivist based out of Houston. I'm also the CMO of a very large decision-led practice. We cover over 100 ICUs around the country and really see all sorts of problems. This has been an interest of mine in terms of building better teams and complex environments. So no financial disclosures for this particular presentation. In terms of what we will cover and learning objectives, I think it's good to start with just understanding where we are today in health care, especially in the ICU, some of the headwinds that we are facing. I do believe that creating the right environment can prevent the need to lift a lot of people, and that is really what we should understand and work on. And finally, we'll talk about what each one of us can do when we go back to our ICUs in lifting others who might be struggling or might be having a difficult time, recognizing that people might have just a bad day or people might have struggles that are a little bit more chronic and burnout, and both of those are things that obviously we would like to help them with getting better. So in terms of headwinds, burnout has been a problem before COVID, and we know that physicians, nurses, but there's also literature in other disciplines within the ICU, like pharmacy, have had an increase in reported burnouts for the last several years. COVID obviously did not help that, and it is something that we have to deal with, and everywhere that I've been, there's been people who are very engaged and satisfied with their jobs, and there's people who are totally burnout, and how can we help everybody move in the right direction is important, but this is just a reality in health care and in the ICU today. COVID seems so distant now, yet it definitely has had an impact that I think still is persistent, and this is literature from the UK looking at mental health parameters after COVID surges, and remarkable basically the level of PTSD, of anxiety disorders, of substance abuse, is very comparable, if not bigger, for ICU providers than those who went to wars recently. So clearly this has had an impact on our workforce, and we've seen that in multiple studies that have come over the last years, and Josh mentioned that earlier, of the intent of people leaving health care, leaving the bedside, leaving the ICU. This is from Mayo Clinic study that looked at a large number of health care providers, and what you can see here, health care workers, is that up to a third of physicians were thinking of decreasing their clinical commitments, a third of APPs, a third of nurses, and really thinking of either decreasing their clinical work in the next 12 months or leaving their current practice in the next 24 months, really staggering numbers that is not something that we had seen pre-COVID. So all of that has really created, I think, an environment where lifting others might be an important part of what we do on a daily basis. So what are some of the things that help people stay where they are or help people maybe find more fulfilling careers? This is data from Breast Gaining, and what's interesting is that I've heard a lot of people over the last couple of years talk about pay and increasing pay as a solution to people leaving, and obviously I think everybody should be paid fairly, but that's not what makes people stay, right? And I think that we should focus as leaders on making sure that we are working on things that make people stay, and in healthcare especially, it's I like the work I do, my work is meaningful, the work I do makes a difference, and I see every patient as an individual and I can make a difference in their life, and how I fit in that team is ultimately what matters to people. So that leads us into the environment. What can we as leaders do to build a better environment? And I have this term I like to use, which is the fearless ICU, which is what I hope every ICU is, becomes, and some might have elements of it, some might have a short run to being fearless, and others might have a very long runway, but the idea is about moving in that direction every day at our ICUs. And how do I define a fearless ICU? It's an ICU where every team member feels comfortable sharing concerns and mistakes without fear of embarrassment or retribution. They are confident they can speak up and won't be humiliated, ignored, or blamed. They know they can ask questions when they are unsure about something. The team members trust and respect each other. The fearless ICU has a growth mindset. It learns from mistakes and aims to perform at the highest level. The fearless ICU creates value and innovates in a complex and changing environment. Who wouldn't want to work there, right? And I think it's our job as leaders to make our ICU a little bit more fearless every day. So that's about the environment, and it really all starts with psychological safety. There are numerous studies that have shown in surgical teams, learning new techniques, ICUs, pediatric ICUs, that psychological safety is the one element that probably has the greatest impact on performance. This is data from Google. Google did a very large project a couple years ago called Project Aristotle, and they looked at thousands of data points trying to predict what are the components of the highest-performing Google team in terms of hard-determined outcomes. And what they found was that the single most important factor was psychological safety. And there were other things that were important, like dependability, structure and clarity, meaning and impact, but those four had less weight in their data analysis than psychological safety by itself. So in terms of environment, what we want to do is create a psychologically safe environment. The case Josh shared earlier is not a safe environment, right? That RT did not feel safe. So how do we become an ICU where that does not happen? Psychological safety is defined as a shared belief that the team is safe for interpersonal risk-taking. We've all seen psychological danger where there's fear of admitting mistakes, there's a lot of blaming, people are less likely to share different views, and then this common knowledge effect occurs where either I assume everybody knows what I know, or when I don't know something, I assume I'm the only one who doesn't know that, so I don't ask, right? And that is not only bad for our colleagues and our team, it's bad for patients. It leads to poor outcomes. A psychological safe environment, you're comfortable admitting mistakes, you learn from failure, everyone openly shares idea, and better innovation and decision-making will be the result leading to better patient care. If that anesthesiologist would have acted differently, it would have been a golden opportunity to later help that RT master a new skill, right? Let me take over the airway, take care of the airway, and then let me show you how you can do this better next time, because as you saw, the SATs dropped, and that is really what we're aiming for. And when you think about it, any time somebody in your team has been really, really burned out, really, really down, it's probably in one of these four categories. So there's different types of psychological safety. There's learner safety. It's safe to discover, to ask questions, to ask for help. Collaborator safety, you can engage in an unconstrained way and share what your thoughts are. You can interact with colleagues in a positive way. You have access to each other. Challenger safety, if something is not looking right, you can ask questions and say, why are we doing this this way? Is this the right way to do things? You can expose problems without fear of being retaliated. And then finally, something I think is very important in 2024 and ever, but moving forward, feeling valued for who you are and inclusion safety. You know that what you bring to the team is valued. You know that it's important. You feel you're going to be treated fairly and that you are included regardless of your title or position and that you are part of making that team better by contributing openly. So in terms of environment, the most important thing is psychological safety. The second aspect I want you to think about in terms of environment is, what does it mean to be a team in healthcare? So there's this question of team, right, which like Michael Jordan in the last dance, that was a fixed number of players, and they had their own culture. They were trained together, rehearsed together, performed at a very high level. So teams, a team is a noun. It's a static, bounded entity, and its performance depends on a good design and structure. Is that what we have in the ICU in healthcare? Absolutely not. We have something that is now being called teaming. That's a verb, and what it means is it's very dynamic. If, for example, the example I'm going to keep going to the example we used, that anesthesia person was not part of that ICU team. He came to help. That's teaming, and how you show up to these teaming events can make a huge difference in creating the right environment. So the performance in healthcare is much more about the mindset and the practices. So when you think about it, in one day, in one shift, you will team up with different people. It's never the same people. Not only that the people in your ICU change, but if you go to the ED to take care of somebody, there's a whole bunch of new people there. If you go to a code, there's a whole bunch of people there. Maybe the transplant team comes in. You have to team up with them. So we're constantly teaming up with people for different tasks, and how we show up to that and how we structure that is going to be very important from an environment standpoint. So the basic foundational principles of teaming are the hardware, which is the scoping, the structuring, and the sorting. So what is the scope of our team? So we're a rapid response team. What is the scope? How do we structure that? Who is part of that team? And then when we show up for a task, how do we sort the different tasks? That's part of how we establish a code team, a sepsis team, an ICU team, a transplant team, whatever you want to call it. And then the more important part, which is what we know also, I guess, in the world of computer, is that the hardware is important, but the software is what really makes the magic happen, is what's the purpose, right? Is this a psychological safe environment? It's hard to build rapport and psychological safety with people you know for a long time. It's a lot harder when you just met them like 10 minutes ago, but you still have to create the right environment. And embracing failure is an important aspect of how we learn, right? So when something doesn't go as we expect it, not berating and yelling at people, but trying to learn from that and how can we do this better next time. Can you imagine how different it would have been if that patient was intubated and then there was a debriefing and said the SATs dropped, maybe there was a problem with bagging, this is what I would do next time. It would be a total different ballgame. So the final part of this talk really relates to lifting others. And like I mentioned earlier, lifting others might be a colleague who is chronically burnt out, or lifting others might be the RT who had a horrible interaction at that given time. Everything was going well until that happened, right? And in both situations, I think it's important for us to really be there and be upstanders as opposed to bystanders like was said earlier. So the first thing that when a colleague comes with a problem, somebody complains, I think we do it at home, do it with my kids. You want to jump to solutions to minimize their problems. Oh, it's not so bad, or oh, right? So the first thing I think is when somebody is going through a different situation is to truly validate what they're going through, to listen to understand, not to reply, which is exactly what we were talking about, conflict, right? To truly ask questions, be empathic, and really try to understand what they're going through. And a lot of the techniques that we use in conflict can be very powerful in lifting somebody else. Even what you're telling me that this has been really hard on you, I hear that, I feel that you're very angry about this, and really ask more questions of what they're feeling. And what we should avoid, I think, is minimize their suffering, which a lot of people tend to say, well, it's not so bad. I mean, it could be worse, right? That's not what they want to hear. They just want to be heard and want to be recognized. And also I think something that a lot of times we do is jump to solutions very quickly of things they could do. And that usually is not when somebody comes to you what they want. You can ask if they want solutions, right? And they might say no. Or you can ask them what do they think they should be doing. But I think this is a very important first step when you're trying to lift somebody else at work is to try to first understand what they're going through and just validate that they're in a difficult position and that we're there to help them, maybe just by listening to them. Especially as you become managers or you have positions where you're in charge of the ICU, you might want to jump to solutions, want to minimize issues. And I think that ultimately that is not a very good way of lifting our colleagues. So validate first. Have any of you seen that video on YouTube? It's not about the nail. So I think that that's a great example. I was going to show it, but I didn't know we were going to have enough time. But maybe later we can look at it. It's not about the nail. How do leaders build psychological safety? Framing the work accurately. I think it's important to recognize, especially in COVID, that what we do is difficult and we don't know what the right answer is many times. Acknowledging the limits that we have as individuals, but also as a team. So I think being vulnerable at the right times is very important. When you don't know what to do, seeking for other people's opinion as a team member, I think is very important. Inviting participation. So if you are in rounds and everybody talks but two people, you should ask them. We value your opinion. Please share what you think. If you're in a small meeting, I think when people are to silence, I mean, you don't feel safe usually, trying to bring them into the conversation is very, very important. And then responding productively to good things and bad things. So one of the things that we talked about in that anesthesia-RT interaction is how you respond to that in that moment is sending a signal to the rest of the team. And either you can build psychological safety or you can make it worse. One of the big challenges of psychological safety is that it's very hard to build, but it's very easy to destroy. So it takes a long time to build, but it takes one second for it to go down the drains. So think about this as leaders. How can you every day, when you show up to the ICU, do these things to make it better for everybody and help others do it as well? And that, I think, is one of the best ways of lifting others. Teaming, we said, is something that's a reality, and you're never going to have the same three people that you work with all the time. It's very rare in health care. You're going to team up with people for different reasons and different situations. And building up rapport in a psychologically safe environment is very, very critical, and you have a short time. So there's four things that I think anybody who wants to be a successful teaming require. One is speaking up. When something's not right or you have a question, raise your hand and ask the question. Raise your hand and ask why. And the more you do it, the more other people will feel that they have a license to do it as well. And that is ultimately what a leader does, right? It shows the way forward for moving things in the right direction. Experimenting, I think, is very important as you create teams. And experimenting here is not clinical experiments, right? I mean, obviously that's research. But how do we organize our work? How do we respond to certain things? How do we round debriefing after we did something? Is there a better way of doing it? Trying something different. Trying small pilots in terms of organizing our teams. Reflection, I think, is very important for being a better team, and that might be debriefing, right? After an incident or after a difficult intubation, taking the time to reflect. What was our goal? Did we accomplish it? What did we do well and we should do again? What could we do differently? Taking the time to reflect, not only after maybe very dramatic events, but maybe even after a week of rounding, right? You could maybe take the team and reflect. We round it every day. What do you guys think we did well? What can we do better? Because otherwise I think we stay in the status quo. And that does not, I think, lead to a great environment. So clearly there's a lot of reasons why people in healthcare might need to be lifted up. I think there are chronic headwinds that have led to a lot of burnout and dissatisfaction. We probably will have future events like COVID that's going to turn our world upside down. And there's also just bad interactions during the daily work that might require for us to interact with our colleagues and lift them up. Prevention is better than treatment always. So creating the right environment is probably the most important thing that we can do in terms of lifting others. And there is where building psychological safety, trying to become a fearless ICU, really, really I think is important. Also recognizing that the team has moving parts. Every day you're going to work with different people in your team. And showing up to those interactions in the best way possible I think makes a big difference. And then finally, in terms of specific actions, I think we talked about validating people and letting them feel that they've really been heard is step number one. A lot of times people are complaining or sharing with you just because they want to be heard. And don't jump to conclusions or to solutions. But then also I think every day show up with the best intentions to build psychological safety, to be a better team member. And ultimately I think that is the best way to go. And a lot of the things that we shared earlier are also very valid when you're trying to interact with somebody who might not have a conflict with you. But clearly has conflict that is causing them a lot of distress. So with that I think that we'll have time for questions I think later. But I believe that this is something that we should all be responsible for. Because burnout is a problem that affects healthcare. And we should all be part of the solution. When people have a bad day, we should all be part of the solution. And I think it really emphasizes what it means to be a leader. Leaders are not bystanders. Right? Leaders are there to make change. And leaders are defined by having followers. If you present people with a better option, you will have followers.

conflict management

psychological safety

teaming

healthcare settings

continuous improvement

supportive workplace environment