Stand Up and Listen Up: Creating Psychological Safety

Podcast Transcript

Brian Bolwell, MD: This is your host Dr. Brian Bolwell with a message for our listeners. In the following episode of Beyond Leadership, you will hear Dr. Leslie Jurecko and I discussing information related to the Covid-19 pandemic. As a disclaimer, this episode was recorded in late 2021, prior to the surge of the Omicron variant. Any statistics and numbers referenced regarding Covid-19 were relevant at the time of the recording.

Welcome to Beyond Leadership, at the intersection of leadership and everything else. In this Cleveland Clinic podcast, we will commingle with extraordinary thinkers and explore the impact of their ideas and experiences on leadership and management.

In today's episode of Beyond Leadership, we're discussing leadership and quality and safety. I'm your host, Dr. Brian Bolwell, Director of Physician Leadership and Development of the Mandel Global Learning and Leadership Institute here at the Cleveland Clinic. And today we're very pleased to have Dr. Leslie Jurecko to join us for today's conversation. Leslie is the Chief Quality and Safety Officer at the Cleveland Clinic, and we're thrilled to have her. Leslie, welcome.

Leslie Jurecko, MD: Thanks. Nice to see you, Brian. Thanks for having me.

Brian Bolwell, MD: So tell us about how you became involved in quality and safety and healthcare organizations. What started all that?

Leslie Jurecko, MD: All right, Brian, here we go. It's going to be a deep dive into Leslie Jurecko for a minute. So I actually started my journey in health care when I was 10. I did not have many healthcare providers in my family at all, but my father was in an accident and ended up being a quadriplegic. So he spent a long time, you can imagine this was, oh gosh, 30 plus years ago, in the hospital. So as a young girl, I was exposed to all of the things that went well and many of the things that did not go well.

So I started asking questions, I think I was pretty into science at the time, I started asking questions about why things were done certain ways, and that just led me into this continuous, I would say, nonstop journey over steep and rugged territory to try to improve healthcare. And that's how I got involved in more quality and safety. And it was really just about trying to get better, as I became a doctor, trying to lean in and understand, why does it have to be like this? Why are patients suffering more than they have to? And trying to solve for some of that.

Brian Bolwell, MD: Well, I'm very sorry about your dad. So specifically, I mean, everybody thinks that they're pretty attuned to quality, but not that many people go into leadership positions. How did that occur?

Leslie Jurecko, MD: So I went on to be a pediatric hospitalist. I was pretty immersed in hospital operations, when you're a hospitalist, and started leading in some simulation world. Was exposed to that where I trained at Northwestern, really liked training teams together in an insight to environment, right in the unit. When things go wrong or there's stressors on the team, how does the team respond together? How do they create that high functioning team we're all after. And so I did a lot with simulation training, built a simulation program. And then like any leader, doors open, whether it's people leaving or opportunity just to expand.

There's always timing to all of those decisions. But some doors opened for me to lead in quality and safety in the children's world. And then I really needed to learn quickly and so started to join in some national collaboration areas. And that's where I really honed my skills around quality and safety leadership, learning from others. Surrounding myself with very, very intelligent people that had done this before and seeing what they did and mirroring what they did. And that's how the journey started for me in quality and safety.

Brian Bolwell, MD: You've been doing it for quite a while. A lot of people talk about a just culture to generate quality and safety. What does that mean to you?

Leslie Jurecko, MD: So just to me means fair. It means when something happens that doesn't go well for the team or an individual, that we approach it in a non-biased way. How we not only support that caregiver, of course the patient and family, but especially the caregiver involved in any of those events. And it's about having that person's back whether they are a caregiver or they're on your business team. Whatever kind of leader you are, you have to have their back and you have to make that assumption that they were doing what was best in the interest of the situation at the time. And so a just culture to me is asking those deeper questions of why this human being may have gone this route and then applying really just and fair questions to the situation. So they get a fair perspective on what happened and that we don't immediately jump to conclusions that are usually false.

Brian Bolwell, MD: So for our audiences, some of whom probably aren't intimately aware about quality and safety issues in medicine. I think a lot of people assume that everything we do is a quality and safe thing to do, but mistakes happen and errors occur. Can you describe some of the more common things that we encounter from a perspective of quality and safety?

Leslie Jurecko, MD: Yeah, absolutely. I wish we were highly reliable as we're striving to. But you're exactly right, Brian, there's errors that happen sadly every day across this country and this globe, in our healthcare settings. And quite frankly, we're very complex and we know. We say that all the time, but of course, we're as complex as can be in any field, I would think, with the patients that we see in healthcare. So we see errors often. Our most common is medication errors. There's thousands of medications. They each have a couple of names, go figure, why wouldn't we just name them one name, but they all have their generic name and their marketable name. And we see a lot of medication errors. We do some weight based medications. So that is a big one for us. We still in the year of 2021, see wrong sight and wrong sighted procedures, right and left and other mix ups like that.

What seems to be fairly black and white, it's very complex when you're looking at the patients that we see and serve. And so those are some of the most common ones, but you can really write a book every day of what happens to some of our caregivers. We put them in these high stress environments and we ask a lot of them to come together at the bedside with a lot of different variables and there's errors that happen. And many are preventable with certain behaviors that we try to teach our staff, but we have not got to zero harm yet.

Brian Bolwell, MD: What are some of the behaviors that we teach?

Leslie Jurecko, MD: Yeah. So we teach our staff to speak up, especially against an authority gradient or any power distance. So a nurse or a pharmacist speaking up against surgeon or an attending physician and saying, this doesn't seem right. That's one of the basic skills we try to teach staff and probably one of the most difficult skills that staff is able to engage in because of the environment we put them in. And I'm sure Brian, you've talked many times about psychological safety, we could talk more about that, but it's really creating an environment that allows our staff to speak up. So we detect things before it reaches the patient. We also teach skills about good communication. How to actually effectively communicate your message, so you get across what's most important. So we try to do what seems basic communication and human skills of interacting and teamwork, but really have to recommit to it, especially in the environments that we see. There's quite a lot of hierarchy in medicine.

Brian Bolwell, MD: So you brought up psychological safety, and Amy Edmondson has written a wonderful book called The Fearless Organization and she's a great speaker. And she points out in her book that there was a Google study that talked about what makes organizations effective. And one of the real drivers is this, psychological safety, which basically means the people feel free to speak up and give their ideas and to question what's going on without any concern about retribution or retaliation. Easier said than done. But certainly I think that all of us who may be managing any team, that's got to be the goal. It's also the way to generate the best ideas. How do you, as the leader of quality and safety in an enormous healthcare organization, continuously try to promote psychological safety?

Leslie Jurecko, MD: Yeah, thanks for that. Starts with the just culture we talked about. If they know we're going to have their back when it comes to it, that's really foundational for them to even feel safe enough to lean in. But other things, sometimes we have to actually kind of mold psychological safety and be intentional about it. So when we do train our teams, we have to put processes in place, so they do speak up. So you think about the checklist we use. It actually gives those pauses. And those moments, when we ask the nurse or ask the surgical tech and almost give them a role to speak up, a time and a moment.

We just, over the last year, inserted a pause into our surgical safety checklist. And that pause is exactly for that reason to create that safe moment when the surgeon and the surgeons lift their hands off the field and give a moment for our nursing team to not only do an appropriate count, but to have a moment to stop the line. And so we're engineering some of this psychological safety, but it is absolutely about what we call standing up and listening up. If someone's not listening to you, man, it's going to be hard to speak up the next time. So it's a lot of those, kind of, really intentional processes that we have to do with our teams, so they do feel safe. Brian Bolwell, MD: You mentioned a checklist. What does that mean in medicine from a quality and safety perspective?

Leslie Jurecko, MD: So we have probably too many checklists, quite frankly, in medicine. [Laughs.] We think about it, like you might with the airlines and an airplane taking off in their checklist for takeoff and landing. We have a lot of that within our procedural spaces and what it means is standardized where we can. So I don't want our very intelligent teams and caregivers to feel they have to do cookbook medicine. That's not what we're after at all.

In fact, we want them to use their brain on what's most important, and it's not actually those steps in that checklist. We want them to follow that, be mindful of it and absolutely follow those checklists, but that is the standardization we can do in medicine. So they can use their intelligent brains for all of those other things they need to think about and interacting with the patients, the teams, and getting to proper care. So that's why we design checklist. Sometimes it gets a bit out of control. There could be a checklist for everything, and we try to reel that in, but it absolutely is the right thing to do in medicine. It's just where and how much do we do that standardization.

Brian Bolwell, MD: Leslie, you joined our organization, what? About a year and a half ago now? Two years ago, something like that?

Leslie Jurecko, MD: Yeah, just a year and a half ago.

Brian Bolwell, MD: How did you approach that? So you've been a successful leader at another organization, you come here. Career transitions are a very interesting topic. What did you do?

Leslie Jurecko, MD: I met with you. [Dr. Brian Bolwell laughs.] I remember quite a bit early on. I think one of the fascinating things that I learned and I hadn't done this before for my leaders during my team, but I will from now on, is I was given some ambassadors and Brian, you were one of my ambassadors. And I think the mix of ambassadors were folks that could have been on my side and folks that could have not been on my side when I entered the organization. I thought the mix was great. So there was intentional meeting set up with myself and those ambassadors when I first joined to teach me about the currents of the organization. So now I do that for my leaders, highly suggest that for any leaders. To get a small group, five, six leaders across the organization that can almost create a brand for you before you start, or as you onboard in.

So they're carrying your message. And I think ambassadors is the right word for it because they are carrying your brand and speaking, I think, intentionally highly about you. So that was extremely helpful for me to commit to that. And I was so humble coming into the Cleveland Clinic. It was the balance of being humble and curious, but also having to stand up that I had some, I should be at this position or I have the content knowledge that I can sit at this table. That's a tough balance for leaders, I'll tell you what. Because you don't want to be coming in and almost overselling yourself, but you have to make a statement for yourself. So you create some followership. And I would say, I failed at that more than I probably was successful at it, but that was one of the things I tried to always balance that.

And lastly, for those leaders transitioning. I came from an organization where I grew up, over a decade. And there is a big difference when you are at an organization for a long time, when you're gaining consensus on something, they just trust you because they know you. They know you, they know your kids. They've seen you over this decade, grow up as a leader. And so when I came to the Cleveland Clinic, a very huge learning for me was I had to be so much more intentional about going out to different stakeholders and gaining consensus. And quite frankly, I'm a doer, I want to get things done. So that to me felt slow, but yet it was so important to be able to do that, because they didn't know me from anyone else. So those are some of my learnings. Still learning [laughs].

Brian Bolwell, MD: Yeah. I think that reaching out to people and listening is always a good way to start and well, certainly you've generated a ton of respect on a very short period of time here. So whatever you did, I think was pretty successful. So what's your leadership philosophy? What do you think works?

Leslie Jurecko, MD: Absolutely. Flipping it over. We call it servant leadership or it's moving from I to we as much as possible. Having that team be able to solve the problems. Giving that team the stage. Servant leadership isn't about draining yourself and working around the clock. Servant leadership is absolutely about serving up opportunities for your team and then removing anything in their way. I wasn't always a great servant leader. Some what I learned, it is such a better way to lead and it just makes sense. So that for me is my philosophy.

Once in a while I'll be driving to work and I catch myself not in that mode. And that's when I feel off as a leader. When I'm the one being asked to present somebody else's work or it feels the credits coming to me when it's absolutely not me, it's the team that was working on it. So sometimes I have to shake myself out of that because organizations, it's easy to oversimplify and put things on the main leader, but we have to work really hard to give our teams the space to show their talents. And that to me is what leadership's all about.

Brian Bolwell, MD: Yeah. I had an interesting conversation the other day with somebody who said that, if you want to be a leader, you've got to realize that you've got to be willing to serve other people. And that's really step one. And I think in academic medicine, a lot of people come into the field because they want to be able to have an academic career. And that means they want to be able to be important in their field of expertise and they want to do research and they want to be respected on a national level. And I think that's great and I think that's appropriate. But that tends to be a somewhat individualistic perspective and leadership is not that.

The command and control style of leadership is one way to execute, but it's not the most effective. I think there's been enumerable studies to show that. So people willing to embrace a role of teamwork and supporting your team and having their back and removing obstacles, as you said. I actually think that's a real key, removing obstacles because a lot of times removing obstacles are political and sometimes those political battles can be draining and they can be risky. But if you're really going to be a serving leader, I think that you have to courage to do what needs to be done to support your team. And one of my favorite lines about serving leadership is that it's not for wimps. I believe that to be true. So how do you go about removing obstacles for your team, Leslie?

Leslie Jurecko, MD: Yeah. Well, I think there's that grit we all have and it definitely takes grit. I think stepping back, I absolutely will remove the obstacles, because if I take the time to learn from the experts and that's the team, big on deference expertise. Of course, we know it's a high reliability principle, but it serves me well every time as a leader, when I'm trying to make a decision or think through the future. The moment I don't include the experts, I always fail on those decisions or I always regret it. So it comes pretty natural for me to lean in on removing obstacles for them when I've taken the time to listen to them because they're the experts. And it just seems to all make sense. So I go about it by actually just taking it on myself most of the time, because I don't want to... For example, today there was some budget issue that the team was getting involved in and I just said, I'm going to take it. Just let me take it off you.

Sometimes it's not worth it, there's certain things we shouldn't actually be trying to empower them to do because it's just a hassle. They need to worry about the things that they're working on and not some of these distractions and it doesn't make them agile or nimble enough to be able to do what they need to do. And so I don't know if I have any magic sauce of removing any barriers or obstacles except really leaning in and understand what they know as experts. And that helps me easily go to the table and say, we need to do those and advocate for that.

Brian Bolwell, MD: Yeah. But that's also a good example of I'll take care of it, I own it, it's my role. And I think that's pretty important. One of the things you've done particularly well is recruit very good people to be part of your team. How do you do that?

Leslie Jurecko, MD: Thank God. [Brian Bolwell, MD and Leslie Jurecko, MD laugh]. I'm just recruiting some new people. I am like a kid in a candy shop, so excited right now to build this team. And I think to do that is you cast a wide net. I interviewed a lot of folks because I wanted to see a diverse pool of applicants. I really did. I didn't want to just have the kind of cookie cutter folks that this was naturally their next step. So we did that and a lot of folks helping me, I can't take credit. A lot of people helping me screen and interview and do that. Also, brought in my international colleagues that lead safety and quality at our international sites, so they were involved, which was very, very helpful. And then, maybe that's the newer way of recruiting, we took to LinkedIn and other ways. We were spreading our contacts as much as we could. And A lot of our applicants were word of mouth from other leaders across the country. So, no real tricks to it, other than, I guess it's taking ownership of it and really doing it yourself.

Brian Bolwell, MD: Do you think about character traits that you're looking for when you hire people? And if there are, how do you figure out if an applicant has those traits?

Leslie Jurecko, MD: For quality and safety, especially, most of what we do is lead by influence. It's not like we have these huge teams, we work with rules like yours, Brian, and especially when you're in the chair role and how to influence, you to align with different quality and safety initiatives. So folks that can influence are key. And I think for them to be good influencers, they have to be curious. They cannot have a closed mindset around anything. So I tend to look for folks that are, naturally, when you talk to them, they're naturally eager to learn more, not only about the role, but about you as a person and around that. Curious around other things, not just what's in it for them is what I look for.

Other things, grit, of course. They'll get into it, they'll get their hands dirty. It's always important. Clinically, they need to be sound. They have to have a... We keep all of our leaders still in clinical practice. I still see patients. It's really important that they can be respected by other clinicians. So those are some of the things that bubble up to the top of what I look for.

Brian Bolwell, MD: And how do you probe those things? How do you find out if somebody's curious? Do you ask them?

Leslie Jurecko, MD: No, it's usually a skill, I find out. What I do, I do a couple of things. I tend to try to get them to talk the whole time during the interview. I will ask them questions about... My favorite question to ask in an interview is actually, "Tell me three words that your leader would use to describe you." And so they'll give me some beautiful adjectives that they do. And then I just, "Tell me an example of that." And try to get them to really share with me some practical examples. And usually that piece comes out pretty good when I ask that question.

Brian Bolwell, MD: So I always like to try to figure out if somebody has emotional intelligence. I think that in terms of teamwork and being able to work with other individuals, that's pretty important. And it's actually interesting, if you go on a search on the web, Google or whatever, and ask to list some questions to try to detect emotional intelligence, they're all over the place. I mean, there's hundreds and hundreds of questions out there. So for our audience, you can actually find this stuff pretty easily. Just pick some you like. One of the more common ones is, tell me about a time you made a mistake and what you learned from it. And you know you're in trouble when the candidate says, "Well, I don't really make many mistakes." Then your interview might as well end right there.

Leslie Jurecko, MD: Yeah, exactly.

Brian Bolwell, MD: Luckily that doesn't happen all that frequently. So we're very complicated. We're a big sprawling organization that covers multiple states, several countries, it's not just one hospital. So what may be true for the main campus, which is our academic hub, I mean, thematically is probably true at all of our locations, but I'm sure there are differences. How do you approach that?

Leslie Jurecko, MD: There are quite a bit of differences, not just culturally, but process-wise, resource-route-wise. And one of the things, I think, is all of our goals, to have the same care at every one of our locations whether you're outside the country, inside the country, at a different county in Ohio or Florida. And we don't have that today, Brian, we don't have it. Very few things keep me up at night after a long day, that keeps me up at night. That someone could go to a Cleveland Clinic location and not have the same care they would get possibly at main campus. And I can play that out with metrics quite a bit. And we talk about it and you know this, Brian, you've been in these conversations at the executive leadership levels. What do we need to do to make sure that that same high quality, safe, exceptional experience is delivered everywhere?

A lot of it starts with system and processes. Even just what we think is basic like the same electronic medical record, is a huge improvement project. And just trying to get some of those things when we integrate front really well, aligned to the Cleveland Clinic way of care, we call it systemness. I call it decrease variation so we can be more reliable for our patients. A huge challenge for growing systems like ours and other systems and a huge challenge for patients to navigate.

Brian Bolwell, MD: Are there any quick wins in this space or is it just take a brick by brick, one by one?

Leslie Jurecko, MD: There are some quick wins, I think-

Brian Bolwell, MD: -Psychological safety is hopefully applicable every place.

Leslie Jurecko, MD: Yes, I think so. We did just culture. We were intentional about just culture about a year ago, where we put in a decision tree, and this is how we handle standard stepwise. It comes from James Reason's work out of the UK. You can Google, obviously ours is probably online, but it's just a decision tree that all leaders can use. I encourage all leaders to have it on their desk. I use it all the time. I joke that I use it at work with my teams, at home with my family. [Laughs.] You can use it at all times because it really walks you through a just way of handling your team members when things don't go right. And so I think that's something we usually do very quickly when we're trying to align on something.

So any of those cultural things that you can do, I do think some of the care paths on how we... They don't feel quick, but some of our hospitals are so eager to get some of that, that they can actually move really quick. And then aligning physician leaders, quality, safety, and patient experience, a great place to align. No one's going to try to keep their own way of doing things when they know there's higher quality, safe care if they come together. So I feel like anything in that realm that can improve quality and safety for patients, I've seen some pretty quick alignment from our newer hospitals on that.

Brian Bolwell, MD: Yeah, I agree. I think among the things you said care paths are a pretty big deal. And we made a decision in the cancer center about eight years ago that we were going to build them ourselves because you can actually purchase care paths from outside vendors. And somewhat surprisingly, when we built these things we found them, number one, to be a wonderful way to engage and to engage teams because getting a group of physicians to agree on a certain way of treating patients, it isn't always easy. One of the learnings was that folks in the region were actually quite thirsty for care paths and a playbook for complicated oncological presentations. And they were adopted very, very quickly.

So I think that there's all sorts of advantages to care paths. I think quality and safety is front and center, but I also think it's important for value-based care because simply by reducing variability, you probably get better outcomes. And I certainly think that you are probably practicing in a more cost effective way as well. So I'm a pretty big believer in care paths and I think that there's unlimited opportunities for them.

So, what do you want to achieve in the next five years? You've only been here for a year and a half. You probably know us pretty well by now. You're starting to figure out all of our idiosyncrasies. And so how do you keep building and making progress?

Leslie Jurecko, MD: Great question. So I want to achieve, if it was a true aim, it would be exactly what we talked about. All of our sites of care, both ambulatory and inpatient. Having this uniformity of care that's top decile, however you measure us. But also it's measured by the patients and their trust. So we'll naturally grow because they know when they come here, it's all about excellence. They feel it, and if it's not main campus, it's regionals, it's Florida, they feel it. And they'll speak to us through their trust and they'll keep coming back and they'll send others to us. So I really want us to see top decile care across safety quality experience in five years across all our sites, that would be like an audacious school, very measurable. But what also, I think, internally struggle with the most right now that's going to be on the backs of our caregivers. It just is. It's going to be, to get that type of transformation, we're pretty darn good, but to get to top decile care across all of our sites, transformative, what we're going to have to do.

And we have some of the best, if not the best, caregivers. I've never seen folks lean in to improvement like I have at the Cleveland Clinic, it's amazing. From our physicians to our nurses to really any role, everybody wants to make it better. And how do we really channel that for the right things without, I don't know if it's burnout or disengagement, I'm worried about something. I'm worried that we're going to take what we have, which is the best ingredient to get there and just squash it. So I'm trying to figure out that pace of change for them because transformation means change and often fast change without disengaging.

Brian Bolwell, MD: Well, I think that's a really important point, Leslie. Again, the tenet of serving leadership is that you've got to take care of your employees and your team and have their back. And at this stage of the game, especially in the peri-COVID period, I think anybody in healthcare knows that our caregivers are working really hard and have been working really, really hard for a year and a half with COVID as well as the regular stuff. And now we have some nursing shortages that are quite real and quite profound. And we have to make sure that we're listening to our caregivers, that we're attentive to their needs, and they have enough time to regenerate and relax and get away from the work environment when it's appropriate. This part is incredibly important, but also very difficult.

Leslie Jurecko, MD: That it is. And I'm a big believer in make the system changes that have to happen so that your people can thrive. And I think that's where we're going to have to begin and double down each and every day on those. Let's make it as seamless as possible for them, but it's definitely hard work. It's going to be a push for us.

Brian Bolwell, MD: Any comments about COVID in the past 18 months. And I mean, I think our organization has performed heroically. I think actually our clinical outcomes have been wonderful, certainly. And that's actually one area, Leslie, that I think we have achieved a certain amount of systemness that the care of our ICU patients with COVID is pretty consistent across our sites.

Leslie Jurecko, MD: It is, yeah. Leaned in really early on, a lot of our teams did, on keeping, making sure they knew the data and watching for variations. So proud of our teams. A study just came out with CDC, just published that most of the nation backtrack, of course, on the typical quality measures like line of infections and pressure, ulcers and falls. I mean, we lost improvement work in one year or 18 months. I'm going to steal your term of peri-COVID because I hadn't used that yet. I like that. We lost years of improvement. As a quality leader, it is so frustrating. But we didn't at Cleveland Clinic, actually.

We actually improved Cloud C rate this year in our ICUs with all these COVID patients because we focused on it. And so we did not see that fall back in our outcomes like many organizations did. And I just commend the teams because I look at our census every day, I mean, we're still at over 400 COVID patients in our Northeast Ohio hospitals, on top of all the other patients we serve. And to ask them to go out and do extra line rounds, to remove those central lines and extra checks so our patients don't fall and they're doing it. They're doing it somehow. They are rising to the occasion and doing it. And that's I think because we focus so heavily on safe care.

Brian Bolwell, MD: Leslie, as we're winding down, do you have any parting thoughts for our viewership in terms of leading physicians, leading in a healthcare organization, being a woman leader in a healthcare organization? The floor is yours.

Leslie Jurecko, MD: Not to overdo the authentic leadership, but if I had to say anything for either up and coming leaders or current leaders, stay who you are, be you. You be you, they say over and over again. The time I try to lean into who I'm not, it just doesn't, it falls flat every time. So that's always my mantra, I think, be authentic. I came from a small rural town and when I show up at the Cleveland Clinic, they don't know what to do with me half the time. And that's okay. I think it's great for us to have that connection and figure out how we're going to work together. And those perspectives are so important. So I think that, you be you is really my advice to anyone. And that helps with being a leader of people because when they see you, be yourself, they will absolutely trust you.

Brian Bolwell, MD: Well, I think that's great advice. This has been a fabulous podcast, Leslie, thank you so much. And for all of our listeners, thank you for listening and have a wonderful afternoon.

Thank you for joining us on this episode of Beyond Leadership. We welcome any topic ideas, comments, or questions about this, or any past episodes. Email us at executiveeducation@ccf.org, or by clicking on the link in the show notes. Thank you very much, everybody and have a wonderful day.