Having served as CEO of one of the world’s largest corporations (Alcoa), and as Secretary of the Treasury of the United States, Paul O’Neill knows something about leadership. A while back, O’Neill was asked to write something about leadership, and he took the assignment quite seriously.
“I spent a lot of time thinking about what I had done for the previous 60 years and how to capture the essential ingredients of real leadership,” he says. O’Neill came up with three clear points focused not on the C-suite, but on what workers within an organization say about their work.
He says organizations with the best leadership – “with the potential for greatness” – are those where every employee can say yes without reservation to three questions:
- Can I say every day I am treated with dignity and respect by everyone I encounter without respect to my pay grade, or my title, or my race, or ethnicity or religious beliefs or gender?
- Am I given the things I need − education, training, tools and encouragement – to develop my full potential so I can make a contribution to the organization that gives meaning to my life?
- Am I recognized and appreciated for the work I do?’’
O’Neill’s questions go directly to a foundational element of the Toyota Production System. While the Toyota approach is commonly viewed as lean management methods and tools, there is more to it than that. A broader view of the Toyota system recognizes that true lean management must embrace “respect for people” principles, as well.
For much of the Virginia Mason journey in adapting the Toyota Production System to health care, the focus had been on the implementation of lean methods and tools. In this work, the teams achieved a significant level of expertise. But there was an aspiration to grow stronger on the people side of the ledger. Part of the reason for this was the belief that greater respect for people within the organization would lead to a safer environment for patients and accelerate this important work.
What does respect for people have to do with patient safety? Consider the culture within a Toyota vehicle assembly plant where every worker is empowered to stop the line if he or she sees a defect in a vehicle. Defects are corrected in the moment, and workers are encouraged and celebrated for identifying and correcting defects.
Virginia Mason leaders adapted the Toyota approach and instituted a Patient Safety Alert system in which every team member is encouraged and empowered to “stop the line” and call in a Patient Safety Alert whenever they see any possible threat to the safety of a patient.
The system worked well for a number of years – Virginia Mason is one of the safest health care organizations in the world − but leaders knew it could be more effective if everyone in the organization truly felt comfortable stopping the line.
In 2011, Virginia Mason leaders invited Boston surgeon Lucian Leape, MD, to visit Seattle and work with them on the respect issue. Dr. Leape is internationally known for his expertise on patient safety, and one of his core beliefs is that Paul O’Neill’s three questions are essential to the kind of culture where patient safety thrives.
Respect and safety, Dr. Leape told the Virginia Mason teams, are joined at the hip. Both are cultural issues. Do workers at all levels feel comfortable speaking up or is there reluctance for fear that management won’t have their backs? Did some workers see the Patient Safety Alert system as punitive? Did they fear getting colleagues into trouble?
Leape made it clear that when doctors, nurses, technicians, pharmacists and many others are reluctant to speak up, patients are at risk. He emphasized several points from his articles in Academic Medicine where he argued that “a substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect. Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.”
Lynne Chafetz, Virginia Mason senior vice president and general counsel, considered Dr. Leape’s visit and the themes he enunciated to be nothing less than “a seminal moment in our journey.”
A sustained effort at Virginia Mason to embed respect more deeply in the culture has had an impact. Catherine Potts, MD, chief, Primary Care, says she sees a greater willingness among team members to speak up when they perceive something might be off kilter. “People now realize that they can speak up freely without fear of retribution; that there will not be anything like a shaming event.”
Engaging team members in improvement work is a key part of demonstrating that respect for people is real and not lip service. Virginia Mason’s Everyday Lean Idea system, in which team members are encouraged to make improvements in their work, is one such method. Another is the commitment to daily management, where leaders are present on the genba, where the work is done – teaching, guiding and coaching – and working with team members to improve daily work by reducing waste.
Charleen Tachibana, RN, hospital administrator and chief nursing officer, adds that the best interests of the patient are paramount “when you create a culture where people can feel safe to say what needs to be said, to be transparent, to call out issues, to bring forth problems, to challenge peoples’ thinking in respectful ways.”
When O’Neill reflects on the power of his three questions, he notes that they derived naturally “from my years of watching the behavior of colleagues, subordinates and bosses and trying to distill what is most likely to release the human energy in an organization.”
Foundational Behaviors of Respect
With widespread feedback and thoughts from workers throughout Virginia Mason, the organization identified 10 foundational behaviors of respect:
- Listen to understand. Good listening means giving the speaker your full attention. Nonverbal cues like eye contact and nodding let others know you are paying attention and are fully present for the conversation. Avoid interrupting or cutting others off when they are speaking.
- Keep your promises. When you keep your word you show you are honest and you let others know you value them. Follow through on commitments and if you run into problems, let others know. Be reliable and expect reliability from others.
- Be encouraging. Giving encouragement shows you care about others and their success. It is essential that everyone at Virginia Mason understand their contributions have value. Encourage your co-workers to share their ideas, opinions and perspectives.
- Connect with others. Notice those around you and smile. This acknowledgement, combined with a few sincere words of greeting, creates a powerful connection. Practice courtesy and kindness in all interactions.
- Express gratitude. A heartfelt “thank you” can often make a person’s day and shows you notice and appreciate their work. Use the Virginia Mason Applause system (an internal recognition program), a handwritten note, verbal praise, or share a story of “going above and beyond” at your next team meeting.
- Share information. When people know what is going on, they feel valued and included. Be sure everyone has the information they need to do their work and know about things that affect their work environment. Sharing information and communicating openly signals you trust and respect others.
- Speak up. It is our responsibility to ensure a safe environment for everyone at Virginia Mason; not just physical safety but also mental and emotional safety. Create an environment where we all feel comfortable to speak up if we see something unsafe or feel unsafe.
- Walk in their shoes. Empathize with others; understand their point of view, and their contributions. Be considerate of their time, job responsibilities and workload. Ask before you assume your priorities are their priorities.
- Grow and develop. Value your own potential by committing to continuous learning. Take advantage of opportunities to gain knowledge and learn new skills. Share your knowledge and expertise with others. Ask for and be open to feedback to grow both personally and professionally.
- Be a team player. Great teams are great because team members support each other. Create a work environment where help is happily offered, asked for and received. Trust that teammates have good intentions. Anticipate other team members’ needs, and clearly communicate priorities and expectations to be sure the work load is level loaded.