How to Make Healthcare a Psychologically Safe Place

Podcast Transcript

Dr. James K. Stoller:

Hello, and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello, welcome to today's episode of MedEd Thread: An Education Institute Podcast exploring the clinic's efforts towards creating a psychologically safe and inclusive space for all patients. I'm your host, Dr. Tony Tizzano, director of student and learner health here at Cleveland Clinic in Cleveland, Ohio. Today, I'm very pleased to have Dr. Cecile Ferrando, associate professor of obstetrics and gynecology, director of the clinic's urogynecology and transgender fellowship programs, and director of transgender surgical services here to join us. Cecile, welcome to the podcast.

Dr. Cecile Ferrando:

Thank you so much Tony for inviting me. It's a pleasure to be here.

Dr. Tony Tizzano:

It is my pleasure. So to get started, Cecile, if you could tell us a little bit about yourself, your background, what brought you to Cleveland and your role here at Cleveland Clinic? 

Dr. Cecile Ferrando:

Sure. So I'm a urogynecologist by training. I did my OB/GYN residency in Boston, and specifically came to Cleveland Clinic to train in urogynecology. We have one of the best fellowships in the country. So the answer was obviously yes, I was a- a hopeful candidate at that time. I then stayed on as urogynecologist here. I've been here for nine years in practice. And I saw a- a big gap in the needs of the clinic when it came to performing gender-affirming care. So I stayed on and started our transgender surgical program as well as our medical program years and years ago. 

Dr. Tony Tizzano:

Superb. Excellent. So what constitutes psychological safety within healthcare and the importance of our efforts towards creating a safe and inclusive environment for all our patients and caregivers?

Dr. Cecile Ferrando:

And that's the key thing, right? Is how do we create that space, first and foremost, for our caregivers, because the hope is that that'll translate to our patients eventually, right? Those two things are simultaneous. I think that when it comes to creating a psychologically safe space, at the end of the day comes down to whether or not we feel comfortable taking what we call interpersonal risks, right? Do we have a shared belief system amongst our teams that allows us to take those risks? And what I mean by risks, asking questions, sharing concerns, and whether they're about events, patient care, the work environment. And if those risks are taken, it usually results in a space where patients themselves will feel safe. They'll be able to disclose things about themselves and also ask questions. But then what happens to teams too is that they become more inclusive. That leads to creativity, the ability to innovate, and usually it improves team performance and the ability to be productive as a team.

Dr. Tony Tizzano:

So we got a better sense of belonging, perhaps, and- and that facilitates learning. 

Dr. Cecile Ferrando:

100%. 

Dr. Tony Tizzano:

So I suspect, given the way you arrived here and the way your interests sorta blossomed, that there's some personal journey behind this trajectory. Would you share some of that with us?

Dr. Cecile Ferrando:

I've always been about the underdog. So I think that that translates to almost everything that I've done and what I intend to do. That's how I ended up in gender-affirming care. Gender-diverse transgender individuals have definitely been underdogs as it relates to society, culture, the medical healthcare system. So I have... At a very early time in my career before I even really had a career and I was thinking about one, I was exposed to transgender individuals, as people, not patients. It was before I went to medical school and I learned a lot about this population and these people and decided that I wanted to help give them a voice both in society and in healthcare. And so I found a space in that respect. So they were really early experiences that influenced again, my early career. But from this patient population, I really learned a lot about advocating for individuals, not just trans people, my colleagues, my other patients, peers, people under me, people above me, so.

Dr. Tony Tizzano:

Yeah, I think, you know, this is a piece of a whole DEI idea, but, you know, this is a tremendous focus and one that's not always easy. And, you know, it's obviously important that we have psychological safety in healthcare and in our teams and in our environments, but I think it's probably often lacking. And I sense that there's some bidirectionality, and I think you've touched upon this, between psychological safety and a safety culture where one enhances the other. You know, how does that look at Cleveland Clinic?

Dr. Cecile Ferrando:

I used to not be so sure that it was bidirectional. Now, I agree with you. I think that's the case. I always felt that psychological safety is what leads to safety culture or a culture that safe, but I do think that now they go hand in hand. 

At Cleveland Clinic, I think that what's happened is that we've had such a emphasis on safety culture, right? Avoiding near misses, creating a culture that speaks up so that any misses that do happen don't evolve into things that are more serious, and creating a culture where people can be honest about events and reporting them, and then just avoiding them entirely, which creates a lot of trust and respect amongst teams. So if we know that we're being transparent, and we know that we are encouraging people to identify things that need to be improved on, right? That sense of safety culture, that trust and respect that happens then allows that sense of safety to come to life. And the more psychologically safe we feel within our spaces, the more we feel that we are sharing the same belief system, which then improves psychological safety further and then allows us to all contribute to a safe culture.

Dr. Tony Tizzano:

Yeah. And, you know, I wonder what the responsibility is when you look at the hierarchy that we have in medicine. If I were the attending and I stepped into the operating room and I, you know, started off by saying, "Look, I want this to be a psychologically safe environment. And whether you're my fellow or you're the medical student, if you see something that you question for one moment, I wanna hear it right then and there in front of the patient or not." Do you think we can actually do that?

Dr. Cecile Ferrando:

I think so. I mean, I think it's hard for people who have certain habits, right? We also have evolved as a medical culture, especially in the operating room. That's a area that I know really well, right? That's where I spend half of my time. That's an explicit way. Teaching people to explicitly say that is very easy. And I think that showing what the consequences of that are, which learners usually express gratitude from their teaching, learners usually improved a lot quicker, nursing staff usually is even more supportive of the environment. Things go quicker, productivity increases, satisfaction in general goes up, and there's this positive feedback loop that happens. So teaching somebody to use those words probably will lead to overall improvement. And again, getting that feedback will likely encourage somebody to keep doing that.

I think the harder thing though, is teaching people to role model that behavior rather than explicitly using words and language that demonstrate psychological safety. You have to remember, people can say that they're creating a psychologically safe environment, but they also have to role model that behavior and walk the walk so to speak.

Dr. Tony Tizzano:

They have to demonstrate it.

Dr. Cecile Ferrando:

Sure.

Dr. Tony Tizzano:

When we look at organizational enablers for psychological safety, what are some measures that we take as an organization to try put this in place?

Dr. Cecile Ferrando:

So, you know, it's tiered. I bet it falls into these different pillars. Starts really big and then gets smaller. So we have to rely on the organization first and foremost. So Cleveland Clinic, we are an enterprise. We have to make sure that the enterprise itself is first supportive and that type of behavior, explicit themselves about the fact that that's part of their mission, that creating those safe spaces is important and creating that shared belief system. Creating formal ways to actually be able to learn about psychological safety and then put it into practice. This is something I think that we've done really well at Cleveland Clinic is creating, again, these formal learning toolkits. So we have this, MyLearning, where recently actually we had this high reliability organizational toolkit that rolled out six or eight months ago for all employees to engage in, which I thought was really well done and helpful. It also gave tools, so to speak, that can be put into practice. We've done a ton of training on implicit bias and microaggression which I think is really helpful. So the organization really has to lead this from a very formal way.

You know, I think also creating continuous improvement projects, I think is important and constantly reminding its employees that we're looking at these as actual metrics.

Dr. Tony Tizzano:

Well, I think you're spot on, Cecile. I remember when we have the patient's first mission of years ago, but this high reliability organization, I've gotten to go through those modules as well and lead by our institute chair, and they really are impactful. And there's some give and take when you're having these conversations. And not only do you have this didactic session you go through online, but then you have this conversation that occurs elsewhere. And we hear it from the very top. We hear our CEO, Dr. Mihaljevic, talk about, you know, this is something we're gonna do and it's- it's reinforced in almost every meeting that we see him at. So I think that's excellent.

In terms of at the team level-

Dr. Cecile Ferrando:

Sure.

Dr. Tony Tizzano:

... what are some of the things that we can do?

Dr. Cecile Ferrando:

So it's about who we put at the lead of our teams, right? How we choose our leaders. I think that that choice needs to be intentional. So we have to choose leaders that aren't afraid to be visible, and who know the teams that they're leading. We think that's very important. We need people who are going to lead by example, and also be explicit about their desire to create psychologically safe spaces at a smaller team level. And again, role modeling that first and foremost, in addition to speaking those words. 

I think that there needs to be, uh, and this is happening, an emphasis on peer support on looking at the way that our hierarchical structure is within teams and encouraging people to also lead from the bottom up, which means providing people with a voice. I think having that kind of team structure is really important but at the end of the day, it really comes down to the person who's leading. 

One of the things that Cleveland Clinic really seeks out are leaders who are transformation oriented, meaning that people who aren't afraid to innovate, people who aren't afraid of change. I think that's where we get a little, you know, stuck is if we're not w- willing to change. And I think the concept of inclusivity is ever evolving. Every minute, every day, every week, we're redefining what it means to be inclusive. So if you have teams that aren't willing to change and adapt, you're probably not going to be able to reach that next level ability to create that psychological safety or seeking.

Dr. Tony Tizzano:

Well, I couldn't agree more. And I think we're beginning to see it as a triad. You've got diversity, we all understand why that's important. And then you've got inclusivity, but then you've got equity. Do the people you include, do they have equal power? So are you flattening that hierarchy that you mentioned? Do you think we do? Do you think we flatten that hierarchy or is that something that's really a- a tougher thing for us to do?

Dr. Cecile Ferrando:

I think that's rooted in tradition. Hierarchy creates structure. And so I think that we can evolve in that aspect and do it better. I know that we are motivated to do so, but I do think that we have a little bit to learn in order to achieve that.

Dr. Tony Tizzano:

Sure enough. So now that brings us to the individual responsibility.

Dr. Cecile Ferrando:

Mhm.

Dr. Tony Tizzano:

I mean, we can have all these things happening around us. What do we need to do as healthcare professionals to enable psychological safety?

Dr. Cecile Ferrando:

I think it starts with just practicing courage. I think that speaking up and understanding our responsibility to the larger structure, you know, this is the whole foundation of the concept of organizational professionalism, right? Is understanding where we fit within an organization and what we can do as a person. So remaining open-minded, understanding our own implicit biases and being aware of them, and bringing those to the table in a constructive way I think is really important. I think that's probably the best thing, you know, that we can do as individuals.

Dr. Tony Tizzano:

Yeah. I think being reflected is so critical in this area. And as I've had an opportunity to do some work in microaggressions, I'm always learning from the group like, "Son of a gun, I- I think I've done that." 

Dr. Cecile Ferrando:

Oh, for sure. 

Dr. Tony Tizzano:

And I need to- to be better about and being observant of the fact that it happens from now and again. 

So now we've got the organization, we've got leadership and we are working on this individually. How does this translate in the patient environment to have persons who walk through our doors feel psychologically safe?

Dr. Cecile Ferrando:

I think that... And this is where that bidirectionality comes into play. If the team feels safe, often it will translate to the type of care we are able to give, but then there are things that have to be implemented. So, you know, I always say your front desk is your frontline. So starting out with ways to make sure that patients are greeted in a way where they know that they're going to be respected, but also seen. I think that visibility rather than being just a part of the clerical day of the person who's receiving them. But then whoever's behind the frontlines matters also, right? Patients get clinical intakes when they come through the door. So having inclusive intakes, good communication between the teams about who the patient is behind that closed door and what they're there for, I think is very important. And that also requires a team that works very well together and understands that good communication is important when it comes to caring for patients. 

But then it's, you know, the environment, making sure that signage is appropriate. Patients sit a long time in our waiting rooms, right? So-

Dr. Tony Tizzano:

Yes, they do. 

Dr. Cecile Ferrando:

So the things that they see in their environment are really important to making them feel like they're in an environment that is one that is safe for them to disclose who they are and what they need from their caregivers.

Dr. Tony Tizzano:

So that makes perfect sense. And I couldn't agree more that that front desk person sets the stage. Maybe even the telephone triage, just how you're managed and handled. What questions do you ask to get to the right place, seeing the right person? So, you know, there are strategies for addressing psychological safety and there's somewhat of a gap perhaps in cultural competency education. With the Affordable Care Act and et cetera, where has that changed? Where has that taken us?

Dr. Cecile Ferrando:

Oh, there's been so much change in the last decade, you know? In 2014, through the Affordable Care Act, the Department of Health and Human Services had this massive mandate to really focus on equity, and also marginalized patient populations to provide better access to people, including LGBTQ+ patients. And so with, uh, you know, I call it this wave since 2014, where we've really made drastic efforts in healthcare, to better understand our patients and to be more inclusive when it comes to gender identity but also sexual orientation, race, ethnicity, gaining better cultural competence in terms of what a patient may be seeking or the underlying intentions behind a patient's requests and needs for care. I think that there's subtext to almost every clinical visit. And I think that legislation has since, you know, that time period has created this foundation for us to better understand the need to know that subtext.

Dr. Tony Tizzano:

Great. So I wonder if something as simple as... I noticed with our students, they always have he/him, she/her, but you don't see a lot of staff having that bite. Is that part of saying that I appreciate that this needs stated, their pronouns need stated? Is that something we should all be doing?

Dr. Cecile Ferrando:

Right. It's this generational thing, and it's a great one. I think that what's happening with the staff, and this is where the... I'm gonna call it a "problem". I'm putting it into qu- into quotation marks. Is that the reason that people are choosing to not put their pronouns next to their name, like on a Zoom meeting, or on a name card when you're at a meeting or at a conference, isn't so much I think, this is just my opinion, that they're offended by that or think that it's silly. I think that they think that they don't need to do that because it's obvious what their pronouns are. Which sort of completely contradicts the actual intention of it, and that it's not supposed to be obvious. We should actually understand that one's gender expression or the way that we present ourselves may actually not be in line with our true identities and how we would choose to be referred to. And so I think that that's what this younger generation is trying to express. And so I think that it is helpful. It allows us the space...

We have to remember, when we do those things, it's for the minority, but it's the minority that has the biggest struggle. And so for us to do a very small gesture, to allow 1% of the people in the room to feel comfortable and safe, that person may be the most important contributor to the entire event, right? And so the onus is on us. Those who like, who can live within privilege, right, to actually help those that are struggling a bit more don't have as big of a voice.

Dr. Tony Tizzano:

Yeah, that is so well said. You know, you mentioned something once to me that really resonated with me that... You said that today's students, this generation of students carry the torch for diversity, equity, inclusion, and it's- it's an opportunity for us, faculty, staff, fellows, residents to learn from this group of individuals who seem so much more sensitive. Could you expand on that?

Dr. Cecile Ferrando:

Well, the knee-jerk reaction is that they're extremists. (laughs) That's what, you know, people want to say but at the end of the day, they just get it. It's inherent to them. There's nothing extreme about that. They just understand it. And for them, that visibility component of who people are, seeing people. They wanna be seen, right? And so they see others, and that's how they express it. So I think that that proverbial torch is really important, because I think that that's what's going to allow this to become more of a standard rather than the exception, which is what we need in order to create this culture.

Dr. Tony Tizzano:

Yeah, I love it. They want to be seen so they see others.

Dr. Cecile Ferrando:

Right.

Dr. Tony Tizzano:

I mean, that is so on the spot. 

So, Cecile, what do you think lies on the horizon in this area of engendering psychological safety in the clinical place?

Dr. Cecile Ferrando:

I think it's just that, right? It's the standard not exception. The big promotion was let's make sure we have a zero-tolerance policy, but I think what's on the horizon in order to have to have such a policy means that there's problems with tolerance. So there needs to be a policy in order to have consequences for that, right? Eventually, again, as this generation enters medicine and starts to shape the way that we interact with our patients and each other, with more open-mindedness, the goal for inclusivity it will become just innate and inherent and part of our culture, that to have policies that don't tolerate anybody who sort of pushes against that probably won't be necessary. So I think... I mean, that- that doesn't sound like this massive innovation, but it's a complete culture shift, right?

Dr. Tony Tizzano:

It is a culture shift. And I think it's because of the... You know, what we have so far is a foundation of understanding. And until we really educate the front desk and ourselves more, we may not see it. Or perhaps we'd like to see it, but we're afraid that we don't see it well enough to do it. And I think that's a piece of it, too-

Dr. Cecile Ferrando:

Right.

Dr. Tony Tizzano:

... to take care of individuals that have some special needs and we just don't know how to deliver that. But we're working on that, I think. 

So we've covered a lot of ground and this is a fascinating area. I wonder if there are some other thoughts that you have or questions that I didn't pursue that you'd like to bring to the audience's attention?

Dr. Cecile Ferrando:

No, I feel like this was really thorough, you know? And just, you know, to- to be piggyback on what we were just talking about, I think it's again, shifting one's, you know, frame from being willing to just do it, right? I think there's a difference between, "I'm willing to learn this. I'm willing to do this if this is what is being asked of me," to just feeling that it is the right way to do it. And I'm hopeful for that future, and I think that it should be the expectation. 

Dr. Tony Tizzano:

Yeah, I couldn't agree more. Well, thank you so much, Cecile. This has been a fascinating and enlightening episode of MedEd Thread. To our listeners, thank you very much for joining and we look forward to see you on our next podcast. Have a wonderful day.

Dr. Cecile Ferrando:

Thanks for having me.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.