Every team member plays a critical role in bringing high reliability to life. In this session, we'll explore our personal accountabilities with a specific focus on the behaviors that are the indispensable foundation for creating healthy cultures, using knowledge effectively, driving the learning system and transforming leadership. We'll practice reflection to increase our self-awareness and identify personal actions that will immediately yield results and advance the journey to high reliability.
I'm now going to introduce our first speaker. So for our first speaker today we welcome Amelia brooks who is the chief knowledge and Innovation officer for safe and reliable healthcare. Amelia is a globally recognized expert in patient safety quality improvement and high reliability initiatives With almost 17 years of experience improving healthcare. She's worked in management and leadership roles in primary care and acute care as well as being the senior director for europe and patient safety at the Institute for Healthcare Improvement. Her works included designing a revised approach to just vulture. Developing safe and reliability is framework for high reliability and training others through the I. H. I patient safety executive development program and high reliability academy. So we are delighted to have Amelia join us today for the safety and quality symposium as she discusses each of our roles and high reliability. Similarly, I will turn it over to you wonderful! Thank you so much Emily thank you john and uh and special thanks especially to tammy for inviting me today. It's an absolute privilege to be with you all. I've heard only wonderful things about this symposium, the legacy of this symposium, but also about the BJC system. So I am coming to you today despite the accent from Maryland. So I'm over on the East coast and as Emily said, I'm the Chief Knowledge and Innovation Officer at a small company called safe and reliable healthcare and collectively, you know, the people in the company um you know, over the last 2025 years we've all been in the world of helping healthcare organizations from the inside and from the outside in in all different locations with their high reliability journeys with their patient safety journeys, quality improvement, human factors, all that fun stuff. And what I'll be focusing most of all on today is the cultural side of high reliability. So everything that john just described in those strategies, I would say that the cultural aspects of, of what we do underpin each and every one of those five components and as we go through thinking particularly about what each of us can do in order to create high reliability in practice, please do put questions into the Q and a function, not into the chat function as Emily was highlighting earlier. I'll try and keep an eye on those as we go through any of the other team can interrupt me if there's a question that seems like a really time you want for us to look at and I'll do my best to leave some time at the end as well for the more Q. And A. As needed. Um, and other than that I just, I'll do my disclosure slide, which is never a very interesting slide for people to look at. But I've been on on here just to say that today is also national employee appreciation day, which is something I only found out about this week. I didn't know that it was a thing previously and the reason I included it just as I guess there's a little mental model for all of us all to have in mind as we kind of go through the slides today and we think about high reliability um, two concepts. One is uh, you know, if, if we really want to have a culture of high reliability, we really need to make every single day employee appreciation day. Um, and so that's, that's perhaps a goal that we could all have. And then equally just to think about how not, not only how we, as individuals feel appreciated and valued and what matters to us, um, you know, in our professional lives, but also what we do to make those around us feel appreciated and valued. So today we'll be focusing more on, you know, how my behavior's impact the culture around me and uh, and what that looks like in practice and, and hopefully there'll be a few interesting things in there for you to listen to and take away. I'm going to start just by reflecting on some of the history of, of high reliability only very briefly, just to give us a foundation on which to build and, and this is a quote from Admiral Rickover and, and it's a particularly wonderful quote I think because it's um, it speaks to the complexity of trying to do this in practice. So the quote is as you can read, I'm always chagrined at the tendency of people to expect that I have a simple, easy gimmick that makes my program function any successful program functions as an integrated whole of many factors. Um like working on only one aspect isn't going to be successful and and that's really the basis of us needing to in the work of high reliability, appreciate the complexity that exists and have mindfulness of that complexity as we go through and so In trying to knit that together, you know, what does that mean? What does that look like for healthcare in 2022, in the Western world? You know, we have increasing levels of complexity in our patients, in our systems, in our technologies, we have increasing complexity that has been only confounded really by the pandemic, you know, we are almost exactly two years into the pandemic being in existence. And and and so I think I heard that two years ago you you managed to get in just before the restrictions came into place with, with your last in person version of this symposium, but with all of that in mind and just reflecting on the personal and professional burnout and burden that exists from um from sort of existing in the world of healthcare today, it's critically important that we understand and appreciate all the different aspects of that complexity. So the definition that we offer today for, you know, the goals of high reliability, what's the end state, you know, where are we trying to get to um is this idea of being failure free and stable over time, clinically operationally and culturally and all those three things will keep knitting those back together. Um So it's impossible to be highly reliable if you like in a clinical and operational sense, if you're not highly reliable in a cultural sense and that's the idea that we really want to keep, keep focused on today. So you'll see on the image on the right, the clinical cultural operational are sort of swirling around the outside of what we then have, which is that the care is ultimately being delivered by a combination of humans and systems and it's how those humans and systems work together sometimes easily, sometimes not so not so easily to provide what's at the heart of this and which is at the heart of actually our framework for high reliability that we use, which is it that engaged teams are partnering with patients and families for a level of care that's exceptionally good and highly reliable, you know, those two concepts and and so in this model of keeping clinical operational and cultural knitted together all of the time, it requires that we are mindful of these different things at the bottom and and that you'll recognize these if you come across any of the high reliability characteristics from why can Sutcliffe and others things like, you know, reluctance to simplify as a great example, all of those are woven into these but just to say that, you know, this concept of mindfulness and we'll keep coming back to as how we continue on this high reliability journey and this is not an expectation of perfection is an expectation that we keep working on it. So in high reliability mindfulness, we all need to be mindful of current state continually and that's being affected by both internal and external factors. We need to be mindful of everybody's expertise which really links to that deference to expertise. Idea from Liken Sutcliffe, the complexity that exists when humans and systems interact, which is a kind of a positive way of framing the reluctance to simplify um that that was referenced earlier, looking at the risks and defects and then also the need for continuous learning. So with all of that in mind, clinical cultural and operational staying together and this concept of mindfulness being the basis of what we do and we have it safe and reliable, published last year, a framework for high reliability healthcare that really builds on all of the previous frameworks and they exist from all over the world. So I've had the privilege of doing this work on a few different continents now and you know, and it's fascinating that we're really not all that different and there's a lot that we all have in common and uh and from Australia to the UK to sort of mainland europe to North America and you know, there are lots of different frameworks and models out there for high reliability. But what we really, really wanted to do was try and put that all in one place, so that organizations had at least a chance of building a single lens through which whoever you are, whatever your role is in the system, you can understand high reliability, but more importantly understand how to bring high reliability to life in practice in whatever your role is. Um and so this is what that framework looks like and the segment will be focusing on today is just the sort of between the 12 o'clock and the one o'clock position um under personal accountability, but I'll just highlight a few other things and we'll do a very quick overview of the full framework just so that you can see where that segment fits in the, in the bigger picture. So you'll notice that the around the outside of the framework there's a gear mechanism, this is continually moving, it links to that idea of continual mindfulness. Um and uh and as we go around, you'll notice that there are four different major domains. The first one is culture, then there's knowledge, then there's a learning system and then there's leadership and and so within that model. Um and at the heart of this, we have that sort of same piece of engaged teams partnering with patients and families very much partnering with. So we have a kind of a dual positive outcome from, you know, from doing this work, one of which is of course that goal of patients having the best care possible and the best experience possible and their families and loved ones and friends, um, you know, experiencing that kind of alongside those patients, that has to be our primary goal. But next to that, you know, those patients can't receive that care unless we have happy, healthy engaged teams doing really great work. And so how we look after those teams as people and human beings in the system as well is equally important if we want to achieve that sort of primary goal of great patient experience and patient patient safety. And so that's the heart of the framework. And then as we sort of roll around, I'd just kind of give you some very brief insight into each of the different domains and we'll start at the 12:00 position and go around from there. So the 12:00 position takes us into personal accountability and that's, as I say, that's the foundation of this entire concept of high reliability starts with me. Um, it's, it's been true for a really long time that, you know, we've understood the importance of culture. We've all heard phrases like culturally strategy for breakfast and, and things like that. Um, you know, anything that we work on, if it's not culturally embedded, it just won't stick, we can work really hard doing all kinds of different activities, putting lots of different things in place if we haven't brought people with us hearts and minds. Um, if we hadn't adjusted in terms of behavior, those things just don't stick and, and so what we found to be really helpful with this new framework is that we start off by talking about each of us as individuals in the system and what my accountabilities are for creating high reliability around me. And that applies whether I'm the chief executive of the system, whether I'm a cook in the kitchen, whether I'm a nurse on a, on a cancer ward, you know, whether I'm a physician leader, whether I'm, you know, the person in charge of the car parking, it really doesn't matter what my role is. Each of us have a role in creating around us the right kind of culture, using our knowledge effectively in the knowledge of others, driving and participating in the learning system and modeling the kind of leadership that's in keeping with high reliability and, and so that personal accountability piece instead of saying culture of someone else's job, um, instead of saying that, you know, it's the responsibility of senior leaders and only senior leaders, we say it's everybody's job and all of us have some accountability there. So it's a slightly different use of the term accountability than you might have come across before. Sometimes. You know, it gets applied in the sense of holding people accountable, it's not that kind of accountability, this is me taking accountability for the way I behaved the activities I engage in how I treat others and how I'm participating in this. So that's our concept of high reliability starts with me and in something of a nutshell and when those individuals have that as their lens and as their perspective, those individuals then roll up into a wide variety of different teams um and different collaborative efforts that can be geographically co located, they can be focused around a specific project or subject very wide and broad definition of teamwork and collaboration here, but when those individuals understand that personal accountability, the ability to collaborate and operate as high functioning teams, um it is so much easier um and so those teams then start to talk about you know, can we give everybody agency, can we start to build what we want to experience around us which really comes under the healthy environment piece of of community. So in the teamwork and collaboration sense when we are doing things like briefing and debriefing and huddles and building situational awareness and using all of those high reliability interventions and activities to make our teamwork more effective. That teamwork is underpinned by this foundation of personal accountability and and that teamwork, all of those teams, all of those individuals need to exist within a healthy environment where we deal with burnout particularly hot topic right now I'm sure lots of lots of you are experiencing it either in yourself or in others but you know we have to address burnout and um and there are lots of wonderful things out there around tools and techniques for addressing burnout. The most valuable one I think that that I think is just under used just as a quick segue into healthy environment rather than personal accountability. Um is what can we stop doing? One of the really interesting things about healthcare is that we are fantastically good at adding to the list of what everybody is doing and we are much less in tune with the idea of we added this as a task, very, very well intentioned. Our theory was it was going to make something better or something safer. It hasn't really had that effect, but we don't necessarily remove it from the system and stop doing it. So, another way of thinking about this is what are the pebbles in your shoes that drive you slightly crazy um that you know, feel like non value added activities and and some of those are, you know, yes, externally kind of created and you know, rules and regulations, we have to abide by um an awful lot of them when you actually go through an exercise of what could we stop doing that's not adding value at any level and for any role in an organization. And an awful lot of them turn out to be internal myths. Um so, you know, we've done this several times. Lots of different places, lots of different organizations and and it's usually about two thirds of the ideas of things that we could stop doing in order to lessen the burden of activity and engagement on our really hard working staff members and teams. Um about two thirds of those tend to be internally created requirements that we just keep keep going with because it's become the status quo. So burnout is a big part of healthy environment, other concepts that in there like just culture and psychological safety. So those teams that we're talking about have to exist within an environment where they know they can experience those things and then we sort of round out the culture domain with consensus and alignment. And consensus and alignment is all about negotiation, how we resolve conflicts and how we connect the individuals teams and the environments and the work that everybody is doing back to the strategic goals of the organization, so that every individual has line of sight to I know how my role adds value, I feel valued and I'm contributing to, you know, towards achieving our mission. So that's the sort of four segments of the culture domain. And then just very briefly, I'll run through the other three domains in the framework. Um Next comes knowledge in previous versions of the framework. It has been really interesting, so this is very close to, we work all worked, I used to work with I h I so as in a number of other people from safe and reliable and we're still faculty, but I h I now and and the previous version of this framework that was co published with I. H. I didn't have a knowledge domain to it. And once we added this one into this one, we kind of sat back and thought, I wonder how we ever lived without this because in the world of high reliability, you know, we talked at the beginning clinical cultural operational current state, we talked about having an awareness of current state and appreciation of that complexity. You can't do that without good data and good knowledge and and that data and knowledge has to be continually knitted back together. So you know, we're not looking at single data points, were not looking at single data sources and then acting and sort of and judging on the basis of those instead in high reliability, we're continually trying to build that complete situational awareness, data needs to be as real time and as complete as possible. Um you know, presented as data over time, you know, in the language of continuous improvement. And then critically transparency becomes almost a cultural attributes of the way that we view data and knowledge. So um if we have all of that information but we're not transparent with it, then it's hard to have a culture of high reliability because those teens and all of their behaviors are impacted by the way that we share information throughout the system and so that's really the knowledge domain and it's a very smooth transition then once you have that knowledge and once you have that deep insight into the learning system which you know nothing rocket science about this is hopefully all very like plain english, which was the idea, but you know, in a learning system, you're continually going through these three segments almost in a cycle of their own where you're trying to learn, you're trying to improve and you're trying to implement and and the learning piece when it's connected to really great data stops us from just implementing the same old sort of superficial actions over and over again and means that we hopefully have the chance to really dig in and understand true root causes and it's always causes, it's never root cause um and really get to the heart of, you know, why things are not the way that we want them to be or equally from a bright spots perspective, why something is working really well in an area and how do we spread and scale that. So the learning piece really is about kind of digging into an understanding, cause I think it was Einstein who said if I had an hour to solve a complex problem, I'd spend 55 minutes trying to understand the problem and only five minutes coming up with solutions, um you know, we tend to skip through the understanding, but a little bit in healthcare and and really start to, we want to make things better, so what can we put in place and then that links back to what I mentioned when I was talking about burnout, which is the a lot of those things get put in place very, very well intentioned, great ideas that may not have been quite the right ideas um and so when we have a deep understanding and learning it's then much easier to apply improvement methodology and the sustainability and spread methodology of of implementation um in order to be more effective in driving that learning system and then that leads us to the last domain where we start to talk about leadership and this is leadership not leaders, so every single person, no matter what your role is in the system at one time or another, like there will be um responsibilities that you that you carry that are around leadership and we've broken leadership down into three segments very intentionally, we also come to it last very intentionally because this is not any of the, you know, we all have a kind of a mental model of leadership, we've all been taught different things, there are many, many leadership frameworks and thoughts out there, but we come to leadership last because we want leadership here to be viewed as in service of everything else we've just talked about in this framework. So so leadership for high reliability is about driving the right culture and continually modeling those behaviors and coaching those into you know different people in the organization, it's about effective use of knowledge and it's about driving the learning system in a participative way um and so you know what we want people to do is to have the skills and the behaviors of leadership sort of you know encapsulating the way that we spend our time in the activities. So skills is that I have the knowledge, I have the insight, I have the methodologies, I have all the technical pieces that I need in order to to engage in leadership for high reliability. Um leadership activities are you know the things that you all know and have heard about, you know leadership grounding for instance leadership huddles briefings, forums, all of those different kinds of activities driving great communications in an organization strategy etcetera. So those activities only work if we have the skills to you know to to do them correctly, but most importantly they're only effective in their intent if the leadership behaviors match up with that simple example, I can go and do a leadership around and I can be really um friendly and engaging and humble and listening and just spending time with the team, just absorbing and learning um you know and that would be a good example of great leadership behaviors that make a lead around an effective activity or I can be distracted or I can dominate the conversation because I feel slightly uncomfortable or I'm checking email at the same time or I'm not really paying attention and you know and and all of a sudden a few behaviors that I exhibit um start to affect the you know the efficacy of the activities that I'm trying to engage in. So we really want that model of leadership behaviors and it's intentionally next to that idea of personal accountability which as well will kind of be digging in today. So that brings us to this idea of you know of high reliability starting with me. Um and uh and and this is exactly what we're going to spend our time on today. So I'm just quickly check in the Q. And A. Um what can we remove question is one of the single most powerful questions any healthcare organization or leader or individual could ask and it's seriously underrated. So I encourage you all to try that one out and then the question around how do we help individuals to take personal accountability and adjust culture to ensure they feel safe in doing so will will start to dig into some of that in the next section. But if I haven't answered that one, by the time we get a little further on do flag and I'll happily come back to it. Thank you so much for for putting questions in. Um so in this idea of personal accountability, what we want to say is you know we have the traditional view of the organization which is top down the people at the top create this sort of model. They you know, they set the direction and strategy and you know the rest of us are participating. Well an alternative view of organizations is that every single one of us um needs to participate and we're all you know in this model the little cells and the cells make up organs and organs makeup organ systems and when all those organ systems are healthy and functioning um you know then we have a nice healthy human body and and in a sort of an organizational view of this with that framework in mind, what we should get is that each individual has that lenses using that framework understands their personal accountability to participate in each area of the framework. And when you have that it's easier for units to kind of convene around that and and have a shared language, you know that that idea of what can we do less of um you know what can we stop doing? One of the things we can stop doing is to describe the same thing in slightly different ways, so it feels like a different thing. So the more we can simplify this and just have one lens um you know, we have a kind of a high reliability academy, it's safe and reliable. Um and the senior leaders, the executives, they get trained first in the framework but what they get trained, what they get taught, the language, the tools and methodologies are the same as the language tools and methodologies of the operational leaders and the frontline leaders and the teams and everyone else gets trained in. So they all have a common language is shared sets of tools um that you know, we're not having to continually adjust and sort of reproduce. And so then those individuals roll up into these units, the units roll up into departments etcetera. And you know, and you get the same idea of of what this looks like overall. And one idea just for us to I think just challenge our own thinking on it. And I've been so I've I've been absolutely guilty of this. I have been within organizations on the inside doing patient safety and quality work. And I have been on the outside doing you know, consulting and strategic strategic, strategic support and everything and you know, and speaking about this, you know, all over the world for the last few years and we have many, many times described this as a linear journey um that you know that you just go in this direction, you do these things and you gradually get more and more highly reliable. Excuse me. And and then we see examples like you know, the, you know, Boeing 737 max where uh an industry that is known for being high reliability takes its eye off the ball becomes a little complacent and are no longer highly reliable. It's also true that you know, I think, you know, as as we look at organizations, I think in any unit, any team, even in any individual, you could look and you could find examples of exceptional high reliability practice in some areas and even on the same day, you know, less exceptional high reliability practice in others. And so for me now, I think that where we are at this point in time in 2022, this idea of this linear progression to high reliability just doesn't really vibe with that idea of appreciating complexity and reluctance to simplify. So instead what we want to give you is this model of perpetual mindfulness where, you know, we see that the organization, the units, the departments, the individuals, we're continually battling the complexity that exists, some of which is internal, some of which is external and that's perpetual because we can't always control what's going on and how it's going to affect different things around us. And so this idea of, you know, the framework for high reliability and you know, whether it's this framework or another framework, you know, none of this is rocket science, leadership, culture, knowledge and learning right? For really simple domains, all trying to achieve high reliability and all the different things we need for high reliability. If you see that that framework, you know, as it moves around this infinity loop and you know, and we try and bring in that idea of perpetual mindfulness lots of different things would be happening within the system around the system for us, as individuals for teams for units, all those different things that are on the right hand side, but there are clearly hundreds of thousands if not millions of other things that would be happening as well and they're all affecting the health of what's going on. So as an example, you know, you could have um you know really unfortunate adverse event occur and that can, either the way it's handled can increase um the psychological safety of you know, of the team involved and you know, and it can be a great example of the learning system and it can increase the health of those different segments or we maybe don't handle it as well and it can decrease psychological safety because we didn't effectively apply just culture and we don't to some conclusions and we blame some individuals and so that idea of just kind of seeing high reliability as this, this, this sort of journey of perpetual mindfulness and you know, and whilst it's daunting to think that it doesn't have an end state, I think there are numerous examples globally of organizations thinking they had achieved high reliability becoming complacent and then all of a sudden not being quite so highly reliable anymore and we can learn lessons from that and and really stick to this idea of perpetual mindfulness and so this gives us the opportunity then with that as our foundation to just dig into the different accountabilities. So I talked about us as individuals, as the first segment of the framework and what that means then is that you know, I have to recognize that culture is not someone else's job, it's my job to create the culture around me. And I know that there's a, there's a sort of a narrative that goes along the lines of culture, change takes years, it's it's like you know, turning the ship around, it's you know, it's sort of trying to change the culture of an entire organization is a huge, big, complex multi year journey and that may well be true. There's an alternative viewpoint that I really find empowering. Um and I think it is perhaps kind of a little more energetic, which is that I can change the culture around me in an instant, I can come into work, I can treat people with respect, I can listen, I can share, I can build human connections and I can create a culture around me that's slightly more positive because of my actions, my choices, my behaviors or I can come into work and I can be grumpy and I can be disrespectful and you know and all kinds of other less pleasant things and I can create a very negative culture around me. So that idea of an organization having one culture makes culture change feel really big and difficult and complicated. This idea of recognizing that there is not one culture in an organization, all culture is local and a big organization is made up of lots of little micro cultures and those micro cultures are continually fluctuating and changing on the basis of the behavior that people experience. So one of the ways of thinking about this is the difference between personality and behavior, which we'll get to shortly. That's really, really where we're going to focus today, my cultural accountability for behavior. The second piece is knowledge. I'm accountable for using knowledge to drive the cultural, clinical and operational decision making. I need to be continually putting that picture back together. I can't take a single data point and react to it and say I've used knowledge effectively. I've got to try and understand and see the big picture and make that as accurate and as situationally aware as I possibly can next stages with the learning system. The learning system only works if I actively participate in it. It's not for everyone else to do. I have to be willing to report defects, make suggestions. I have to be willing to test new ideas. I have to, this is a critical one. I have to be willing to let go of the old way of doing something when a better way comes along. If that's now the standard we're trying to subscribe to so that that's my, my responsibility for participating in the learning system. You know, we one of the phrases we often stay, it's safe and reliable is high reliability is a contact sport, you know, we're all in this. Um if we wanted to work and then lastly under leadership, um I have a responsibility for developing the skills and behaviors that make my activities effective when I engage in them. Um you know, I I can only have great leadership activities if I have the right skills and most importantly if I'm displaying the right behaviors and then the output being as I commit to everything that's above this is how patients and families get safer and more reliable care. Um let me just check the Q. And a one second. Um Actually I love that suggestion of the arrow being bi directional. Yeah, we're really trying to convey that and we're talking about the micro to macro um imagery. We're really trying to convey that build of you know, each of us as individuals as cells contributing to the whole as an alternative. But you're like absolutely right. The and the arrows go in both directions and actually in all kinds of crazy directions as well in reality, which is the wonderful complexity of the systems we work in. Um so let's dig into this idea of cultural accountability. So each of the concepts on here, personality and behavior, respect, trust and courage. Um you know, followership, we're going to dig into all of those over the next few minutes but it really does get to this point of it starts with me. Um you know, I I have, if you haven't heard me say it enough times already changing culture is not someone else's job. I have to influence the culture around me in a positive way. Sometimes that's easy and sometimes it's not and and so you know, a couple of foundational mental models here. So personality and behavior. Now I heard this from many years ago, I did some human factors training with british airways. I wasn't working for british airways. I was in the National Health Service in England at the time, in a role that was a regional and national patient safety and quality improvement role. And I had the opportunity to do my human factors and crew resource management team, resource management training with, with british airways and um and it was really fascinating and it was a concept that I've just carried with me um you know, and I've said it many times in many different venues but differentiating our personality from our behavior is critical for creating the right culture at work. Um and so here's the here's the concept your personality is yours. Nobody can tell you um that your personality should be different or that you know, you should be a different person or any of those things. So that's yours. It's yours alone. It's complicated, it's built up of all of experience and history and you know, your personal culture and geography and all those different things like that's yours. That's great own it don't let anyone else touch it. Your behavior when you're at work, on the other hand is absolutely fair game. So it is absolutely appropriate for your organization, for your colleagues, for your patients to have expectations of your behavior when you're at work. Because our behavior is something that we choose. Um, and then when we choose that behavior, we have the opportunity to either create healthy culture or destroy healthy culture. So differentiating those two things, it's quite a helpful thing for us not feeling like we lose our identity in the process, but understanding that we are part of something that's not about our personality when we're at work, it's about our behavior and the impact that that has. So that's one choice for us to make. And then the second is in respect and professionalism. So the phrase that you'll hear us say over and over again, non negotiable mutual respect for everyone all the time. There's never an appropriate scenario for disrespecting someone in the workplace workplace. And there's a lot of data out there to suggest and actually proved that when people witnessed this respect, it creates an environment and an expectation of disrespect for everybody. So the ramifications of those small examples of the less helpful behaviors are absolutely huge. And you know, and so that concept then of professionalism and defining professionalism through our behaviors as an organization becomes really critical and you know, we'll just take a brief pause here and I'll give each of you just a little bit of time to reflect on this question, um everyone's heard of Brandy Brown. If you haven't heard of Renee Brown, you should absolutely look around to you as a master of coining some of the most helpful tools and insights um and really helping us to feel courageous about, you know, being vulnerable as individuals and that's what this kind of thing means. So, you know, in her engaged feedback checklist, she has this great quote, I can hold you accountable without blaming or shaming you. Um and you know, and that applies to ourselves and the way we hold ourselves accountable as it does to our colleagues and how we hold them accountable. So the reflection question here and I'd encourage you not just to think about this now, but to carry it with you throughout the rest of the sessions this morning. We have some wonderful speakers um and also just throughout kind of the next few days, Next few experiences interactions at work, but really starting to think about, Are there aspects of your personality that make it challenging in terms of behaviors and respecting everyone and staying professional? Um and I'll give you an example, I'll give you a personal example of mine. Um you'll probably have gathered by now that I talked quite quickly. Um I try to sort of control myself and slow things down and um and everything, but when I'm really passionate about the subject, I get animated and I talk rapidly the other time I talk rapidly is when I'm busy. So the more work you give me to do, the more energetic I feel. But the faster I talk and the faster I talk has an impact on those around me because it makes those people feel like they can't interject that they can't stop the line that they can't say, hold on, Amelia, I didn't quite get that or hold on, Amelia, I've got an idea about a better way to do that. And so, you know, it's it's an example. It's there's no malcontent. I'm not trying to destroy anyone's psychological safety, but it's a behavior linked to my personality that I'm aware of, that I have to consciously address in order to fulfill my cultural accountability in terms of the framework and sometimes I do it and sometimes I don't, and you know, and when I don't, it's not about beating myself up and saying I'm a terrible person. Um it's about saying, let me understand. So I I need to be self reflecting an improvement, capable as an individual. Was I start to understand and pay attention to what are the behaviors that I exhibit that contribute to a healthy culture around me and what are the behaviors I exhibit that may not be contributing to a healthy culture, regardless of intent, intent and impact two entirely different concepts, it doesn't matter how good my intent is if my impact isn't a positive one, so that's a reflection that, you know, it's a great question, I carry it with me all the time, my team carry it with them all the time. We talk about it in our feedback, in our conversations with each other. And it's just a great question to take with you, as long as that, as well as that sort of question around what can I stop doing around Burnett and you know, and then as we start to dig into respect and professionalism, we tend to go down these roads of what are the signals and you know, so lots of organizations have respect in their kind of core values. Um you know, it appears on lanyards and posters and screen savers and you know, on the back of little cards that we might carry, like access cards and things like that. Um, and and it's great to have that sort of called out, that really has to be the foundation, we have to specify non negotiable, mutual respect for everyone all the time as a core value. We have to say that in order to make it happen. There are also lots of other things that we can say in order to make it happen as we dig into here and try and make that transition from culture feeling big and nebulous and challenging and we're not quite sure what to do, the more that we dig into, what are the specific actions of respect. So what does respect look like in the workplace? What specific actions, behaviors, interactions, experiences, what makes you feel respected? Um and then how do you make sure that you're showing respect to others? And then how do you model or measure the levels of professionalism that you personally are exhibiting? And you know this is all about personal accountability, this is all about high reliability starts with me. So we have to apply this to ourselves before we can expect it of others. And you know, we spend a lot of time with you know, the most senior executives of you know huge health systems going through this process with them. And I can tell you from, you know, recent experiences we've had you know the really senior executives from you know, very large East Coast academic systems, you know very very well like highly regarded, just like B. J. C. Of like some of these individuals who are sitting back and reflecting and saying, you know, and actually direct quotes, you know, I spent the whole weekend thinking about all the times that I witnessed disrespectful behavior and I did nothing and I'm ashamed of myself for it. You know, getting to that idea of I personally have to create this is absolutely critical. So this kind of really practical step, it's great to have the values called out, but you've got to take the step of saying practically what does that look like? How are we going to show respect, How will we know it's happening um, and how will we dig into that for different people and then, so this is an example of you know what we went through. So top left respect everyone. This is a page from a safe and reliable website. Um, you know, respect everyone is one of our values. Um, and then these are all direct quotes from members of our team who started to share what respect meant to them. And you'll see here there's a there's there's wonderful rich, diverse variety um where you know, things like espoused and hidden values are demonstrably the same. Um, here's another great one. Always presume good intent, be open and mutual support and trust. Listen twice as much as you speak, you know, fantastic concepts, all different respect means different things to different people and and then that kind of brings me to this point of what about if our model of respect is, you know, is to go back and ask the team, you know, how can we respect everyone um and start to generate what are the behaviors, how will we recognize and know that we are respecting everyone and actually let me just share one final thing on respect before we move on to the next piece, which is that one of the most powerful questions I think. Is that, is that just this concept of, I respect you enough to ask you what respect means to you. So rather than assuming rather than coming up with a load of you know prescribed pieces and interventions of you know of you know us deciding for other people, what what what respect looks like, How about if we respected them enough to ask them the question and then truly listen to their answers and their responses. Um and so you know, we have to get really practical with our behaviors and start to dig into the detail. Um you heard me call out that quote of listen and respond and support, you know, the I think there's an old Scottish proverb actually of you have you have two ears and one mouth and you should use them in that proportion. Um it's a helpful one to bear in mind. Um and so how do we really listen to people? It's not just us waiting our turn to jump in and share what we wanted to say, but you know, I'm really hearing someone else and I know that I'm hearing them because what they're saying is adding to my thoughts to my experiences. It's changing my mind. It's making me think of different things and being able to really channel some of that. Um and so and this is a quote and I absolutely love this. This actually comes from a book called the Trusted Advisor which is a really wonderful easy read um and contains lots of really useful lists and tools for kind of connecting with people in a trusted way? Um but just the phrase of I am not the center of the university like, and when I came across this, it was sort of in that concept of, you know, I need to just have this in my mind all the time. All of us have to have this narrative kind of continually playing of, I'm not the center of the universe so that I silenced myself and really listen to others. And the more I listen to others, the more I'm modeling that concept of deference to expertise, which is just so foundational in high reliability and this has nothing to do with hierarchy. This is not about how important you are or what professional group you're from or how long you've worked at the organization, deference to expertise is really about connecting to everyone, but you can't make that connection unless you're capable of listening to understand rather than listening to respond and then another personal reflection. And it's probably no surprise that a lot of the the questions and the activities that flow from this particular topic, our personal reflections, but really thinking about when different people speak up to you, when they raise concerns when something goes wrong or something goes well when it's one person that you really love working with versus another person that you maybe struggle with, working with, you know, just reflecting on your response and going back to that concept of personal accountability, culture and behavior. Um you know, am I being positive or negative? Am I encouraging or am I criticizing? Am I dismissing what they say or am I absorbing it? Do I interrupt you know, am I being defensive? Am I seeking to understand and asking more questions or am I just providing my own answer and you know, all these questions help us to be better at modeling the behaviors of high reliability that go back to underpinning or john described at the beginning of those, you know, major scientific concepts of high reliability and practice and then just you know, critical concept here, we talk all the time about leadership and we rarely talk about followership and the challenge with that is that we can't all be leaders all the time. Sometimes the most important thing a leader can do is to follow someone else and be that sort of first follower that says, I think that's a great idea, how can I support you? And and so most of us, even when we're in leadership roles actually have more of a responsibility or at least more frequent responsibility for following others, for supporting people for helping them to generate ideas for you know, contributing in an active way for participating in the learning system by being willing to test changes. So, you know, one of my accountabilities here in that concept of personal cultural accountability is to be the kind of follower that kelly described in his book, the power of followership which is committed, competent, courageous and self managing. Um you know self managing as I'm accountable for you know my role, the technical skills in order to do it. Um you know I choose my actions and behaviors appropriately. All of the others are around me making choices to support other people. Um and so it's a really critical concept and one that we just probably don't spend quite enough time on but that is a really important one. And then you know like I say human human sort of behavior is not about perfection. Um you know I am capable of doing many many very silly things as all of my friends, family and colleagues will attest to you for any of you at any time. Um you know but I'm capable of accepting the fact that I make mistakes I have to be, I have to be able to say no matter how bad I feel about that no matter how hurt I feel. You know tomorrow is a new day and I have the opportunity to choose my behaviors all over again. Um You know I can say when I'm not feeling okay, I know that I have weaknesses and I'm continually like critical one at the bottom here, I'm continually looking for opportunities for learning and growth um and specifically in the behavioral space, you know, I it's really hard to improve without data and it's really hard to get data on behaviors. Um So that's where concepts like feedback and having some of those cycles built in really come into their own of you know uh and there's a phrase from deming which I've always loved as a quote which is in God we trust all others bring data well, data is no different in the cultural space. We need data to know how people experience ours. I might think I am great at building psychological safety but on my team might think I'm terrible at it or I might think I'm terrible at something else and everyone else thinks I'm great at it or some people do and some people don't. Um and so I need that data and feedback in order to be my own self reflecting improvement capable learning system. Um and modify my behaviors in order to create a culture of high reliability around me. Um and that kind of brings us full circle like back into the sort of headlines of personal cultural accountability, you know how I behave affects the culture around me. I can behave one way in a moment and I can create a positive or a negative culture and experience that those that I am kind of interacting with and that's a choice every single time. Um Sometimes we have the time and the headspace to sit back and really think about the choice we're making other times. It just comes in the moment but they're all equally important and the way that we reflect and learn from those is what becomes really critical. Um, and so this is, this is the question I really want to leave you all with and you know and for you to just start weaving into you know, your your days at work and your days at home with your family, whatever whatever particular environment you'd like to apply. The wonderful thing about culture is it has nothing to do with the environment we're in wherever we are, if we're human beings, we're all having to deal with culture all the time. Um and so take a moment just to find 10 minutes sometime today hopefully to sit back and really celebrate the positives of all the things that you do personally that enhance the culture around you, you know really focus on the bright spots there and also just take a moment in a very humble moment of self reflection to think about what undermines the culture around you and Even if it's unintentional which is like 99.9% of the time it is um you know what undermines that culture and you know, and what you what you want to be your pathway of learning and growth for your behavior to create a culture of high reliability that then supports and enables and is the kind of fertile soil for all the activities of high reliability that take place and I've included in the slide just um a little grid just to help with some of that reflection. Um it's a grid that, you know I probably look at once every couple of weeks for my own personal learning journey but just in case that's a resource that's helpful and and that's just really a repetition of that. So I know there are a few questions which I'll try and get to Emily if you'd like to jump in and highlight any please do. Um and just a huge thank you. It's such a privilege to be starting the day with you this morning. Um I'm absolutely delighted to have been able to participate move. That was absolutely fantastic. And um a lot of the things you talked about are things that we're thinking about here at B. J. H. B. J. C. And Washington University in ST louis Children's hospital. So I think it really reinforces some of the things that we're trying to develop and I think gives us new ideas and new ways of thinking about high reliability culture and the personal accountability in terms of questions. I think you can see them. The first one was, have you encountered those responsible for deploying a reliability system to be too rigid? And what was the reception for healthcare workers? Yeah, it's a, it's a great question and I again on that concept of you know good intent and it's a, it's one we all carry with us assume good intent, we've seen that happen and it comes from a place of good intent. It comes from often a place of wanting to get things done and wanting to be organized about it. Um, the challenges that when it's too rigid, it's hard for for it to be appreciative of the complexity that exists and, and the rigidity often misses the cultural aspect of all of this. Um, and so, you know, when we forge ahead, when we kind of force threw things around high reliability, we end up undermining it as a brand almost. Um, and it ends up not being successful because we haven't really brought people with us. Um, those of you that no change management and know the ad car model, you know, the first like two, well three actually awareness, desire and knowledge, you know, three critical steps and change. And so um, you know, I think those models are helpful for making sure that we keep the connection. Um, and one final piece on that one would be just to say, never underestimate the power of great communications because um, you know, we, we often don't involve communications in these kinds of organizational transformations and that's often what bridges that gap and it enables the dialogue between those deploying, um, that may have a very fixed view of the world and you know, and those who are experiencing or expected to change who maybe aren't up to speed or kind of haven't been engaged appropriate enough for them to know how it relates to them personally. And so communications is often the link between those two concepts that determine success or failure. I think we have time for one more question. Um, so what suggestions do you have for employees to help leaders understand the impact of minimizing employee experiences? And I think part of the context of this question is that we often normalized issues such as short staffing and supply chain that do impact the employee's ability to provide highly reliable and high quality care. Um, but sometimes they're the folks are told that these are out of scope even though those are root causes of the issues. Yeah. And it's, I mean such a pertinent question for this point in time as well. So whoever put that in, I really appreciate you calling it out the phrase out of scope I think is, is interesting and it's an interesting choice and and again, good intent. It often comes from a place of, I can't fix that for you. So we just need to sort of ignore it. I think I think a more helpful way of dealing with those things is to say like what can we control versus what can't we control what's within and what's without the, that, you know, our gift of power in this moment and we can't, you know, everywhere, not just in North America, you know, every single health system we're working with here is, is suffering from these terrible staffing shortages and retention issues. Um, you know, and, and that's it exactly the same over in the UK right now. You know, this is all over the world and it's such a, a terrible reality of the situation we're in. Um, but it's still the reality. So it has to be in the scope. And that's why that question of, so what can we stop doing? You know, what's not essential. That's the power of that question. Because if we only have so much resource, we can't keep saying everything is a priority all the time. We have to say these are the two or three things that are a priority, which of course should be very focused on patient care. And then we'll do everything we can to make everything else simpler knowing that that resource is so limited and that people are so burnt out right now. And, and so the it's it's really critical and I think it comes from um, you know, there's sort of an emotional intelligence point of view. If that's your reality, like perception is reality in this world. So it's not my job to say, we're not going to talk about that. It's my job as a leader to listen and say, we can't change that. But what can we change in order to make that manageable. Um, and that's different from saying it's out of scope and those are the kinds of conversations we do a lot with executive leadership teams, you know, and, and, and and and and again, it's um like the only thing I would say is, you know, that in this world we have uh we have the opportunity to assume good intent from everybody and help them to understand. So sometimes that really direct conversation if you have a senior leader and you have the psychological safety to do it or you know, somebody that does to just give them that that feedback of when you tell us that's out of scope, it hurts us more than helps us. And here's another way of us being able to have that conversation that validates what we're experiencing um without minimizing our experiences, but also being realistic about what we can and can't change. And so like we we tend to give senior leaders the least feedback of all just by because of hierarchy and position. So finding ways to do that is really critical if we want people to hear those messages and here the impact because they may not know the impact of what they're saying. Right? Look and Amelia, thank you so much. Um we really really appreciate your time this morning um for the conference. We are at time for this presentation. We now invite everybody to take a short break and then also to make sure to look at the posters that are available um as a reminder, all of the sessions today are being recorded and those will be available for viewing within one week, I'm using the same platform, so you can also go back and look at it and also take a look at the slides. So thank you everybody, and we will see you at our next session.