I have no financial disclosures for this talk or any of the talks. There's a generational differences in practice and learning in the materials. There's also a podcast we did before. Basically, the idea here is very simple. Generational differences and tension has been around for thousands of years. We have different generations in the workplace right now, and these generations might have different communication preferences and different values regarding work. But ultimately, I think Timothy mentioned it, we all have similar motivators and everybody wants to show up and do a good job and have a fulfilling career. And that really centers around purpose, autonomy, and mastery. And a lot of what we talked about throughout the day is about personal growth, but when we introduced the idea of ultra skills, the ultimate goal is really to help others grow as well and to grow as a team. So how do we create a culture where growth and learning is what motivates us on a day-to-day basis, which ultimately leads to the best patient outcomes. So what I'm gonna cover in the next 15 minutes is gonna talk about the power of culture a little bit, gonna talk about solving the culture puzzle, and ultimately, what are some actionable items that you as leaders can take on a day-to-day basis to create a culture of growth. Kwame mentioned this earlier. When you look at any team or any organization, there is a third of people who are extremely engaged and maybe rowing in the right direction. There is a larger group, 50% or more, of people who are not fully engaged, right? That we wanna try to bring along. And then there's a small group of 15% who are actively disengaged and actually are counterproductive, create more disengagement, and actually poison the well, right? The idea is, how do we grow that green group? And how do we identify maybe people in the 15% of disengaged who are maybe not at the right place because it's not a good fit for them? And help them find a place where they can also be engaged or help them become engaged. Ultimately, I think that as an individual, being engaged is what makes our career fulfilling. It's what helps us combat burnout. As an organization, having engaged colleagues is what leads to success at all levels, from patient outcomes to obviously other types of success. So what is culture? Ultimately, I mean, I think working on culture is very hard, but there's different definitions. One of the textbook definitions is it's a pattern of shared basic assumptions learned by a group as it solves its problems of external adaptation and internal integration. It's a product of joint learning. I like to say that culture is what happens when nobody's looking. So what happens at your ICU when you're not there? And it's not really a set of beliefs. It's what people do. It's this is the way we do things here. Now, in terms of the importance of culture, it's very interesting that the vast majority of candidates applying for jobs believe that fitting in a place that has a good culture is more important than compensation, yet when people don't really investigate their own values and what are the values of a given culture, they can't make that decision. And like Timothy said earlier, all they look at is, okay, what are they gonna pay me, what time off I'm gonna get? But the reality is that ultimately, people wanna be in a place where they fit in the culture, where they're aligned with what's important for them, and where the culture allows them to play to their strengths, right, and show up every day. And less than 5% of candidates will value compensation over the right culture. Now, I think that when you look at these studies, people always roll their eyes, but the truth is that this is assuming that we're starting at a pay structure, right, that you're being paid fairly. But I think that ultimately, people over time will realize that being in a culture that speaks to our values is perhaps the most important. When you look at results, this is a fascinating story. I don't know how many of you, I mean, have followed this, but Microsoft obviously has been one of the mega companies for decades. But they were actually not going very well or growing very well, and they made an important change. And Balmer was replaced by Sajjan Adel as a new CEO in 2014. And his whole mission and what he worked on the first couple of years was to change the culture of Microsoft. And to recapture what he thought would make Microsoft successful when it first started, which was a growth culture of learning from mistakes, of trying to do things better, of trying to think out of the box, of moving in different directions. And you can see that as he moved that needle on that culture, they started a very, very high inflection point in terms of their growth. And now really, I mean, are dominating in many areas that in the past, you even wouldn't think about, like cloud computing, quantum computing. These are things that we're not even thinking about, even in AI. They have obviously an important presence with Copilot. But it all really started with changing the culture of how they did things and becoming what he calls a growth culture. So when you think about culture and solving that puzzle, there's three things I want you to think about. One is psychological safety, which I think is the most important element of a high performing team. Number two is mindset, and I know that Lilian mentioned mindset in terms of how we relate to our work in burnout versus non-burnout. But the idea of growth versus fixed mindset and how we think about that from an organizational standpoint. And finally, how teams are changing in healthcare. And the concept of teaming is, I think, a very important concept that we need to understand, because the reality is that we work in many teams, and our teams are constantly changing. So we'll talk about that a little bit as well. Without going too far, I mean, when you look at what is most important in high performance, study after study, where the NCT surgery teams or Google, like this particular study that was portrayed in the New York Times several years ago. And what they found is when they looked at all their teams and what was associated with the highest performance was psychological safety. So what is psychological safety? It's a shared belief that the team is safe for interpersonal risk taking. So we were talking about problem solving, and that you might be a great problem solver, but you want your team to be a great problem solver. Well, I'll tell you, the members of your team have great solutions. They're not sharing them is because they don't feel safe to share them. They don't feel safe to take that risk. And our job as leaders is to create that environment. So I think we've all seen psychological danger, where people fear admitting mistakes, where there's blaming of others when something goes wrong, right? There's less likely to share different views. And then there's this common knowledge effect that I think is very problematic, where we don't expand what is needed to take care of a patient. And everybody operates from the available information or things that everybody knows what they know. And we're not asking the right questions. We're not bringing new information to the arena. And that, I think, creates a lot of problems for our patients. In a psychologically safe environment, if you make a mistake, you admit it. You feel comfortable. Now, nobody wants to make mistakes, right? But when there's something that you don't know or something that you did wrong, you bring it up so we can solve it. People learn from failure. Failure is inevitable in our ICU, period. We will fail. Every day we fail on something. The question is, are we learning from it so that we can be better and try to prevent it in the future? Everyone openly shares their ideas. Doesn't mean that somebody starts to make decisions, but everybody can contribute. And finally, these teams are much better at innovating and making complex decisions, which is what we have in critical care. So there's four stages for psychological safety. The first one is inclusion safety. Do I feel part of this team? Do I feel that the team values what I bring to the table? I always remind people that every single person on rounds or every person that you meet knows something that you don't know. So, right, they can teach you something and that by itself I think merits a lot of respect. And the same thing applies to when you're caring for patients. Everybody knows something or has a set of skills that are complementary in trying to move the needle for our patients. The second one is learner safety. If I don't know something, will I ask for help? If I don't know something, is it okay for me to ask, right? And how you respond to certain things is going to dictate that. So if I was in URT and I witnessed what Josh presented, and I didn't know something, there is no way I'm going to ask for somebody to help me out, right? I'm not going to feel safe because I'm going to think that anesthesia clinician is just going to bite my head off, right? So we have to create the right environments for people to feel that they're there to learn, right? Contributor safety. So if I think that there's a better way of doing things, do I feel safe to contribute my ideas? Does it mean that they're going to take all my ideas, but do I just feel safe to share them? And finally, challenger safety is when we don't think something is right or when we don't feel that something's not done according to our values. Are we willing to step up and raise our hand? So the best example of lack of challenger safety resulting in bad outcomes is sentinel cases where they amputate the wrong leg, right? It has happened in hospitals. They amputate the wrong leg because even though somebody in the OR knew that that was not the likely leg, they didn't feel comfortable questioning the surgeon. That is, I think, the ultimate example of how a lack of psychological safety has a direct impact on our patients. But it happens maybe in more and less dramatic ways every day over and over again. And I think it's important to build that psychological safety if we want to have a high performing team. The second thing that I talked about in solving this culture puzzle is the mindset. And I'm sure a lot of you have heard Carol Dweck's work on fixed mindset versus growth mindset, right, and how it applies to individuals. So the fixed mindset is, if I fail, it's because I'm not good enough. People who are fixed mindset are usually raised with a lot of praise, that they're intelligent, that they're very strong, right? And then when they, they don't, but so they don't like to be challenged because if they're challenged, it means that they're not that intelligent. They're not that strong, right? When other people succeed, they're jealous about that success. They can't celebrate the success of colleagues, and they usually don't want to try new things. Now, growth mindset is about understanding that failure is an opportunity to learn. How am I gonna get better if I don't make mistakes, right? So I can learn from, and I can learn to do anything. So instead of praising how intelligent they are when they're young, they probably got praised for their effort. And there's amazing research that if you praise a group of fifth graders on how smart they are, and then you praise another group constantly on how hard they work, and you give them harder and harder math problems, the people who are always told that they're smart enough will stop trying or get more wrong sooner because they just think that, okay, maybe I'm not that smart. The kids who are praised on their effort get better results and try harder and longer because they feel that if they try hard enough, they'll get it. So I think that that's the growth mindset. If I don't know something now, it's not because I'm not good enough, it's just because I have to learn it, and I can learn it and become better. And when you see other people succeed, instead of being jealous, you try to learn from that. How can I do that? How can I achieve that as well? And I think that from a personal perspective, we all talk about trying to be on this growth mindset at all times. The reality is that it's a continuum, right? I think that as much as you want to think that you have a growth mindset, there might be certain situations in which you revert to a little bit of a fixed mindset. And I think for a lot of people in healthcare, because of their trajectory, they were probably from very young praised on a lot of things that they do. It's not uncommon to have a lot of fixed mindsets, right? But we want to be more of that growth mindset. But the truth is that it's a continuum. And in the workplace, what happens is that there are certain situations that can trigger you one way or the other, right? So if you are in a situation when you're being evaluated, if you are, for example, let's say, on an ECMO team, and they bring a whole bunch of CT surgeons and cardiology experts to evaluate how you cannulate, you're going to feel like you're, right, I mean, sweating, and you might revert very quickly to a fixed mindset, like you're not good enough, or if things aren't working, as opposed to take that with a growth mindset, which is an opportunity to grow. Same thing with high-effort situations. When you're usually very successful, and all of a sudden something's very difficult, if you have the growth mindset, it's about, okay, how can I learn to overcome this? Versus if you have a fixed mindset, you might say, I might just not be good enough for this, right? Critical feedback. So, for example, if you are in a leadership position, and you think you're doing a great job, and then in one of your team meetings, they start criticizing a lot of the things that you're doing, you can get very defensive and really quickly go into a fixed mindset, or you can embrace that and try to really learn from what people are saying, and maybe recognizing that there's a blind spot that you had, and that what you thought was working is not working for your people, and how can I grow and learn from that? And finally, the success of others, right? Think about when one of your colleagues gets recognized. Can you truly celebrate their success as yours? Can you learn from that? Or are you immediately thinking that they got it because they're friends with somebody, or because of this, or because of that? Those are examples of how a growth mindset versus a fixed mindset might work with the success of others. So, when I talk about growth organizations, sometimes I ask people who wants to be part of a culture of genius, and all the docs raise their hand, right? And that's a fixed mindset. Unfortunately, that's not what we want, right? Cultures of genius usually offer highest performance opportunities, their emphasis on talent and success, and their focus is on results, and the atmosphere of best, of the best instincts, the best ideas, the best people, I think we've heard that elsewhere. And for those who have kids, when you look at a lot of schools, especially private schools, they have cultures of geniuses. All they tell you is the type of students they take, and they're all super smart, and they're all super successful. But what you want to know as a parent is, what's the delta if my kid comes here? What are you going to help my kid grow? Yet, all these schools will tell you their standard, their average SAT scores, and this and that. And all they're telling you is that they bring all these super bright kids to their school, right, that's not what we care about. What we want to care about is cultures of growth, offer the highest opportunity to grow. They emphasize the motivation and hard work. They focus on the results and the process, right? If you have a great process, you're going to have good results over and over again, right? And the atmosphere that fosters a love for learning, for passion, creativity, and resourcefulness. And that's really what we need in healthcare. We need to be a learning organization. We're going to fail over and over again in the ICU, but if we can't learn from that in a safe way, it's very hard to be the highest performing team. And you'll see that the highest, highest, truly highest performing teams have these elements of psychological safety, have these elements of a growth mindset. And the last component of this puzzle is the idea of team versus teaming. So I obviously spent my residence years in Chicago, and the good years of MBA, basketball in Chicago, and that was a team, right? And when you think of teams in healthcare, people always refer to sports teams. There's no correlation. What we do in healthcare is totally different. And why? Because a team is a noun, right? It's a static bounded entity. You know the components, and they know what they have to do. And they practice that over and over again. In healthcare, what we have is teaming, which is a verb. It's a dynamic activity. Every time I show up to the ICU, there's different people. Every time I go to a quote on a different floor, there's people I never met. If I get called to an ECMO cannulation in another unit, there's people I never worked with before. But we have to coalesce as a team, and it's the mindset and practices that make a difference there. So think about that. You are part of multiple teams, and your team keeps evolving. Think about how many new people every couple of months are in your ICU. Or think about when you have to work with another department, right? So it's not like you have a set team of five people that always do all the work. Plus, in healthcare, you're playing an infinite game, not a finite game like in sports. In basketball, it's very easy. There's four quarters, there's a time limit, and whoever scores more points wins. In healthcare, there is no limit. And all you're doing is coming the next day trying to be a little bit better than the day before, right? So it's very different the way that we have to show up as a team. So when you think of cultures of growth, at the individual level, right, it's about having a growth mindset, right, where you view intelligence as incremental and can develop and grow, same as your leadership skills. At the team level, it's embracing that growth mindset as a team and learning from failure and creating that psychological safe environment. And ultimately, at the organization level, it's embracing a growth mindset that really fosters the growth of every one of our colleagues and our professional development, recognizing that we will fail, but we can learn from our failure, and that's how we're going to perform at a higher and higher level. So the final part of this is just some actionable items of things that you actually can do to promote a growth mindset or a growth culture, a culture of growth in your ICU. There is a lot of studies by Emmy Edmonton and others about psychological safety. She actually coined the term psychological safety. And when you look at different ICUs, depending on the role that people play and their professional status, there might be different baselines of psychological safety. And that is something that we have to recognize. The other thing that's very important is that one of the factors that moves the needle the most, it's what's called leader inclusiveness. So a very practical example of leader inclusiveness is you're on the ICU attending rounding and people give their comments and then maybe one team member doesn't say anything. Inviting them to participate, telling them that their opinion is very important, they want to know what they think, is a way of including people into the team. So when you have a team meeting and there's one person who's very quiet who didn't speak, making sure that they have an opportunity to speak and we explain to them that we want their opinion and we want to know what they feel is a way of including everybody, right? So valuing everybody's opinion and everybody's skills. And what they found is that when the leader is viewed as inclusive, they not only improve everybody's psychological safety, but they flatten that difference maybe between different roles within the team. So we can always be more inclusive. How do we build psychological safety as a leader? You frame the work accurately and I think that goes back to the comment made earlier about transparency. What is, I mean, when we had COVID, teams that were able to say, look, I mean, we have no idea what's coming at us. This is what we need to do. This is going to change very quickly. Let's get together, figure out what works, what doesn't work. It's going to be hard. You're much more likely to allow people to feel safe, to give their opinions. The second thing you do is you invite participation. You want people to tell you what they think, right? So the whole concept of shooting the messenger, do you know where that comes from? So historically, in the Persian army, when they had bad news, they would have to send a messenger to the king and usually that messenger, they brought bad news, was shot. So obviously, eventually what happened? Bad news was not relayed to the king, right? And a good leader embraces the messenger of bad news because they're giving you an opportunity to make something better. So when somebody points out something that's a problem, right, we have to embrace that, thank that, and move forward, right? So I think invite people to participate. How you respond, right, to what people say is very important. Ask people for their opinion and then respond productively and that goes both ways. When there's a problem, how you respond is going to dictate if the next person is going to want to bring up a problem. When somebody misbehaves, like Josh talked about disruptive behavior, if we allow that behavior to go on and go on, what do you think is going to happen to psychological safety? It's going to go away. If we respond to that appropriately, it helps build that psychological safety. And it's hard, it takes courage, but that's what leadership is about, right? So frame the work accurately, invite people to participate, and respond productively. And even if you're not the director of your unit, if every day you show up to work, you do those three things, you will slowly help build psychological safety, right? And when people see that you're doing it, they're more likely to do it as well. What about successful teaming? Same thing. You show up to a team that you're not part of it, speak up. If you see something that's wrong, speak up. If you think something's going to work, speak up. If I speak up, it's more likely somebody next to me will feel good speaking up next time. Experiment as a team, right? What do I mean by that? Try different ways of organizing things and making things work, which is different than clinical experimentation. But again, I mean, experiment how to make things work better. Reflection is very important as an individual, but also as a team. After you go through something, reflect, I mean, on what worked, what didn't work. We'll do that today at the end. We'll reflect what worked, what didn't work. That's how we're all going to learn, right? So that we can do better next time. And finally, I think this is something that we can't emphasize enough. And I think it started from the first talk that Josh gave about listening and asking questions and being very intentional. So deliberate listening, I think he modeled. I mean, what did you call it? You called it something different. When I rephrase, if I hear what you're saying, active listening is the same thing as deliberate listening, right? So make it very clear to the person who's talking to you or talking to the team that we are paying attention to what they're saying. And in terms of the organizational level, you can't have a culture of growth if you don't make it safe for people to take risks. So I think that without psychological safety, it's very difficult. Your organization that wants to be a culture organization focuses on learning. So they encourage new ideas. They encourage learning from what we do. They experiment different ways of doing things, different way of organizing things. They learn from their own experience. I think COVID, although it brings some PTSD back, was a great example, right? If you were really in that learning phase, we started learning that certain things worked and certain things didn't work, right? And you can adapt very, very quickly and try to learn from that. And then finally, cultures of growth are great at giving feedback, right? What's working, what's not working, but you need, again, to be in a safe place to be able to do that.

generational differences

growth culture

psychological safety

growth mindset

teaming

Satya Nadella