The Fearless Organization Creating Psychological Safety in the Workplace - Comportamento Organizacional (2025)

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<p>the</p><p>fearless</p><p>organization</p><p>the</p><p>fearless</p><p>organization</p><p>Creating Psychological Safety in the</p><p>Workplace for Learning,</p><p>Innovation, and Growth</p><p>Amy C. Edmondson</p><p>H A R V A R D B U S I N E S S S C H O O L</p><p>Copyright © 2019 by John Wiley & Sons, Inc. 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Neither the</p><p>publisher nor author shall be liable for any loss of profit or any other commercial damages, including</p><p>but not limited to special, incidental, consequential, or other damages.</p><p>For general information on our other products and services or for technical support, please contact our</p><p>Customer Care Department within the United States at (800) 762-2974, outside the United States at</p><p>(317) 572-3993 or fax (317) 572-4002.</p><p>Wiley publishes in a variety of print and electronic formats and by print-on-demand. Some material</p><p>included with standard print versions of this book may not be included in e-books or in</p><p>print-on-demand. If this book refers to media such as a CD or DVD that is not included in the</p><p>version you purchased, you may download this material at http://booksupport.wiley.com. For more</p><p>information about Wiley products, visit www.wiley.com.</p><p>Library of Congress Cataloging-in-Publication Data</p><p>Names: Edmondson, Amy C., author.</p><p>Title: The fearless organization : creating psychological safety in the</p><p>workplace for learning, innovation, and growth / Amy C. Edmondson.</p><p>Description: Hoboken, New Jersey : John Wiley & Sons, Inc., [2019] | Includes</p><p>index. |</p><p>Identifiers: LCCN 2018033732 (print) | LCCN 2018036160 (ebook) | ISBN</p><p>9781119477228 (Adobe PDF) | ISBN 9781119477266 (ePub) | ISBN 9781119477242</p><p>(hardcover)</p><p>Subjects: LCSH: Organizational behavior. | Organizational</p><p>learning—Psychological aspects. | Psychology, Industrial.</p><p>Classification: LCC HD58.7 (ebook) | LCC HD58.7 .E287 2019 (print) | DDC</p><p>658.3/82—dc23</p><p>LC record available at https://lccn.loc.gov/2018033732</p><p>Cover Design: Wiley</p><p>Printed in the United States of America</p><p>10 9 8 7 6 5 4 3 2 1</p><p>http://www.copyright.com</p><p>http://www.wiley.com/go/permissions</p><p>http://www.wiley.com/go/permissions</p><p>http://booksupport.wiley.com</p><p>http://www.wiley.com</p><p>https://lccn.loc.gov/2018033732</p><p>To George</p><p>Whose curiosity and passion make him a great scientist and</p><p>leader – and who knows all too well that fear is the enemy</p><p>of flourishing.</p><p>Brief Contents</p><p>Introduction xiii</p><p>PART I The Power of Psychological Safety 1</p><p>Chapter 1 The Underpinning 3</p><p>Chapter 2 The Paper Trail 25</p><p>PART II Psychological Safety at Work 51</p><p>Chapter 3 Avoidable Failure 53</p><p>Chapter 4 Dangerous Silence 77</p><p>Chapter 5 The Fearless Workplace 103</p><p>Chapter 6 Safe and Sound 129</p><p>PART III Creating a Fearless Organization 151</p><p>Chapter 7 Making it Happen 153</p><p>Chapter 8 What’s Next? 187</p><p>vii</p><p>viii Brief Contents</p><p>Appendix: Variations in survey measures to Illustrate Robustness</p><p>of Psychological Safety 213</p><p>Acknowledgments 217</p><p>About the Author 219</p><p>Index 221</p><p>Contents</p><p>Introduction xiii</p><p>What It Takes to Thrive in a Complex, Uncertain</p><p>World xiii</p><p>Discovery by Mistake xvi</p><p>Overview of the Book xviii</p><p>Endnotes xxi</p><p>PART I The Power of Psychological Safety 1</p><p>Chapter 1 The Underpinning 3</p><p>Unconscious Calculators 4</p><p>Envisioning the Psychologically Safe Workplace 6</p><p>An Accidental Discovery 8</p><p>Standing on Giants’ Shoulders 12</p><p>Why Fear Is Not an Effective Motivator 13</p><p>What Psychological Safety Is Not 15</p><p>Measuring Psychological Safety 19</p><p>Psychological Safety Is Not Enough 21</p><p>Endnotes 22</p><p>ix</p><p>x Contents</p><p>Chapter 2 The Paper Trail 25</p><p>Not a Perk 26</p><p>The Research 29</p><p>An Epidemic of Silence 30</p><p>A Work Environment that Supports Learning 35</p><p>Why Psychological Safety Matters for Performance 39</p><p>Psychologically Safe Employees Are Engaged</p><p>Employees 41</p><p>Psychological Safety as the Extra Ingredient 43</p><p>Bringing Research to Practice 45</p><p>Endnotes 46</p><p>PART II Psychological Safety at Work 51</p><p>Chapter 3 Avoidable Failure 53</p><p>Exacting Standards 54</p><p>Stretching the Stretch Goal 60</p><p>Fearing the Truth 63</p><p>Who Regulates the Regulators? 66</p><p>Avoiding Avoidable Failure 68</p><p>Adopting an Agile Approach to Strategy 70</p><p>Endnotes 72</p><p>Chapter 4 Dangerous Silence 77</p><p>Failing to Speak Up 78</p><p>What Was Not Said 79</p><p>Excessive Confidence in Authority 83</p><p>A Culture of Silence 86</p><p>Silence in the Noisy Age of Social Media 92</p><p>Endnotes 97</p><p>Contents xi</p><p>Chapter 5 The Fearless Workplace 103</p><p>Making Candor Real 104</p><p>Extreme Candor 109</p><p>Be a Don’t Knower 113</p><p>When Failure Works 116</p><p>Caring for Employees 119</p><p>Learning from Psychologically Safe Work</p><p>Environments 123</p><p>Endnotes 124</p><p>Chapter 6 Safe and Sound 129</p><p>Use Your Words 130</p><p>One for All and All for One 135</p><p>Speaking Up for Worker Safety 138</p><p>Transparency by Whiteboard 142</p><p>Unleashing Talent 146</p><p>Endnotes 147</p><p>PART III Creating a Fearless Organization 151</p><p>Chapter 7 Making it Happen 153</p><p>The Leader’s Tool Kit 154</p><p>How to Set the Stage for Psychological Safety 158</p><p>How to Invite Participation So People Respond 167</p><p>How to Respond Productively to Voice – No Matter</p><p>Its Quality 173</p><p>Leadership Self-Assessment 181</p><p>Endnotes 183</p><p>Chapter 8 What’s Next? 187</p><p>Continuous Renewal 187</p><p>Deliberative Decision-Making 189</p><p>xii Contents</p><p>Hearing the Sounds of Silence 191</p><p>When Humor Isn’t Funny 193</p><p>Psychological Safety FAQs 195</p><p>Tacking Upwind 208</p><p>Endnotes 209</p><p>Appendix: Variations in survey measures to Illustrate Robustness</p><p>of Psychological Safety 213</p><p>Acknowledgments 217</p><p>About the Author 219</p><p>Index 221</p><p>Introduction</p><p>“No passion so effectively robs the mind of all its powers of acting and reasoning</p><p>as fear.”</p><p>—Edmund Burke, 1756.1</p><p>Whether you lead a global corporation, develop software, advise</p><p>clients, practice medicine, build homes, or work in one of today’s</p><p>state-of-the-art factories that require sophisticated computer skills</p><p>to manage complex production challenges, you are a knowledge</p><p>worker.2 Just as the engine of growth in the Industrial Revolution</p><p>was standardization, with workers as laboring bodies confined to</p><p>execute “the one best way” to get almost any task done, growth</p><p>today is driven by ideas and ingenuity. People must bring their brains</p><p>to work and collaborate with each other to solve problems and</p><p>accomplish work that’s perpetually changing. Organizations must</p><p>find, and keep finding, new ways to create value to thrive over the</p><p>long term. And creating value starts with putting the talent you have</p><p>to its best and highest use.</p><p>What It Takes to Thrive in a Complex,</p><p>Uncertain World</p><p>While it’s not news that knowledge and innovation have become</p><p>vital sources of competitive advantage in nearly every industry,</p><p>xiii</p><p>xiv Introduction</p><p>few managers stop to really think about the implications</p><p>you have to “be willing to be vulnerable and</p><p>be open about your mistakes so others feel safe” to report their own.2</p><p>Alluding to the risk of hubris, Costa added, “If you think you have</p><p>all the answers, you should quit. Because you’re going to be wrong.”3</p><p>In today’s organizations, psychological safety is not a “nice-to-</p><p>have.” It’s not an employee perk, like free lunch or game rooms, that</p><p>you might care about so as to make people happy at work. In con-</p><p>trast, I’ll argue that psychological safety is essential to unleashing talent</p><p>and creating value. Hiring talent simply isn’t enough anymore. People</p><p>have to be in workplaces where they are able and willing to use their</p><p>talent. In any organization that requires knowledge – and especially in</p><p>one that requires integrating knowledge from diverse areas of exper-</p><p>tise – psychological safety is a requirement for success. In short, when</p><p>companies rely on knowledge and collaboration for innovation and</p><p>growth, whether or not to invest in building a climate of psycholog-</p><p>ical safety is no longer a choice. Every manager must follow Mark</p><p>Costa’s lead.</p><p>Not a Perk</p><p>In any company confronting conditions that might be characterized</p><p>as volatility, uncertainty, complexity, and ambiguity (VUCA), psy-</p><p>chological safety is directly tied to the bottom line. This is because</p><p>The Paper Trail 27</p><p>350</p><p>300</p><p>250</p><p>200</p><p>150</p><p>100N</p><p>um</p><p>be</p><p>r</p><p>of</p><p>M</p><p>en</p><p>tio</p><p>ns</p><p>50</p><p>0</p><p>19</p><p>90</p><p>19</p><p>91</p><p>19</p><p>92</p><p>19</p><p>93</p><p>19</p><p>94</p><p>19</p><p>95</p><p>19</p><p>96</p><p>19</p><p>97</p><p>19</p><p>98</p><p>19</p><p>99</p><p>20</p><p>00</p><p>20</p><p>01</p><p>20</p><p>02</p><p>20</p><p>03</p><p>20</p><p>04</p><p>20</p><p>05</p><p>20</p><p>06</p><p>20</p><p>07</p><p>20</p><p>08</p><p>20</p><p>09</p><p>20</p><p>10</p><p>20</p><p>11</p><p>20</p><p>12</p><p>20</p><p>13</p><p>20</p><p>14</p><p>20</p><p>15</p><p>20</p><p>16</p><p>20</p><p>17</p><p>Figure 2.1 Mentions of Psychological Safety in Popular</p><p>Media.4</p><p>employee observations, questions, ideas, and concerns can provide</p><p>vital information about what’s going on – in the market and in the</p><p>organization. Add to that today’s growing emphasis on diversity,</p><p>inclusion, and belonging at work, and it becomes clear that psy-</p><p>chological safety is a vital leadership responsibility. It can make or</p><p>break an employee’s ability to contribute, to grow and learn, and to</p><p>collaborate.</p><p>One measure of practitioner interest in psychological safety can</p><p>be found in the term’s use frequency in the popular media. To gauge</p><p>the popularity of the concept, I used Factiva to see how many times</p><p>the term had been mentioned in newspapers, articles, blogs, and other</p><p>news media. The graph in Figure 2.1 depicts the results, indicating</p><p>mentions of “psychological safety” and its variants (i.e. psychologi-</p><p>cally safe) each year since 1990.</p><p>The uptick in mentions in recent years reflects, I believe, growing</p><p>recognition that psychological safety matters in any environment in</p><p>which people are attempting to do something novel or challenging.</p><p>From leading a project team in the office5 to caring for patients in</p><p>the hospital ward,6 from coaching a cricket squad on the pitch7 to</p><p>teaching and counseling young students at school,8 from encouraging</p><p>28 The Power of Psychological Safety</p><p>0</p><p>100</p><p>200</p><p>300</p><p>400</p><p>500</p><p>600</p><p>700</p><p>20</p><p>01</p><p>20</p><p>02</p><p>20</p><p>03</p><p>20</p><p>04</p><p>20</p><p>05</p><p>20</p><p>06</p><p>20</p><p>07</p><p>20</p><p>08</p><p>20</p><p>09</p><p>20</p><p>10</p><p>20</p><p>11</p><p>20</p><p>12</p><p>20</p><p>13</p><p>20</p><p>14</p><p>20</p><p>15</p><p>20</p><p>16</p><p>20</p><p>17</p><p>C</p><p>ita</p><p>tio</p><p>ns</p><p>Figure 2.2 Citations of 1999 Article Introducing Team</p><p>Psychological Safety.12</p><p>others to speak out about wrong-doing9 to even reaching Mars(!),10</p><p>psychological safety is essential for communicating, collaborating,</p><p>experimenting, and ensuring the well-being of others in a wide</p><p>variety of team and organizational settings.</p><p>Another measure of interest on the part of researchers can be</p><p>found in academic citations to the article that introduced the concept</p><p>and measure of team psychological safety.11 As shown in Figure 2.2,</p><p>the article has been frequently cited, with each year since its publi-</p><p>cation in 1999 showing more citations than the year before. This is</p><p>a quick and simple index of the degree to which academic research</p><p>has found that the psychological safety variable explains outcomes of</p><p>interest.</p><p>This chapter reviews the evidence for psychological safety’s</p><p>benefits from two decades of research, laying the foundation for the</p><p>real-world stories of low and high psychological safety workplaces</p><p>that lie ahead in Part II. Over the past 20 years, scholars, consultants,</p><p>and company insiders have published dozens of rigorous studies</p><p>showing effects of psychological safety in a variety of industry</p><p>settings. By sharing some of the highlights, I hope to give the reader</p><p>confidence in the importance of psychological safety in the modern</p><p>The Paper Trail 29</p><p>workplace. My hope is that knowing that the ideas and stories in this</p><p>book are backed up by data will motivate many readers to act on this</p><p>knowledge.</p><p>The Research</p><p>My colleagues and I reviewed the academic literature on psycholog-</p><p>ical safety. We were surprised by the number of studies we found</p><p>and by the range of settings in which psychological safety has been</p><p>examined. Studies conducted in companies, government organiza-</p><p>tions, nonprofits, school systems, hospitals, and classrooms highlight</p><p>the growing cross-sector interest in psychological safety.</p><p>Reading more than 100 articles, we found plenty of evidence that</p><p>psychological safety matters. It affects measurable outcomes ranging</p><p>from employee error reporting13 to company return on investment.14</p><p>Unfortunately, the research also makes clear that many workplaces</p><p>lack psychological safety, cutting themselves off from the kinds of</p><p>employee input, engagement, and learning that are so vital to success</p><p>in a complex and turbulent world.</p><p>I organized the studies into five categories. Group 1 reveals the</p><p>extent to which psychological safety is lacking in many workplaces.</p><p>Group 2, which is the largest, investigates relationships between</p><p>psychological safety and learning. In these studies, we find the</p><p>evidence that psychological safety leads to, among others, creativity,</p><p>error reporting, and knowledge sharing, as well as behaviors that</p><p>detect the need for change or that help teams and organizations make</p><p>change. Group 3 finds positive relationships between psychological</p><p>safety and performance, and Group 4 finds positive relationships</p><p>between psychological safety and employee engagement.</p><p>Lastly, Group 5 encompasses what researchers call “moderator</p><p>studies,” in which psychological safety alters a relationship between</p><p>another team attribute and an outcome, such as team performance.</p><p>A team attribute might be diverse expertise, which would naturally</p><p>challenge the team to figure out how to work effectively. Similarly,</p><p>30 The Power of Psychological Safety</p><p>a team with members located in multiple geographic regions might</p><p>struggle to coordinate. Studies show that psychological safety makes</p><p>it easier for teams to manage such challenges. When people can speak</p><p>up, ask questions, and get the help they need from each other to sort</p><p>things out, they are more likely to overcome the barriers created by</p><p>working together across diverse disciplines or time zones.</p><p>1. An Epidemic of Silence</p><p>Chances are you’ve had the experience at work when you did not ask</p><p>a question you really wanted to ask. Or you may have wanted to offer</p><p>an idea but stayed quiet instead. Several studies show that these types</p><p>of silence are painfully common. Collecting and analyzing data from</p><p>interviews with employed adults, studies have investigated when and</p><p>why people feel unable to speak up in the workplace. From this work</p><p>we learn, first and foremost, that people often hold back even when they</p><p>believe that what they have to say could be important for the organization, for</p><p>the customer, or for themselves.</p><p>There is a poignancy in these discoveries. No one gains from the</p><p>silence. Teams miss out on insights. Those who fail to speak up often</p><p>report regret or pain. Some wish they had spoken up. Others rec-</p><p>ognize they could be experiencing more fulfillment and meaning in</p><p>their jobs were they more able to contribute. Those deprived of hear-</p><p>ing a colleague’s comments may not know what they are missing, but</p><p>the fact is that problems go unreported, improvement opportunities</p><p>are missed, and occasionally, tragic failures occur that could have been</p><p>avoided.</p><p>In an early study of workplace silence, New York University man-</p><p>agement researchers Frances Milliken, Elizabeth Morrison, and Patri-</p><p>cia Hewlin interviewed 40 full-time employees working in consult-</p><p>ing, financial services, media, pharmaceuticals, and advertising, to</p><p>understand why employees failed to speak up at work and what issues</p><p>they failed to raise most often.15 When pressed to explain why they</p><p>remained silent, people often said they did not want to be seen in a</p><p>The Paper Trail 31</p><p>bad light. Another common reason was not wanting to embarrass or</p><p>upset someone. Still others expressed a sense of futility – along the</p><p>lines of, “it won’t matter anyway; why bother?” A few mentioned</p><p>fear of retaliation. But the two most frequently mentioned reasons</p><p>for remaining silent were one, fear of being viewed or labeled neg-</p><p>atively, and two, fear of damaging work relationships. These fears,</p><p>which are definitionally the opposite of psychological safety, have no</p><p>place in the fearless organization.</p><p>What issues employees wanted to speak up about were both orga-</p><p>nizational and personal. They ranged from concerns that are under-</p><p>standably difficult to raise: for example, about harassment, a super-</p><p>visor’s competence, or having made a mistake. More surprisingly,</p><p>however, they also held back on suggestions for improving a work</p><p>process. In short, as later research would demonstrate more systemat-</p><p>ically, people at work are not only failing to speak up with potentially</p><p>threatening or embarrassing content, they are also withholding ideas</p><p>for improvement. Notably, every individual interviewee reported fail-</p><p>ing to speak up on at least one occasion. Most had found themselves</p><p>in situations where they were very concerned about an issue and yet</p><p>still did not raise it to a supervisor.</p><p>A later and larger study conducted in a manufacturing company</p><p>used survey data to identify very similar reasons for silence.16 Specif-</p><p>ically, employees who did not feel psychologically safe to speak up</p><p>cited reasons that included fear of damaging a relationship, lack of</p><p>confidence, and self-protection. In another study, social psychologist</p><p>Renee Tynan surveyed business school students about their relation-</p><p>ships with a prior boss to gain insight into when and why people</p><p>do (or don’t) communicate their thoughts upward. She found that</p><p>when people felt psychologically safe, they spoke up to their bosses.</p><p>They were able to ask for help and admit errors, despite interpersonal</p><p>risk. When they did not feel psychologically safe, they tended to keep</p><p>quiet or to distort their message so as not to upset their bosses.</p><p>A few years ago, University of Virginia Professor Jim Detert</p><p>and I interviewed more than 230 employees in a large multinational</p><p>high-tech company.17 We asked interviewees, who spanned all levels,</p><p>32 The Power of Psychological Safety</p><p>regions, and functions, to describe instances in which they did and</p><p>did not speak up at work to their managers or anyone else higher</p><p>in the company. Here too, all individuals could readily describe</p><p>a time in which they failed to speak up about something they</p><p>believed mattered. Jim and I combed through the thousands of pages</p><p>of accumulated responses to find out what drove people to speak</p><p>up – and, perhaps more importantly, what drove them to hold back.</p><p>Consider the manufacturing technician in a US plant who told</p><p>us he didn’t share an idea he had for speeding up the production pro-</p><p>cess. When we asked why, he replied, “I have kids in college.” At first</p><p>glance, a nonsensical reply. But his meaning was clear; he felt he could</p><p>not take the risk of speaking up because he could not afford to lose his</p><p>job. When we probed further, hoping to hear a story about someone</p><p>losing a job related to speaking up, the associate admitted that it really</p><p>didn’t work that way. In fact, he replied, “Oh, everyone knows we</p><p>never fire anybody.” He was not speaking sarcastically; he was admit-</p><p>ting that his reticence to rock the boat with what he believed was</p><p>a good idea was irrational, and deep down he understood that. Yet</p><p>the gravitational pull of silence – even when bosses are well-meaning</p><p>and don’t think of themselves as intimidating – can be overwhelming.</p><p>People at work are vulnerable to a kind of implicit logic in which safe</p><p>is simply better than sorry. Many have simply inherited beliefs from</p><p>their earliest years of schooling or training. If they stop to think more</p><p>deeply, they may realize they’ve erred too far on the side of caution.</p><p>But that kind of reflection is rarely prompted.</p><p>Ultimately, we discovered a small set of common, largely</p><p>taken-for-granted beliefs about speaking up at work. We called them</p><p>implicit theories of voice. Shown in Table 2.1, they are essentially beliefs</p><p>about when it is and isn’t appropriate to speak to higher ups in</p><p>an organization. To test these implicit theories, gleaned from one</p><p>company, Jim and I conducted a vignette study with managers from</p><p>many other companies. We designed fictional vignettes to test when</p><p>and if people would employ specific decision rules in determining</p><p>whether or not to speak up. For example, one vignette involved an</p><p>important correction an employee wanted to share with the boss; in</p><p>The Paper Trail 33</p><p>Table 2.1 Taken-for-granted Rules for Voice at Work.</p><p>Taken-for-granted Rule</p><p>Governing when to Speak</p><p>or Remain Silent Examples from Interviews</p><p>Don’t criticize something the</p><p>boss may have helped</p><p>create.</p><p>“It’s inherently risky since bosses may feel</p><p>personal ownership of the tasks I am</p><p>suggesting are problematic.”</p><p>“The boss may have created these</p><p>processes and may be offended because</p><p>he’s attached to them.”</p><p>Don’t speak unless you have</p><p>solid data.</p><p>“I think that presenting an</p><p>under-developed, under-researched idea</p><p>is never a good idea.”</p><p>“You are questioning their ideas and had</p><p>better have proof to back up your</p><p>statements.”</p><p>Don’t speak up if the boss’s</p><p>boss is present.</p><p>“If there is a higher level individual</p><p>present it is risky because you would be</p><p>afraid that your direct boss would feel as</p><p>if you were going over their head.”</p><p>“My boss would see [speaking up to his</p><p>boss] as undermining and</p><p>insubordinate.”</p><p>Don’t speak up in a group</p><p>with anything negative</p><p>about the work to prevent</p><p>boss from losing face.</p><p>“Managers hate to be put on the spot in</p><p>front of others. It is best to brief them</p><p>one-on-one so the boss doesn’t look</p><p>bad in front of the group.”</p><p>“You should pass it by the boss in private</p><p>first, so you don’t ‘cut his legs out from</p><p>under him.’”</p><p>Speaking up brings career</p><p>consequences.</p><p>“To stop or criticize a project would be a</p><p>career ender at our place.”</p><p>“The long-term consequences are bad</p><p>because [higher ups] will resent being</p><p>put on the spot.”</p><p>34 The Power of Psychological Safety</p><p>one of the versions of the vignette, the boss’s boss was present. In the</p><p>other vignette, only the boss was present. The managers we studied</p><p>were significantly more likely to point out the correction if the boss’s</p><p>boss was not present.</p><p>By and large, these beliefs (taken-for-granted rules) about</p><p>speaking up make it harder to achieve productivity, innovation,</p><p>or employee engagement. It’s an old truism that bad news doesn’t</p><p>travel up the hierarchy. But what we found is that people err so far</p><p>on the side of caution at work that they routinely hold back great</p><p>ideas – not just bad news. They intuitively recognize what Jim and</p><p>I call the asymmetry of voice and silence. Consider the automatic</p><p>calculus that governs speaking up. As depicted in Table 2.2, voice is</p><p>effortful and might (but might not) make a real difference in a crucial</p><p>moment. Unfortunately, much of the time the potential benefit will</p><p>take a while to materialize and might not even happen at all. Silence</p><p>is instinctive and safe; it offers self-protection benefits, and these are</p><p>both immediate and certain.</p><p>Table 2.2 Why Silence Wins in the Voice-Silence</p><p>Calculation.</p><p>Who Benefits</p><p>When Benefit</p><p>Occurs</p><p>Certainty</p><p>of Benefit</p><p>Voice The organization and/</p><p>or its customers</p><p>After some delay Low</p><p>Silence Oneself Immediately High</p><p>Another way to think about the voice-silence asymmetry is cap-</p><p>tured in the phrase “no one was ever fired for silence.” The instinct</p><p>to play it safe is powerful. People in organizations don’t spontaneously</p><p>take interpersonal risks. We don’t want to stumble into a sacred cow.</p><p>We can be completely confident that we’ll be safe if we are silent, and</p><p>we lack confidence that our voices will really make a difference – a</p><p>voice inhibiting combination.</p><p>Another of the implicit theories of voice that Jim and I found that</p><p>explains why people hold back on good ideas, not just bad news, is</p><p>The Paper Trail 35</p><p>related to a fear of insulting someone higher up in the organization by</p><p>implying that the current systems or processes are problematic. What</p><p>if the current system is effectively the boss’s baby? By suggesting a</p><p>change, we might be calling the boss’s baby ugly. Better to stay silent.</p><p>In failing to challenge these widely held taken-for-granted speak-</p><p>ing rules, employees around the world at this particular company</p><p>(which, ironically, was dependent on employee expertise and ideas for</p><p>its future success) were depriving their colleagues of their ideas and</p><p>ingenuity. They were depriving themselves as well – missing out on</p><p>the satisfaction of the chance to act on their ideas and create change.</p><p>Instead of helping to create a learning organization, they were just</p><p>showing up and doing their jobs.</p><p>2. A Work Environment that Supports Learning</p><p>Given this well-documented tendency for people in the workplace</p><p>to choose silence over voice, sometimes it seems surprising that any-</p><p>one ever speaks up at all with potentially sensitive or interpersonally</p><p>threatening content. This is where psychological safety comes in.</p><p>A growing number of studies find that psychological safety can exist</p><p>at work and, when it does, that people do in fact speak up, offer ideas,</p><p>report errors, and exhibit a great deal more that we can categorize as</p><p>“learning behavior.”</p><p>Learning from Mistakes</p><p>For example, in a study of nurses in four Belgian hospitals, a team of</p><p>researchers led by Hannes Leroy explored how head nurses encour-</p><p>aged other nurses to report errors, while also enforcing high standards</p><p>for safety.18 The challenge here is one of asking people to perform the</p><p>highest quality (arguably, error-free) work yet still be willing to talk</p><p>about the errors that do occur. Leroy and his colleagues surveyed</p><p>the nurses in 54 departments, measuring a set of interrelated factors.</p><p>36 The Power of Psychological Safety</p><p>These were psychological safety, error reporting, the actual number</p><p>of errors made, and nurses’ beliefs about how much the department</p><p>prioritized patient safety and about whether the head nurse practiced</p><p>the safety protocols.</p><p>Leroy found that groups with higher psychological safety reported</p><p>more errors to head nurses. That finding was consistent with what I</p><p>had seen back in graduate school in my study of medication errors.19</p><p>More interestingly, they found that when nurses thought patient safety</p><p>was a high priority in the department and when psychological safety</p><p>was high, fewer errors were made. In contrast, when psychological</p><p>safety was low, despite believing in the department’s professed com-</p><p>mitment to patient safety, staff made more errors. In short, psycho-</p><p>logically safe teams made fewer errors and spoke up about them more</p><p>often. What I have found in similar settings is that good leadership (for</p><p>instance, on the part of head nurses who demonstrate a commitment</p><p>to safety and to openness), together with a clear, shared understand-</p><p>ing that the work is complex and interdependent, can help groups</p><p>build psychological safety, which in turn enables the candor that is so</p><p>essential to ensuring the quality of patient care in modern hospitals.</p><p>Quality Improvement: Learn-What and Learn-How</p><p>Nearly every organization wants quality improvement. Hospitals,</p><p>especially, constantly pursue efforts to improve the innumerable</p><p>processes of patient care. Does it make a difference whether a unit</p><p>supervisor creates the conditions for psychological safety or simply</p><p>commands staff to work on improvement projects?</p><p>With Wharton Professor Ingrid Nembhard and Boston Univer-</p><p>sity Professor Anita Tucker, I studied over a hundred quality improve-</p><p>ment (QI) project teams in neonatal intensive care units (NICUs) in</p><p>23 North American hospitals.20 By asking the QI team members to</p><p>report on what they did to improve unit processes, we found that these</p><p>clustered into two distinct sets of learning behavior, which we called</p><p>learn-what and learn-how. Learn-what described largely independent</p><p>The Paper Trail 37</p><p>activities like reading the medical literature to get caught up with</p><p>the latest research findings. Learn-how, in contrast, was team-based</p><p>learning that included sharing knowledge, offering suggestions, and</p><p>brainstorming better approaches.</p><p>We were intrigued to find that psychological safety predicted an</p><p>uptick in learn-how behaviors (those that came with interpersonal</p><p>risk) but had no statistical relationship whatsoever with the more</p><p>independent behaviors captured by learn-what activities. This result</p><p>provided a reassuring demonstration that psychological safety does</p><p>promote learning by helping people overcome interpersonal risk for</p><p>engaging in learn-how behaviors. Not surprisingly, for the kinds of</p><p>learning that you can do alone (read a book, take an online course),</p><p>psychological safety is not essential. The results also offer support for</p><p>why psychological safety was not as important in days of yore when</p><p>work might consist primarily of well-defined tasks such as typing let-</p><p>ters for the boss, or passing the surgeon the correct scalpel.</p><p>Reducing Workarounds</p><p>“Workarounds,” a phenomenon identified by Anita Tucker in her</p><p>remarkable ethnographic study of nurses in the early 2000s, are short-</p><p>cuts that people take at work when they confront a problem that</p><p>disrupts their ability to carry out a required task.21 A workaround</p><p>accomplishes the immediate goal, but does nothing to diagnose or</p><p>solve the problem that triggered the workaround in the first place.</p><p>The problem with workarounds is that well they, work. They</p><p>seem to get the job done, but, in so doing, they create new, subtle,</p><p>problems. First, workarounds sometimes create unintended risks or</p><p>problems in other areas. For example, confronted with a shortage of</p><p>a needed material input (say, linens in a hospital unit), a worker might</p><p>simply find a supply of linens in another unit, thereby getting what</p><p>she needs but depleting her colleagues who will encounter a shortage</p><p>later. Second, workarounds delay or prevent process improvement.</p><p>The problems that trigger workarounds can be seen as small signals of</p><p>38 The Power of Psychological Safety</p><p>a need for change in a system or process. The workaround bypasses</p><p>the problem, thereby silencing the signal by getting the immediate job</p><p>done – but getting it done in a way that is inefficient over the longer</p><p>term. More difficult, because it would require working across silos,</p><p>would be for nurses to devise a new linen supply system for all units.</p><p>Workarounds can occur when workers do not feel safe enough</p><p>to speak up and make suggestions to improve the system. Indeed,</p><p>in another study of hospitals, Jonathon Halbesleben and Cheryl</p><p>Rathert found that cancer teams with low psychological safety relied</p><p>more on workarounds, while teams with high psychological safety</p><p>focused more on diagnosing the problem and improving the process</p><p>that caused it so it didn’t happen again.22 Halbesleben and Rathert</p><p>gave us additional evidence that psychological safety is important for</p><p>organizations interested in achieving process improvement. Their</p><p>work shows that psychological safety makes it easier for people to</p><p>speak up about problems and to alter and improve work processes</p><p>rather than engaging in the counterproductive workarounds.</p><p>Another study of process improvement projects, this time in</p><p>a manufacturing company, also</p><p>found that projects with greater</p><p>psychological safety were more successful. Here the researchers</p><p>studied 52 process-improvement teams following principles of total</p><p>quality management (TQM). They found that even when employing</p><p>a highly-structured process improvement technique, interpersonal</p><p>climate matters for success.23</p><p>Sharing Knowledge When Confidence Is Low</p><p>You might think that speaking up with creative ideas is easier than</p><p>speaking up about errors. Now, imagine you’re at work and you’ve</p><p>got an idea you’re 95% confident is creative or interesting. You’ll</p><p>probably have no trouble speaking up. Now imagine that same sit-</p><p>uation but you’re only 40% confident of your idea. Most people will</p><p>hesitate, perhaps trying to size up the receptivity of their colleagues.</p><p>Stated another way, when you feel extremely confident in the value</p><p>The Paper Trail 39</p><p>or veracity of something you want to say, you are more likely to sim-</p><p>ply open your mouth and say it. But when your confidence in your</p><p>idea or your knowledge is low, you might hold back.</p><p>In a particularly compelling study in several US manufacturing</p><p>and service companies, University of Minnesota Professor Enno</p><p>Siemsen and his colleagues found an intuitively interesting relation-</p><p>ship between confidence and psychological safety.24 As expected,</p><p>the more confident people were in their knowledge, the more</p><p>they spoke up. More interestingly, a psychologically safe workplace</p><p>helped people overcome a lack of confidence. In other words, if</p><p>your workplace is psychologically safe, you’re more able to speak</p><p>up even when you have less confidence. Given that an individual’s</p><p>confidence and the value of his idea are not always tightly linked, the</p><p>usefulness of psychological safety for facilitating knowledge sharing</p><p>can be immense. Communication frequency among coworkers also</p><p>led to psychological safety. In other words, the more we talk to each</p><p>other, the more comfortable we become doing so.</p><p>3. Why Psychological Safety Matters</p><p>for Performance</p><p>To understand why psychological safety promotes performance, we</p><p>have to step back to reconsider the nature of so much of the work in</p><p>today’s organizations. With routine, predictable, modular work on the</p><p>decline, more and more of the tasks that people do require judgment,</p><p>coping with uncertainty, suggesting new ideas, and coordinating and</p><p>communicating with others. This means that voice is mission criti-</p><p>cal. And so, for anything but the most independent or routine work,</p><p>psychological safety is intimately tied to freeing people up to pursue</p><p>excellence.</p><p>When I set out to study 50 teams – including sales, production,</p><p>new product development, and management teams – in a manufac-</p><p>turing company in the mid 1990s, my goal had been to establish</p><p>a relationship between psychological safety and learning behavior.</p><p>While I was at it, I measured performance. I did this in two ways:</p><p>40 The Power of Psychological Safety</p><p>The first was self-report, meaning team members confidentially rated</p><p>their team’s performance on a scale of one to seven. The other was</p><p>somewhat more objective. I asked managers who evaluated the team’s</p><p>work, along with (internal) customers who received the work, to rate</p><p>each team’s performance on a similar scale, also with complete con-</p><p>fidentially. Happily, the data showed that teams with psychological</p><p>safety also had higher performance – a result that held for both types</p><p>of performance measures.25</p><p>Researchers Markus Baer and Michael Frese took this question</p><p>up to the next level of analysis by showing that psychological safety</p><p>increased company performance in a sample of 47 mid-size German</p><p>firms in both industrial and services industries. Performance was mea-</p><p>sured in two ways: longitudinal change in return on assets (holding</p><p>prior return on assets constant) and executive ratings of company</p><p>goal achievement.26 All of the companies were engaged in process</p><p>innovations. But process innovation efforts only led to higher per-</p><p>formance when the organization had psychological safety. In short,</p><p>process innovation can be a good way to boost firm performance, but</p><p>a psychologically safe environment helps the investment pay off.</p><p>Research also shows a relationship between psychological safety</p><p>and innovation. For instance, Chi-Cheng Huang and Pin-Chen</p><p>Jiang collected survey data from 245 members of 60 Research and</p><p>Development (R&D) teams in several Taiwanese technology firms</p><p>and found that psychologically safe teams outperformed others.27</p><p>Without psychological safety, the researchers explained, team</p><p>members were unwilling to offer their ideas or knowledge because</p><p>of the fear of being rejected or embarrassed. They emphasized the</p><p>particular importance of psychological safety for teams in R&D</p><p>because they necessarily have to take risks and confront failure before</p><p>they achieve success.</p><p>Finally, a multi-year study of teams at Google, code-named</p><p>Project Aristotle, found that psychological safety was the critical</p><p>factor explaining why some teams outperformed others, as reported</p><p>in a detailed feature article by Charles Duhigg in the New York Times</p><p>Magazine in 2016, and widely discussed in the blogosphere.28 Google</p><p>The Paper Trail 41</p><p>researchers from the company’s sophisticated “people analytics”</p><p>group reviewed the academic literature on team effectiveness. Their</p><p>first line of attack was to consider team composition – a variable</p><p>considered important in historical research on teams, primarily in</p><p>terms of whether the skills team members hold are a good match for</p><p>the work they’re expected to do.</p><p>Led by Julia Rozovsky, the researchers considered people’s edu-</p><p>cational backgrounds, hobbies, friends, personality traits and more,</p><p>in their analysis a set of 180 teams from all over the company. They</p><p>found nothing. No mix of personality types or skills or backgrounds</p><p>emerged that helped explain which teams performed well and</p><p>which didn’t. It seemed like there was no answer to the question</p><p>of why some teams thrive and others fail. And then, as Duhigg</p><p>wrote, “When Rozovsky and her Google colleagues encountered</p><p>the concept of psychological safety in academic papers, it was as if</p><p>everything suddenly fell into place.”29 What they had discovered was</p><p>that even the extremely smart, high-powered employees at Google</p><p>needed a psychologically safe work environment to contribute the</p><p>talents they had to offer. The team also found four other factors</p><p>that helped explain team performance – clear goals, dependable</p><p>colleagues, personally meaningful work, and a belief that the work</p><p>has impact. As Rozovsky put it, however, reiterating the quote at</p><p>the start of Chapter 1, “psychological safety was by far the most</p><p>important . . . it was the underpinning of the other four.”30</p><p>4. Psychologically Safe Employees Are Engaged</p><p>Employees</p><p>Executive interest in employee engagement has taken hold in recent</p><p>years, building on the longtime focus on employee satisfaction as an</p><p>important measure for predicting turnover. Today, most managers</p><p>understand that employee satisfaction is important but incomplete.</p><p>Satisfaction, which refers to how happy or content employees are,</p><p>doesn’t capture emotional commitment to the work, or motivation</p><p>42 The Power of Psychological Safety</p><p>to pour oneself into doing a good job. Engagement, defined as the</p><p>extent to an employee feels passionate about the job and committed to</p><p>the organization, is seen as an index of willingness to put discretionary</p><p>effort into one’s work. Validated measures of employee engagement</p><p>are widely available, and most executives recognize employee engage-</p><p>ment as a vital element of strong company performance.</p><p>Recent studies of employee engagement include attention</p><p>to psychological safety. For instance, a study in a Midwestern</p><p>insurance company found that psychological safety predicted worker</p><p>engagement. In turn, psychological safety was fostered by supportive</p><p>relationships with coworkers.31 Another study looked at the rela-</p><p>tionship between employee trust in top management and employee</p><p>engagement. With survey data from</p><p>170 research scientists working</p><p>in six Irish research centers, the authors showed that trust in top</p><p>management led to psychological safety, which in turn promoted</p><p>work engagement.32 Finally, a study of Turkish immigrants employed</p><p>in Germany found that psychological safety was associated with work</p><p>engagement, mental health, and turnover intentions. Moreover, they</p><p>found that the positive effects of psychological safety were higher</p><p>for the immigrants than for the German employees in the same</p><p>company.33</p><p>One place where worker engagement really matters is healthcare</p><p>delivery. Frontline staff confront high stress and emotionally laden</p><p>work with life and death consequences. Disengaged employees lead</p><p>to safety risks and to staff turnover. Turnover means higher recruiting</p><p>and training costs, as well as a higher percentage of less experienced</p><p>workers on staff. Experts’ concerns about staff turnover have thus</p><p>given rise to interest in improving the healthcare work environment</p><p>as a strategy for employee retention. In one recent study, a survey of</p><p>clinical staff at a large metropolitan hospital found that psychological</p><p>safety was related to commitment to the organization and to patient</p><p>safety. The authors noted that a work environment in which work-</p><p>ers felt safe to speak up about problems was especially important in</p><p>healthcare for helping people feel able to provide safe care and stay</p><p>engaged in the work.34</p><p>The Paper Trail 43</p><p>5. Psychological Safety as the Extra Ingredient</p><p>The fifth and final group of studies emphasizes psychological safety’s</p><p>role in altering the strength of relationships between other variables.</p><p>In these studies, psychological safety acts (using statistical language)</p><p>as a moderator that makes other relationships weaker or stronger.</p><p>Psychological safety has been found to help teams overcome the chal-</p><p>lenges of geographic dispersion, put conflict to good use, and leverage</p><p>diversity.</p><p>Overcoming Geographic Dispersion</p><p>It’s increasingly common for teams to have members working in dif-</p><p>ferent locations around the world who may not even have met in</p><p>person. These so-called virtual teams face the related challenges of</p><p>communicating through electronic media, managing national cultural</p><p>diversity, coping with time zone differences, and dealing with shift-</p><p>ing membership over time. Psychological safety has been shown to</p><p>help such teams manage these challenges. For instance, in an ambi-</p><p>tious study of 14 innovation teams with members dispersed across</p><p>18 nations, University of Western Australia Professor Cristina Gibson</p><p>and Rutgers University Professor Jennifer Gibbs showed that psycho-</p><p>logical safety helped these dispersed teams navigate the challenges of</p><p>dispersion.35 With psychological safety, team members felt less anx-</p><p>ious about what others might think of them and were better able to</p><p>communicate openly.</p><p>Putting Conflict to Good Use</p><p>Conflict is another challenge most teams confront – whether they</p><p>work face to face or spread around the globe. In theory, conflict</p><p>promotes better decision-making and fosters innovation because it</p><p>ensures consideration of diverse views and perspectives. In practice,</p><p>44 The Power of Psychological Safety</p><p>however, people are not always good at navigating conflict and putting</p><p>it to good use.36 It’s easy to get upset or dig in one’s heels, effec-</p><p>tively squandering the opportunity to improve the work by working</p><p>through differences. Some recent research has found that psycho-</p><p>logical safety can make the difference between conflict being put to</p><p>good use and conflict getting in the way of team performance. For</p><p>instance, in a study of 117 student project teams, Bret Bradley and his</p><p>colleagues showed that psychological safety moderated the relation-</p><p>ship between conflict and performance such that conflict led to good</p><p>team performance when teams had high psychological safety and low</p><p>performance otherwise.37 They attributed this result to the ability to</p><p>express relevant ideas and critical discussion without embarrassment</p><p>or excessive personal conflict between team members.</p><p>As you can see, studies that look at psychological safety have been</p><p>done in many settings, including factories, hospitals, and classrooms.</p><p>Yet it is also the case that executives wrestling with strategic deci-</p><p>sions can benefit from attention to creating a climate of curiosity and</p><p>candor – in other words, psychological safety. When I studied top</p><p>management teams with action scientist Diana Smith, we analyzed</p><p>detailed transcripts of their conversations to show how a psycholog-</p><p>ically safe climate for candid discussion of strategic disagreement can</p><p>be created, even in high-level teams confronting strategic challenges,</p><p>and how this can enable productive decision-making.38</p><p>Gaining Value from Diversity</p><p>Teams are often put together to leverage diverse expertise. But too</p><p>often, the challenge of integrating diverse knowledge, perspectives,</p><p>and skills is underestimated, and the hoped-for synergy never mate-</p><p>rializes. One recent study showed that psychological safety can make</p><p>or break achievement of team performance in diverse teams. The</p><p>researchers surveyed master’s students participating in 195 teams in a</p><p>French university and found that expertise-diverse teams performed</p><p>well when psychological safety was high and badly otherwise.39</p><p>The Paper Trail 45</p><p>Finally, a number of studies have investigated effects of demo-</p><p>graphic diversity on team performance. Some have shown that diver-</p><p>sity helps performance, while others have found a negative relation-</p><p>ship between diversity and performance. When different studies show</p><p>conflicting results like this, it’s usually a sign of a missing moderator.</p><p>In this case, psychological safety could be that missing ingredient –</p><p>the factor that could make or break a diverse team’s ability to put</p><p>its different perspectives to good use. Indeed, in one study in a</p><p>Midwestern mid-size manufacturing company, a positive climate for</p><p>diversity and psychological safety together led to more discretionary</p><p>effort. These relationships were stronger for minorities than for</p><p>whites, suggesting that psychological safety may be playing an</p><p>especially crucial role for minorities in creating engagement and a</p><p>feeling of being valued at work.40</p><p>Bringing Research to Practice</p><p>The research summarized here, which is steadily growing with con-</p><p>sistent observations across diverse industry settings, provides further</p><p>confidence that psychological safety truly offers benefits for orga-</p><p>nizations and countries around the world. No longer confined to</p><p>academic interest, psychological safety has garnered attention from</p><p>practitioners in almost every industry – especially in the aftermath</p><p>of Google’s Project Aristotle, with its feature pieces in the New York</p><p>Times and on Fareed Zakaria GPS on CNN.41 More and more pro-</p><p>fessionals – consultants, managers, physicians, nurses, engineers – can</p><p>be found talking about psychological safety. Yet few may be aware</p><p>of the full weight of supporting evidence that it matters. And fewer</p><p>still may have stopped to reflect on what their companies lose when</p><p>psychological safety is missing.</p><p>One of the most important things to keep in mind, wherever</p><p>you work, is that the failure of an employee to speak up in a crucial</p><p>moment cannot be seen. This is true whether that employee is on the</p><p>front lines of customer service or sitting next to you in the executive</p><p>46 The Power of Psychological Safety</p><p>board room. And because not offering an idea is an invisible act, it’s</p><p>hard to engage in real-time course correction. This means that psy-</p><p>chologically safe workplaces have a powerful advantage in competitive</p><p>industries.</p><p>The four chapters ahead in Part II vividly portray the conse-</p><p>quences of workplace fear (Chapters 3 and 4) and the benefits of</p><p>psychological safety (Chapters 5 and 6) for both organizational perfor-</p><p>mance and human safety. We’ll visit more than 20 organizations – old</p><p>and new, large and small, private and public sector, domestic and over-</p><p>seas. Examining events that transpired</p><p>in companies as diverse as Volk-</p><p>swagen and Wells Fargo, I hope to convey a visceral understanding of</p><p>what is lost in fear-based workplaces, which are, alas, all too often still</p><p>the default in organizations around the world, even after two decades</p><p>of research providing evidence of its costs. Taking a look inside a range</p><p>of fearless organizations, such as Pixar Animation Studios and DaVita</p><p>Kidney Centers, I also hope to convey all that is gained.</p><p>Chapter 2 Takeaways</p><p>◾ Psychological safety is not a perk; it’s essential to producing</p><p>high performance in a VUCA world.</p><p>◾ Psychological safety is too often missing in today’s organizations</p><p>◾ Twenty years of research on psychological safety finds positive</p><p>benefits for learning, engagement, and performance in a wide</p><p>range of organizations.</p><p>Endnotes</p><p>1. Mark Costa, CEO of Eastman Chemical, HBS class comments, April</p><p>18, 2018.</p><p>2. Ibid.</p><p>3. Ibid.</p><p>4. The data in this chart comes from a Factiva search, conducted May 25,</p><p>2018. Factiva, Inc. is a business information and research tool owned</p><p>The Paper Trail 47</p><p>Dow Jones & Company. Factiva provides access to more than 30,000</p><p>sources, such as newspapers, journals, magazines, and more from nearly</p><p>every country in the world. Thus, the search was quite comprehensive.</p><p>5. Corcoran, S. “A good boss makes for a happy team.” The Sunday Times.</p><p>September 24, 2017. https://www.thetimes.co.uk/article/a-good-</p><p>boss-makes-for-a-happy-team-r30ndjjfv Accessed June 13, 2018.</p><p>6. Blumental, D. & Ganguli, I. “Patient Safety: Conversation to Curricu-</p><p>lum.” The New York Times. January 26, 2010. https://www.nytimes</p><p>.com/2010/01/26/health/26error.html Accessed June 13, 2018.</p><p>7. “Six and Out? What Australia’s cricket scandal tells us about the six</p><p>golden rules of integrity.” The Mandarin, March 28, 2018. https://</p><p>www.themandarin.com.au/90552-australian-cricket-scandal-six-</p><p>golden-rules-integrity/ Accessed June 13, 2018.</p><p>8. Vander Ark, T. “Promoting Psychological Safety in Classrooms for</p><p>Student Success.” GettingSmart.com, December 29, 2016. http://</p><p>www.gettingsmart.com/2016/12/promoting-psychological-safety-in-</p><p>classrooms/ Accessed June 13, 2018.</p><p>9. Wallace, K. “After #MeToo, more women feeling empowered.”</p><p>CNN Wire, December 27, 2017. https://www.cnn.com/2017/12/</p><p>27/health/sexual-harassment-women-empowerment/index.html</p><p>Accessed June 13, 2018.</p><p>10. Landon, L.B., Slack, K.J., & Barrett, J.D. “Teamwork and Collabora-</p><p>tion in Long-Duration Space Missions: Going to Extremes.” American</p><p>Psychologist 73.4 (2018): 563–575.</p><p>11. Edmondson, A.C. “Psychological Safety and Learning Behavior in</p><p>Work Teams.” Administrative Science Quarterly 44.2 (1999): 350–83.</p><p>12. This citation data was obtained from Google Scholar, accessed May 25,</p><p>2018.</p><p>13. Frese, M. & Keith, N. “Action Errors, Error Management, and</p><p>Learning in Organizations.” Annual Review of Psychology 66.1 (2015):</p><p>661–87.</p><p>14. Baer, M. & Frese, M. “Innovation Is Not Enough: Climates for Initiative</p><p>and Psychological Safety, Process Innovations, and Firm Performance.”</p><p>Journal of Organizational Behavior 24.1 (2003): 45–68.</p><p>15. Milliken, F.J., Morrison, E.W., & Hewlin, P.F. “An Exploratory Study of</p><p>Employee Silence: Issues That Employees Don’t Communicate Upward</p><p>and Why.” Journal of Management Studies 40.6 (2003): 1453–76.</p><p>16. Brinsfield, C.T. “Employee Silence Motives: Investigation of Dimen-</p><p>sionality and Development of Measures.” Journal of Organizational Behav-</p><p>ior 34.5 (2013): 671–97.</p><p>https://www.thetimes.co.uk/article/a-good-boss-makes-for-a-happy-team-r30ndjjfv</p><p>https://www.thetimes.co.uk/article/a-good-boss-makes-for-a-happy-team-r30ndjjfv</p><p>https://www.nytimes.com/2010/01/26/health/26error.html</p><p>https://www.nytimes.com/2010/01/26/health/26error.html</p><p>https://www.themandarin.com.au/90552-australian-cricket-scandal-six-golden-rules-integrity</p><p>https://www.themandarin.com.au/90552-australian-cricket-scandal-six-golden-rules-integrity</p><p>https://www.themandarin.com.au/90552-australian-cricket-scandal-six-golden-rules-integrity</p><p>http://gettingsmart.com</p><p>http://www.gettingsmart.com/2016/12/promoting-psychological-safety-in-classrooms</p><p>http://www.gettingsmart.com/2016/12/promoting-psychological-safety-in-classrooms</p><p>http://www.gettingsmart.com/2016/12/promoting-psychological-safety-in-classrooms</p><p>https://www.cnn.com/2017/12/27/health/sexual-harassment-women-empowerment/index.html</p><p>https://www.cnn.com/2017/12/27/health/sexual-harassment-women-empowerment/index.html</p><p>48 The Power of Psychological Safety</p><p>17. Detert, J.R. & Edmondson, A.C. “Implicit Voice Theories: Taken-for-</p><p>Granted Rules for Self-Censorship at Work.” The Academy of Manage-</p><p>ment Journal 54.3 (2011): 461–88.</p><p>18. Leroy, H., Dierynck, B., Anseel, F., Simons, T., Halbesleben, J.R.B.,</p><p>McCaughey, D., Savage, G.T., & Sels, L. “Behavioral Integrity for</p><p>Safety, Priority of Safety, Psychological Safety, and Patient Safety: A</p><p>Team-Level Study.” Journal of Applied Psychology 97.6 (2012): 1273–81.</p><p>19. Edmondson, A.C. “Learning from Mistakes Is Easier Said Than Done:</p><p>Group and Organizational Influences on the Detection and Correction</p><p>of Human Error.” The Journal of Applied Behavioral Science 32.1 (1996):</p><p>5–28.</p><p>20. Tucker, A.L., Nembhard, I.M., & Edmondson, A.C. “Implementing</p><p>New Practices: An Empirical Study of Organizational Learning in Hos-</p><p>pital Intensive Care Units.” Management Science 53.6 (2007): 894–907.</p><p>21. Tucker, A.L. & Edmondson, A.C. “Why hospitals don’t learn from</p><p>failures: Organizational and psychological dynamics that inhibit system</p><p>change.” California Management Review 45.2 (2003): 55–72.</p><p>22. Halbesleben, J.R.B. & Rathert, C. “The Role of Continuous Quality</p><p>Improvement and Psychological Safety in Predicting Work-Arounds.”</p><p>Health Care Management Review 33.2 (2008): 134–144.</p><p>23. Arumugam, V., Antony, J., & Kumar, M. “Linking Learning and</p><p>Knowledge Creation to Project Success in Six Sigma Projects: An</p><p>Empirical Investigation.” International Journal of Production Economics</p><p>141.1 (2013): 388–402.</p><p>24. Siemsen, E., Roth, A.V., Balasubramanian, S., & Anand, G. “The</p><p>Influence of Psychological Safety and Confidence in Knowledge on</p><p>Employee Knowledge Sharing.” Manufacturing & Service Operations</p><p>Management 11.3 (2009): 429–47.</p><p>25. Edmondson, A.C. (1999), op cit.</p><p>26. Baer, M. & Frese, M. (2003), op cit.</p><p>27. Huang, C., & Jiang, P. “Exploring the Psychological Safety of R&D</p><p>Teams: An Empirical Analysis in Taiwan.” Journal of Management &</p><p>Organization 18.2 (2012): 175–92.</p><p>28. Duhigg, C. “What Google Learned From Its Quest to Build the</p><p>Perfect Team.” The New York Times Magazine, February 25, 2016.</p><p>https://www.nytimes.com/2016/02/28/magazine/what-google-</p><p>learned-from-its-quest-to-build-the-perfect-team.html Accessed June</p><p>13, 2018.</p><p>29. Ibid.</p><p>https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html</p><p>https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html</p><p>The Paper Trail 49</p><p>30. Rozovsky, J. “The five keys to a successful Google team.” re:Work Blog.</p><p>November 17, 2015. https://rework.withgoogle.com/blog/five-keys-</p><p>to-a-successful-google-team/ Accessed June 13, 2018.</p><p>31. May, D.R., Gilson, G.L., & Harter, L.M. “The Psychological Condi-</p><p>tions of Meaningfulness, Safety and Availability and the Engagement of</p><p>the Human Spirit at Work.” Journal of Occupational and Organizational</p><p>Psychology 77.1 (2004): 11–37.</p><p>32. Chughtai, A. A. & Buckley, F. “Exploring the impact of trust on research</p><p>scientists’ work engagement.” Personnel Review 42.4 (2013): 396–421.</p><p>33. Ulusoy, N., Mölders, C., Fischer, S., Bayur, H., Deveci, S., Demiral,</p><p>Y., & Rössler, W. “A Matter of Psychological Safety: Commitment and</p><p>Mental Health in Turkish Immigrant Employees in Germany.” Journal</p><p>of Cross-Cultural Psychology 47.4 (2016): 626–645.</p><p>34. Rathert, C., Ishqaidef, G., May, D.R. “Improving Work Environments</p><p>in Health Care: Test of a Theoretical Framework.” Health Care Manage-</p><p>ment Review 34.4 (2009): 334–343.</p><p>35. Gibson, C.B. & Gibbs, J.L. “Unpacking the Concept of Virtuality:</p><p>The</p><p>Effects of Geographic Dispersion, Electronic Dependence, Dynamic</p><p>Structure, and National Diversity on Team Innovation.” Administrative</p><p>Science Quarterly 51.3 (2006): 451–95.</p><p>36. Edmondson, A.C. & Smith, D.M. “Too Hot to Handle? How to Man-</p><p>age Relationship Conflict.” California Management Review 49.1 (2006):</p><p>6–31.</p><p>37. Bradley, B.H., Postlethwaite, B.E., Hamdani, M.R., & Brown, K.G.</p><p>“Reaping the Benefits of Task Conflict in Teams: The Critical Role of</p><p>Team Psychological Safety Climate.” Journal of Applied Psychology 97.1</p><p>(2012): 151–58.</p><p>38. Edmondson, A.C. & Smith, D.M. (2006), op cit.</p><p>39. Martins, L.L., Schilpzand, M.C., Kirkman, B.L., Ivanaj, S., & Ivanaj, V.</p><p>“A Contingency View of the Effects of Cognitive Diversity on Team</p><p>Performance: The Moderating Roles of Team Psychological Safety and</p><p>Relationship Conflict.” Small Group Research 44.2 (2013): 96–126.</p><p>40. Singh, B., Winkel, D.E., & Selvarajan, T.T. “Managing Diversity at</p><p>Work: Does Psychological Safety Hold the Key to Racial Differences</p><p>in Employee Performance?” Journal of Occupational and Organizational</p><p>Psychology 86.2 (2013): 242–63.</p><p>41. “How to Build the Perfect Team.” Fareed Zakaria GPS. CNN, April</p><p>17, 2016. https://archive.org/details/CNNW_20160417_170000_</p><p>Fareed_Zakaria_GPS Accessed June 1, 2018.</p><p>https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team</p><p>https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team</p><p>https://archive.org/details/CNNW_20160417_170000_Fareed_Zakaria_GPS</p><p>https://archive.org/details/CNNW_20160417_170000_Fareed_Zakaria_GPS</p><p>PART</p><p>II Psychological Safety</p><p>at Work</p><p>3</p><p>Avoidable Failure</p><p>“I feel misused by my own company.”</p><p>—Oliver Schmidt, Volkswagen engineer1</p><p>“Until I know what my boss thinks, I don’t want to tell you.”</p><p>—Regulator, Federal Reserve Bank of New York (FRBNY)2</p><p>In May 2015, the Volkswagen Group had every reason to feel proud.3</p><p>It had sold over 10 million vehicles the previous year, thereby lay-</p><p>ing claim to the title of world’s largest automaker. One of the largest</p><p>employers in Germany, the company was credited with helping the</p><p>country recover from the global financial crisis of 2008. Ironically, as</p><p>it would turn out, its Jetta TDI Clean Diesel won the Green Car of</p><p>the Year at the 2008 Los Angeles Auto Show. A firm with a 78-year</p><p>history in Germany, made famous by the iconic Beetle of the 1960s,</p><p>and with a pristine reputation for engineering prowess, Volkswagen’s</p><p>star shone bright enough to be blinding.</p><p>As the saying goes, pride cometh before the fall. Merely months</p><p>later, Volkswagen (VW), the world’s largest automotive company,</p><p>53</p><p>54 Psychological Safety at Work</p><p>was facing unimaginable scandal. The clean diesel engines that had</p><p>anchored its impressive US sales were discovered to have been –</p><p>essentially – a hoax. German officials raided the company headquar-</p><p>ters in Wolfsburg, searching for incriminating evidence. Criminal</p><p>investigations were opened by the United States and the European</p><p>Union to figure out who knew what, when, and how. The company</p><p>halted sales, reported its first quarterly loss in 15 years, and witnessed</p><p>a third of its market value vanish. CEO Martin Winterkorn resigned</p><p>in September of 2015, taking “full responsibility” while denying</p><p>“wrongdoing,” and at least nine senior managers were suspended or</p><p>put on leave.4</p><p>In the following years, prosecutors in the United States and Ger-</p><p>many would identify more than 40 people, “spread out across at least</p><p>four cities and working for three VW brands” involved an elaborate</p><p>scheme to defraud government regulators.5 “Dieselgate,” as the scan-</p><p>dal was dubbed, referred to VW’s deceptiveness in complying with</p><p>the regulations required by the US Environmental Protection Agency</p><p>(EPA) to sell automobiles in the United States.</p><p>Exacting Standards</p><p>How could this have happened? When Winterkorn had taken the</p><p>helm in 2007, he’d set a goal that was both precise and ambitious:</p><p>to triple the company’s US sales within 10 years, thereby surpassing</p><p>rivals Toyota and General Motors to become the world’s largest auto-</p><p>mobile maker. The company’s so-called clean diesel vehicles, touted</p><p>for their high performance and excellent fuel economy, were essential</p><p>to this strategy. There was only one problem: diesels produced more</p><p>nitrous oxide (NOx) than gasoline engines and would not pass the</p><p>United States environmental regulations. As VW manager-engineer</p><p>Wolfgang Hatz admitted in 2007 about the challenge to create clean</p><p>diesel for the US market, “The CARB [California Air Resources</p><p>Board] is not realistic. We can do quite a bit, and we will do quite a</p><p>bit. But impossible we cannot do.”6</p><p>Avoidable Failure 55</p><p>Hatz and his engineering colleagues then went to work. Some-</p><p>where in the millions of lines of software code they wrote for what</p><p>became the “clean diesel” vehicles, they embedded instructions that</p><p>would enable the cars to pass the strict US emissions tests. Conceptu-</p><p>ally, the trick was simple enough. The engineers designed and imple-</p><p>mented software that could determine when a vehicle was undergoing</p><p>standard emissions testing in a lab, in which case only two wheels</p><p>rotated, as opposed to four wheels when the vehicle was driven on the</p><p>road. When tested in a lab, the diesel engines complied with accept-</p><p>able NOx levels. However, that compliance sacrificed performance</p><p>and fuel economy, which made the cars unacceptable to consumers.</p><p>That’s why the software directed the exhaust control equipment to</p><p>stop working once the vehicle was off the regulators’ test beds. On the</p><p>road, the so-called clean diesel engines spewed into the atmosphere</p><p>as much as 40 times the level of NOx permitted by regulations.7</p><p>For nearly 10 years, all appeared to be going well. The defeat</p><p>devices, as they were later called, enabled VW to reach its ambitious</p><p>sales goals four years ahead of its target date.8 In 2013, an interna-</p><p>tional nonprofit group, partnering with engineers at West Virginia</p><p>University’s Center for Alternative Fuels, Engines, and Emissions,</p><p>along with California environmental regulators, became interested</p><p>in how diesel engines performed. They decided to compare in-lab</p><p>and on-road emissions and mileage performances on several types</p><p>of diesel vehicles, including those of Volkswagen. Soon enough, the</p><p>defeat device came to light. For the next two years, the US envi-</p><p>ronmental agencies presented their findings, VW denied, covered up,</p><p>and finally confessed. Winterkorn then resigned, saying, “I am not</p><p>aware of any wrongdoing on my part.”9 Across VW’s brands, about</p><p>11 million of the diesel vehicles worldwide would be discovered to</p><p>have the cheating device installed.</p><p>How could this failure have been avoided? It’s natural to want to</p><p>point a finger at someone, or at a small group, to hold responsible for,</p><p>at the very least, the 59 unnecessary deaths and 30 cases of chronic</p><p>bronchitis that researchers estimated are the result of VW’s deceptive</p><p>emissions practices.</p><p>56 Psychological Safety at Work</p><p>Martin Winterkorn is certainly a good candidate to be cast as the</p><p>villain. He had a reputation as an arrogant, perfectionistic martinet</p><p>with an obsessive attention to detail. As one executive at VW told</p><p>reporters, “There was always a distance, a fear and a respect . . . If</p><p>he [Winterkorn] would come and visit or you had to go to him,</p><p>your pulse would go up. If you presented bad news, those were the</p><p>moments that it could become quite unpleasant and loud and quite</p><p>demeaning.” Other managers cited instances when Winterkorn</p><p>blamed engineers for paint that exceeded regulations by less than a</p><p>millimeter, or for not offering a specific shade of red that was selling</p><p>well on competitors’ models.10 A video shot at the Frankfurt motor</p><p>show in 2011 and widely viewed on YouTube shows Winterkorn’s</p><p>irritation at discovering that Hyundai, a so-called lesser automotive</p><p>brand, had managed to engineer a steering wheel that was silent</p><p>when adjusted from the driver’s seat – a feat VW had been unable</p><p>to master.11 “Bischoff!” barks Winterkorn, as if to lay the blame on</p><p>his design chief, Klaus Bischoff, and voices displeasure that a rival</p><p>company managed to get rid of the “clonking sound.”</p><p>Yet, there are reasons to question this temptingly simple explana-</p><p>tion with its singular villain. First, many organizational leaders gen-</p><p>uinely believe that “no news” means that things are going well. They</p><p>assume that if people were struggling to implement some directive or</p><p>another, they would speak up and push back. They take for granted</p><p>that their own voices are welcome and fail to appreciate that others</p><p>might feel unable to bring bad news up the chain of command. For</p><p>sure, this kind of blindness does not constitute effective leadership,</p><p>but it also cannot be called villainous. Second, and more specific to</p><p>this case, Winterkorn’s leadership was not born in a vacuum. He was</p><p>the protégé of the immensely powerful Ferdinand Piech, VW’s for-</p><p>mer chairman, CEO, and top shareholder. A brilliant and visionary</p><p>automotive engineer, Piech had been convinced that terrorizing sub-</p><p>ordinates was the way to achieve profitable design. Chrysler executive</p><p>Bob Lutz recounted a conversation he had with Piesch at an industry</p><p>dinner in the 1990s. When Lutz expressed admiration for the exte-</p><p>rior design of Volkswagen’s new model Golf and wished for similar</p><p>Avoidable Failure 57</p><p>success at Chrysler, Piech offered up an explanation that might serve</p><p>as a textbook example of how to create a psychologically unsafe envi-</p><p>ronment while seeking to motivate:</p><p>I’ll give you the recipe. I called all the body engineers, stamping people,</p><p>manufacturing, and executives into my conference room. And I said, “I am</p><p>tired of all these lousy body fits. You have six weeks to achieve world-class</p><p>body fits. I have all your names. If we do not have good body fits in six</p><p>weeks, I will replace all of you. Thank you for your time today.12</p><p>Writing soon after VW’s fall, Lutz speculated that Piech was</p><p>“more than likely the root cause of the VW diesel-emissions</p><p>scandal” because he instigated “a reign of terror and a culture where</p><p>performance was driven by fear and intimidation.”13 Although</p><p>perhaps an extreme case, the fact is that many managers are sym-</p><p>pathetic to the use of power to insist that people achieve certain</p><p>goals – offering clear metrics and deadlines. The belief that people</p><p>may not push themselves hard enough without a clear understanding</p><p>of the negative consequences of failing to do so is widespread and</p><p>even taken for granted by many in management roles, along with</p><p>just as many casual onlookers contemplating human motivation</p><p>at work. What many people do not realize is that motivation by</p><p>fear is indeed highly effective – effective at creating the illusion that</p><p>goals are being achieved. It is not effective in ensuring that people</p><p>bring the creativity, good process, and passion needed to accomplish</p><p>challenging goals in knowledge-intensive workplaces.</p><p>But even Piech was not, as Lutz remarked, the “root cause” of</p><p>Dieselgate. Just as CEO Martin Winterkorn’s beliefs about how best</p><p>to motivate people were learned from his mentor, Ferdinand Piech,</p><p>Piech’s management beliefs were learned from his mentor – his</p><p>grandfather, Ferdinand Porsche, who had been the brilliant lead</p><p>engineer for the Beetle. Nor was Herr Porsche the root cause.</p><p>Porsche, for his part, was hugely inspired in his efforts by Henry</p><p>Ford and in the mid-1930s traveled to Detroit to study Ford’s River</p><p>Rouge factory complex, eventually using what he’d learned to</p><p>build the first automotive assembly line in Germany.14 This was</p><p>58 Psychological Safety at Work</p><p>still the golden age for the manufacturing industry, when fear and</p><p>intimidation were, arguably, a proven managerial technique to</p><p>motivate speed and accuracy in factory workers. When authoritative</p><p>demands, combined with process improvements, could reduce an</p><p>automobile’s assembly line production time from 12 hours to 3, as</p><p>Ford’s factory did, the company’s profits were real.</p><p>The root cause of VW’s Dieselgate scandal in 2015 cannot be</p><p>located in the personality or leadership of any single person or small</p><p>group. Perhaps one could say the failure was caused by holding</p><p>fast to an outdated belief about what motivates workers. A scene</p><p>in Charlie Chaplin’s classic film Modern Times parodies what such</p><p>old-fashioned motivation-by-fear can look like. Chaplin plays an</p><p>assembly line worker who fails to keep pace tightening the widgets</p><p>as they appear before him on the moving belt, only to be kicked by</p><p>a coworker, chastised and hit by a manager, and ordered to increase</p><p>speed by an executive.15 Today, when simple tasks have increasingly</p><p>become automated and knowledge workers do not tighten widgets</p><p>but rather collaborate, synthesize, make decisions, and continually</p><p>learn, such methods seem especially comedic.</p><p>Interestingly, Bischoff, the designer who was chastised by Win-</p><p>terkorn for the clonking steering shaft, defended this management</p><p>style, telling a reporter, “Of course [Winterkorn] went through the</p><p>roof when something went wrong . . . ” and excused the behavior by</p><p>pointing out that his boss could also be “extremely human with a soft</p><p>spot for people’s personal fates.”16 What’s at stake here isn’t whether</p><p>or not a CEO is extremely human or not. Winterkorn’s kindness</p><p>and “soft spots” were likely within a normal range when measured</p><p>against other human beings. What’s at stake is what he believed was</p><p>the best way to motivate employees – and the relevance of these beliefs</p><p>for today’s work. Given what we now know about the relationship</p><p>between psychological safety and learning, a leader who threatens to</p><p>fire managers and engineers if they do not come up with world-class</p><p>body fits in six weeks seems best cast in a silent film.</p><p>Like the noxious fumes the faulty VW diesel engines emitted, low</p><p>psychological safety affects everyone who breathes it in. As Professor</p><p>Avoidable Failure 59</p><p>Ferdinand Dudenhoffer, an automotive expert of at the University</p><p>of Duisburg-Essen, put it “ . . . there is a special pressure at VW.”17</p><p>The company’s governance dynamics contributed to that special pres-</p><p>sure. According to Dudenhoffer, unlike at other German automobile</p><p>manufacturers, where the supervisory board ultimately controlled the</p><p>CEO, at VW the board held “no such authority.”18 That may be</p><p>because relatives of the founding Porsche family held a quarter of the</p><p>20 board seats; two seats were held by regional politicians, eager to</p><p>do whatever it took to keep jobs in the region, and two were held by</p><p>representatives of Qatar’s sovereign wealth fund.</p><p>Given this insidious culture of fear, it’s unsurprising that when</p><p>faced with a seemingly insurmountable technical obstacle – to pro-</p><p>duce a diesel engine that could pass US environmental testing – and</p><p>pressed for a solution that could meet the company’s target goals,</p><p>engineers and regulatory officials at VW decided to find a way. How-</p><p>ever clever and lucrative the idea may have seemed at the time, and</p><p>however much VW’s sales and reputation soared, history has shown</p><p>us that it was not, in the long run, a viable solution.</p><p>At least one member of the supervisory board was unafraid</p><p>to speak up. Bernd Osterloh, 1 of the 10 elected members who</p><p>represented employees (comparable to union representatives in the</p><p>US), sent a telling letter to the VW staff on September 24, 2015,</p><p>shortly after the US regulators revealed the cheating. As if citing</p><p>central tenets of psychological safety, Osterloh wrote, “we need in</p><p>the future a climate in which problems aren’t hidden but can be</p><p>openly communicated to superiors. We need a culture in which it’s</p><p>possible and permissible to argue with your superior about the best</p><p>way to go.”19</p><p>After the emissions scandal broke, Winterkorn claimed the com-</p><p>pany needed stricter rules to make sure this kind of deceit did not</p><p>happen again. But it’s unclear how stricter rules would have engi-</p><p>neered an environmentally safe diesel engine or enabled the company</p><p>to reach its goal to become the world’s largest car company. In retro-</p><p>spect, the goal itself seems suspect. Could failure</p><p>have been avoided if</p><p>the engineers, working in a psychologically safer environment, could</p><p>60 Psychological Safety at Work</p><p>report back the “bad news” that attaining a clean diesel engine under</p><p>the terms demanded was simply not feasible?</p><p>Perhaps most stunning thing about the VW emissions debacle is</p><p>that it’s by no means a singular event. The same script – unreachable</p><p>target goals, a command-and-control hierarchy that motivates by fear,</p><p>and people afraid to lose their jobs if they fail – has been repeated again</p><p>and again. In part that’s because it’s a script that was useful in the past,</p><p>when goals were reachable, progress directly observable, and tasks</p><p>largely individually executed. Under those conditions, people could</p><p>be compelled to reach them simply by fear and intimidation. The</p><p>problem is that, in today’s volatile, uncertain, complex, and ambigu-</p><p>ous (VUCA) world, this is no longer a script that’s good for business.</p><p>Rather than success, it’s a playbook that invites avoidable, and often</p><p>painfully public, failure.</p><p>In the rest of this chapter, we will see a similar script play out</p><p>in three other organizations: Wells Fargo, Nokia, and the Federal</p><p>Reserve Bank of New York. In each of these cases, a psychologically</p><p>unsafe culture appeared to be working for some period of time, but,</p><p>like a ticking bomb, it eventually exploded from within, decimating</p><p>reputations of once-venerated companies.</p><p>Stretching the Stretch Goal</p><p>A year before its notorious fall, Wells Fargo could still call itself the</p><p>most valuable bank, ranking first in market value among all US banks</p><p>and serving roughly one in three American households.20 Rated by</p><p>Barron’s as one of the “world’s most respected companies,” the lion’s</p><p>share of Wells Fargo’s success stemmed from its Community Banking</p><p>division; in 2015, with over 6000 local branches across the US, the</p><p>division accounted for over half the company’s revenue.21 Commu-</p><p>nity Banking provided a range of financial services, including check-</p><p>ing and savings accounts, loans, and credit cards, to households and</p><p>small businesses.</p><p>Avoidable Failure 61</p><p>Community Banking relied heavily on cross-selling, the practice</p><p>of selling existing customers additional products, for its growth strat-</p><p>egy. Wells Fargo believed it could gain a competitive advantage in the</p><p>banking industry by becoming a one-stop shop for all of its customers’</p><p>financial needs. The bank took pride in its ability to sell its customers</p><p>additional products. In fact, in his 2010 letter to shareholders, CEO</p><p>John Stumpf boasted that the company was “the king of cross-sell.”22</p><p>By 2015, Wells Fargo’s claim to that title seemed strong: it was aver-</p><p>aging 6.11 products per customer, compared to the industry average</p><p>of 2.71.23</p><p>Yet superior cross-selling was to Wells Fargo what clean diesel was</p><p>to the Volkswagen Group: involving an ultimately unattainable target</p><p>goal that was nonetheless demanded of employees by the company’s</p><p>top leaders upon penalty of job loss.</p><p>By September 8, 2016, it was all over. The ticking time bomb</p><p>had exploded from within, shattering the king of cross-sell’s illusory</p><p>one-stop shop. After having been found guilty of widespread miscon-</p><p>duct in sales practices in its Community Banking division, Wells Fargo</p><p>announced a $185 million settlement with the Consumer Financial</p><p>Protection Bureau (CFPB) and two other US regulatory agencies.</p><p>John Stumpf resigned the following month.24</p><p>What happened at Wells Fargo was both predictable and avoid-</p><p>able. And it could not have persisted as long as it did without a</p><p>psychologically unsafe culture. Let’s look more closely at how events</p><p>unfolded.</p><p>In the early 2000s, Wells Fargo had adopted a cross-selling cam-</p><p>paign called “Going for Gr-Eight,” meant to motivate Community</p><p>Banking employees to sell, on average, a previously unheard of</p><p>eight products per customer. To accomplish this, incentive schemes</p><p>were put in place up and down the hierarchy: personal bankers and</p><p>tellers were given a percentage commission for each sale, district</p><p>managers were required to hit specific sales numbers to earn bonuses,</p><p>and cross-selling success was factored into top executives’ annual</p><p>bonuses.25</p><p>62 Psychological Safety at Work</p><p>Metrics tracking was strict and unforgiving. Branch personnel</p><p>were assigned ambitious sales numbers and their progress was tracked</p><p>closely in a daily “Motivator Report.”26 Each branch was required</p><p>to report daily sales four times per day: at 11 a.m., 1 p.m., 3 p.m.,</p><p>and 5 p.m.27 One area president told employees to “do whatever it</p><p>takes” to sell.28 At some branches, employees reportedly could not</p><p>leave until they reached their daily sales goal.29</p><p>Bank personnel who did not meet sales goals were coached to</p><p>increase their numbers, including “objection-handling” training to</p><p>coerce people into buying more products. If they could still not hit</p><p>their numbers, they were terminated from the company. Managers</p><p>who did not do well enough were publicly criticized or fired.30</p><p>Beginning in 2013, reports began to surface that Wells Fargo</p><p>employees had engaged in, and were still currently engaging in,</p><p>questionable practices to hit their sales numbers. A former employee</p><p>reported that members of his Los Angeles branch opened accounts or</p><p>credit cards for customers without their consent, saying a computer</p><p>glitch had occurred if customers complained. He also reported that</p><p>employees lied to customers-saying that certain products could only</p><p>be purchased together-to hit their numbers.31 Other tactics to meet</p><p>sales goals included encouraging customers to open unnecessary</p><p>multiple checking accounts – one for groceries, one for travel, one</p><p>for emergencies, and so on32 – and creating fake email addressees to</p><p>enroll customers in online banking.33</p><p>Before the scandal went public, Wells Fargo made a number of</p><p>changes that seemed to try to address its problems. The company</p><p>fired over 5300 employees for ethics violations between 2011 and</p><p>2016,34 rolled out a “Quality of Sale” Report Card that set limits</p><p>on the terms of a sale,35 expanded ethics training, and explicitly told</p><p>employees not to create fake accounts.36 There was, however, one</p><p>glaring omission: no changes were made to “Going for Gr-Eight.”</p><p>Just as VW engineers were unable to design a clean diesel engine</p><p>in ways that were “permissible,” Wells Fargo employees were unable</p><p>to meet sales goals without engaging in shady practices. There was</p><p>simply a limit to how many products any one customer’s wallet could</p><p>Avoidable Failure 63</p><p>allow. As one former banker put it, “They [the higher ups] warned</p><p>us about this [unethical] type of behavior . . . but the reality was that</p><p>people had to meet their goals. They needed a paycheck.”37</p><p>Eventually, federal and state regulators opened an investigation</p><p>into the bank’s practices. Their report found that from 2011 to 2016,</p><p>employees in the Community Banking division, in order to boost</p><p>sales figures, opened two million unauthorized customer accounts</p><p>and credit cards and sold products and services to customers under</p><p>false pretenses.38 The investigation also found that several employees</p><p>who witnessed the unethical behavior had reported it to their super-</p><p>visors or to the ethics hotline. One even claimed to have emailed</p><p>Stumpf about it. Some employees were later terminated for blowing</p><p>the whistle.39</p><p>Like Volkswagen, Wells Fargo’s avoidable failure was not the</p><p>result of one bad apple but of a system that demanded hitting targets</p><p>so ambitious they could only be met by deceit. Employees operated</p><p>in a culture of fear that brooked no dissent. Rather than manifesting</p><p>interest in salespeople’s experiences while executing the cross-selling</p><p>strategy and using what was being learned in the field to shift or</p><p>sharpen the company’s strategy,40 managers sent a clear message:</p><p>produce – or else.</p><p>Fearing the Truth</p><p>A similar script to that of VW and Wells Fargo was followed years</p><p>earlier – across the ocean and in another industry. Nokia, which</p><p>traces its origins as a company to an 1865 paper mill in the town</p><p>of Nokia, Finland,41</p><p>had become, by the 1980s, a pioneering tele-</p><p>com company in the world’s burgeoning cellular networks. Led by</p><p>CEO Kari Kairamo, by the late 1990s Nokia was the world’s leading</p><p>mobile phone manufacturer, with a 23% market share.42 By the early</p><p>2000s, as a developer of the Symbian operating system, the company</p><p>seemed well poised to ride what would become the smartphone’s</p><p>exponential rise.</p><p>64 Psychological Safety at Work</p><p>Instead, Nokia became another casualty of avoidable failure. By</p><p>June 2011, the company’s share of the smartphone market had fallen</p><p>far, and by 2012, its market value had dropped by over 75%.43 The</p><p>company had lost its innovative edge, its lead as a handset manufac-</p><p>turer, and over two billion euros. In September 2013, the company,</p><p>conceding defeat, announced the sale of its Device and Services busi-</p><p>ness to Microsoft.44</p><p>Although it was not a tangled web of deceit that destroyed Nokia,</p><p>as at Volkswagen and Wells Fargo, all three companies were handi-</p><p>capped by a culture of fear. For instance, an in-depth investigation of</p><p>Nokia’s rise and fall in the smartphone industry between 2005 and</p><p>2010, which included interviews with 76 managers and engineers at</p><p>Nokia, concluded that the company lost the smartphone battle not as</p><p>a result of poor vision or a few bad managers but at least partly due</p><p>to a “fearful emotional climate” that created company-wide inertia,</p><p>especially in response to threats from powerful competitors.45 Such</p><p>fear, said the study’s authors, was “grounded in a culture of tempera-</p><p>mental leaders and frightened middle managers, scared of telling the</p><p>truth.”46</p><p>The truth was that beginning in the first decades of the</p><p>twenty-first century, the mobile phone industry had become increas-</p><p>ingly competitive. Having staked its claim on the featurephone,</p><p>Nokia was unwilling or unable to recognize the potential of the</p><p>complex and expensive-to-develop software platform that became</p><p>today’s smartphone. In contrast Apple and Google, following the</p><p>Canadian company RIM’s introduction of the Blackberry, spent</p><p>billions developing the proprietary platforms IOS and Android, both</p><p>of which overshadowed Nokia’s Symbian platform and effectively</p><p>launched the smartphone revolution. In other words, Nokia found</p><p>itself in a rapidly changing, knowledge-intensive industry, where col-</p><p>laboration, innovation, and communication were quickly becoming</p><p>vital to future success.</p><p>Lacking a psychologically safe climate where candor was</p><p>expected, Nokia’s top managers and middle managers engaged in a</p><p>subtle dance of mutual fear. When middle managers asked critical</p><p>Avoidable Failure 65</p><p>questions about the company’s direction, they were told to “focus</p><p>on implementation.”47 People who could not comply with top</p><p>managers’ unreasonable requests were “labeled a loser” or “put</p><p>their reputations on the line.”48 One executive president was said to</p><p>have “pounded the table so hard that pieces of fruit went flying.”49</p><p>Olli-Pekka Kallasvuo, former chairman and CEO of Nokia, was</p><p>described as “extremely temperamental.”50 Managers reported that</p><p>they regularly saw him “shouting at people at the top of his lungs”</p><p>and “it was very difficult to tell him things he didn’t want to hear.”51</p><p>For their part, executives, fearful of the external market threats the</p><p>company was facing, particularly from software developers at Apple</p><p>and Google, did not communicate the severity of those threats to mid-</p><p>dle managers. One top manager, confessing to the fear that higher ups</p><p>felt and the way that influenced management practice, said, “it was</p><p>clear that we feared the iPhone. So we told the middle managers that</p><p>they had to deliver touch-phones quickly.”52 Middle managers, afraid</p><p>to deliver bad news, led their superiors to develop an overly optimistic</p><p>perception of Nokia’s technological capabilities in featurephones and</p><p>to neglect long-term investments in developing more complex inno-</p><p>vation. As one manager put it, “In Nokia’s R&D, the culture was</p><p>such that they wanted to please the upper levels. They wanted to give</p><p>them good news . . . not a reality check.”53</p><p>A reality check would have required that managers (both the tem-</p><p>peramental and the frightened) put aside their fears and speak candidly</p><p>to one another. Yet such candor seemed impossible, and the win-</p><p>dow for innovation and redirection passed. In 2007, as the industry</p><p>became ever more software-reliant, the Finnish telecom company</p><p>sank still lower. More and more mobile phone companies turned</p><p>to Google’s open source Android operating system. By 2008, when</p><p>Apple launched the iPhone 3G and the App Store, it was too late to</p><p>catch up. Although Nokia continued to develop software and launch</p><p>new products, it would underperform and undersell compared to its</p><p>more agile competitors.</p><p>Clearly, it is not possible to say that psychological safety would</p><p>have ensured Nokia’s success in an increasingly competitive industry.</p><p>66 Psychological Safety at Work</p><p>Success required constant innovation, fueled by expertise, ingenuity,</p><p>and teamwork. But without psychological safety, it is difficult for</p><p>expertise and ingenuity to be put to good use. And with Nokia’s</p><p>senior executives in the dark about where the company and its tech-</p><p>nology really stood, the company simply could not learn fast enough</p><p>to survive. A decade later, Nokia was able to make a comeback. As</p><p>you will learn in Chapter 7, members of senior management would</p><p>later realize that they had to change how they spoke and interacted</p><p>to develop a better strategy.</p><p>Who Regulates the Regulators?</p><p>In the Nokia, Wells Fargo, and VW cases, we saw the pernicious</p><p>effects of a culture of fear inside companies with ambitious dreams.</p><p>What about when one company provides services to, or reviews the</p><p>activities of, another? When relationships between companies are ham-</p><p>pered by a culture of fear, the risks intensify, both for the organizations</p><p>and for society.</p><p>Following the 2008–2009 global financial crisis, the Federal</p><p>Reserve Bank of New York (FRBNY) received ample condemnation</p><p>and criticism from the American public and Congress for its failure</p><p>to effectively regulate the excessive financial risk-taking of several of</p><p>the big US banks.54 In response, the FRBNY commissioned a report</p><p>to study itself. Bill Dudley, President of FRBNY, asked Columbia</p><p>Business School Professor David Beim to investigate and assess the</p><p>FRBNY’s “organization and practices, with a particular focus on</p><p>Bank Supervision.”55 The intention was to reveal lessons learned</p><p>that could be used to improve the Feds’ ability to supervise banks</p><p>and monitor systemic risk going forward.</p><p>Beim and a small team interviewed approximately two dozen</p><p>people who worked at the FRBNY, mostly senior officers, about</p><p>things the Fed did well and didn’t do well leading up to the crisis.</p><p>The result of the examination was the 2009 Report of Systemic Risk</p><p>and Bank Supervision. The report allocated considerable attention to</p><p>the FRBNY’s culture and communication. In it, Beim described a</p><p>Avoidable Failure 67</p><p>workplace suffused with low psychological safety in which regula-</p><p>tory officers tasked with monitoring individual banks like Goldman</p><p>Sachs felt “intimidated and passive,” and thus were not “effective in</p><p>communicating with other areas, forming their own views and sig-</p><p>naling when something important seems to be wrong.” As a result,</p><p>the regulators “just followed orders.”56</p><p>As part of their jobs, regulatory supervisors were involved in dis-</p><p>cussions about individual bank processes and policies, often focusing</p><p>on specific and large-scale transactions a bank had made or was con-</p><p>sidering making. Every large bank was assigned a FRBNY regulatory</p><p>team, tasked with the job of deciding whether a particular transaction</p><p>was kosher. Here, Beim found that real decision-making was stymied</p><p>by groupthink or “striving for consensus” – issues were discussed at</p><p>length without moving to constructive action. The discussions were</p><p>notably devoid of frank debate and cooperation, where people spoke</p><p>up about problems and offered solutions, as warranted</p><p>of this</p><p>new reality – particularly when it comes to what it means for the</p><p>kind of work environment that would help employees thrive and</p><p>organizations succeed. The goal of this book is to help you do just</p><p>that – and to equip you with some new ideas and practices to make</p><p>knowledge-intensive organizations work better.</p><p>For an organization to truly thrive in a world where innovation</p><p>can make the difference between success and failure, it is not</p><p>enough to hire smart, motivated people. Knowledgeable, skilled,</p><p>well-meaning people cannot always contribute what they know at</p><p>that critical moment on the job when it is needed. Sometimes this</p><p>is because they fail to recognize the need for their knowledge. More</p><p>often, it’s because they’re reluctant to stand out, be wrong, or offend</p><p>the boss. For knowledge work to flourish, the workplace must be</p><p>one where people feel able to share their knowledge! This means</p><p>sharing concerns, questions, mistakes, and half-formed ideas. In most</p><p>workplaces today, people are holding back far too often – reluctant</p><p>to say or ask something that might somehow make them look bad.</p><p>To complicate matters, as companies become increasingly global</p><p>and complex, more and more of the work is team-based. Today’s</p><p>employees, at all levels, spend 50% more time collaborating than they</p><p>did 20 years ago.3 Hiring talented individuals is not enough. They</p><p>have to be able to work well together.</p><p>In my research over the past 20 years, I’ve shown that a factor</p><p>I call psychological safety helps explain differences in performance in</p><p>workplaces that include hospitals, factories, schools, and government</p><p>agencies. Moreover, psychological safety matters for groups as dis-</p><p>parate as those in the C-suite of a financial institution and on the front</p><p>lines of the intensive care unit. My field-based research has primar-</p><p>ily focused on groups and teams, because that’s how most work gets</p><p>done. Few products or services today are created by individuals acting</p><p>alone. And few individuals simply do their work and then hand the</p><p>output over to other people who do their work, in a linear, sequen-</p><p>tial fashion. Instead, most work requires people to talk to each other</p><p>to sort out shifting interdependencies. Nearly everything we value</p><p>Introduction xv</p><p>in the modern economy is the result of decisions and actions that are</p><p>interdependent and therefore benefit from effective teamwork. As I’ve</p><p>written in prior books and articles, more and more of that teamwork</p><p>is dynamic – occurring in constantly shifting configurations of people</p><p>rather than in formal, clearly-bounded teams.4 This dynamic collab-</p><p>oration is called teaming.5 Teaming is the art of communicating and</p><p>coordinating with people across boundaries of all kinds – expertise,</p><p>status, and distance, to name the most important. But whether you’re</p><p>teaming with new colleagues all the time or working in a stable team,</p><p>effective teamwork happens best in a psychologically safe workplace.</p><p>Psychological safety is not immunity from consequences, nor is</p><p>it a state of high self-regard. In psychologically safe workplaces, peo-</p><p>ple know they might fail, they might receive performance feedback</p><p>that says they’re not meeting expectations, and they might lose their</p><p>jobs due to changes in the industry environment or even to a lack</p><p>of competence in their role. These attributes of the modern work-</p><p>place are unlikely to disappear anytime soon. But in a psychologically</p><p>safe workplace, people are not hindered by interpersonal fear. They</p><p>feel willing and able to take the inherent interpersonal risks of can-</p><p>dor. They fear holding back their full participation more than they</p><p>fear sharing a potentially sensitive, threatening, or wrong idea. The</p><p>fearless organization is one in which interpersonal fear is minimized</p><p>so that team and organizational performance can be maximized in</p><p>a knowledge intensive world. It is not one devoid of anxiety about</p><p>the future!</p><p>As you will learn in this book, psychological safety can make the</p><p>difference between a satisfied customer and an angry, damage-causing</p><p>tweet that goes viral; between nailing a complex medical diagnosis</p><p>that leads to a patient’s full recovery and sending a critically ill patient</p><p>home too soon; between a near miss and a catastrophic industrial</p><p>accident; or between strong business performance and dramatic,</p><p>headline-grabbing failure. More importantly, you will learn crucial</p><p>practices that help you build the psychologically safe workplaces</p><p>that allow your organization to thrive in a complex, uncertain, and</p><p>increasingly interdependent world.</p><p>xvi Introduction</p><p>Psychological safety is broadly defined as a climate in which</p><p>people are comfortable expressing and being themselves. More</p><p>specifically, when people have psychological safety at work, they</p><p>feel comfortable sharing concerns and mistakes without fear of</p><p>embarrassment or retribution. They are confident that they can</p><p>speak up and won’t be humiliated, ignored, or blamed. They know</p><p>they can ask questions when they are unsure about something. They</p><p>tend to trust and respect their colleagues. When a work environment</p><p>has reasonably high psychological safety, good things happen:</p><p>mistakes are reported quickly so that prompt corrective action can be</p><p>taken; seamless coordination across groups or departments is enabled,</p><p>and potentially game-changing ideas for innovation are shared.</p><p>In short, psychological safety is a crucial source of value creation</p><p>in organizations operating in a complex, changing environment.</p><p>Yet a 2017 Gallup poll found that only 3 in 10 employees strongly</p><p>agree with the statement that their opinions count at work.6 Gallup</p><p>calculated that by “moving that ratio to six in 10 employees, organi-</p><p>zations could realize a 27 percent reduction in turnover, a 40 percent</p><p>reduction in safety incidents and a 12 percent increase in produc-</p><p>tivity.”7 That’s why it’s not enough for organizations to simply hire</p><p>talent. If leaders want to unleash individual and collective talent, they</p><p>must foster a psychologically safe climate where employees feel free</p><p>to contribute ideas, share information, and report mistakes. Imagine</p><p>what could be accomplished if the norm became one where employ-</p><p>ees felt their opinions counted in the workplace. I call that a fearless</p><p>organization.</p><p>Discovery by Mistake</p><p>My interest in psychological safety began in the mid-1990s when</p><p>I had the good fortune to join an interdisciplinary team of researchers</p><p>undertaking a ground-breaking study of medication errors in hospi-</p><p>tals. Providing patient care in hospitals presents a more extreme case</p><p>of the challenges faced in other industries – notably, the challenge</p><p>Introduction xvii</p><p>of ensuring teamwork in highly-technical, highly-customized, 24/7</p><p>operations. I figured that learning from an extreme case would help</p><p>me develop new insights for managing people in other kinds of</p><p>organizations.</p><p>As part of the study, trained nurse investigators painstakingly</p><p>gathered data about these potentially devastating human errors</p><p>over a six-month period, hoping to shed new light on their actual</p><p>incidence in hospitals. Meanwhile, I observed how different hospital</p><p>units worked, trying to understand their structures and cultures and</p><p>seeking to gain insight into the conditions under which errors might</p><p>happen in these busy, customized, occasionally chaotic operations,</p><p>where coordination could be a matter of life-or-death. I also</p><p>distributed a survey to get another view of how well the different</p><p>patient care units worked as teams.</p><p>Along the way, I accidentally stumbled into the importance of</p><p>psychological safety. As I will explain in Chapter 1, this launched me</p><p>on a new research program that ultimately provided empirical evi-</p><p>dence that validates the ideas developed and presented in this book.</p><p>For now, let’s just say I didn’t set out to study psychological safety but</p><p>rather to study teamwork and its relationship to mistakes. I thought</p><p>that how people work together was an important element of what</p><p>allows organizations to learn in a changing world. Psychological safety</p><p>in any orga-</p><p>nization where highly complex processes are constantly unfolding</p><p>at a furious pace. The report emphasized fear of speaking up as a</p><p>frequent theme that characterized FRBNY meetings and employee</p><p>experiences in all aspects of their job. It presented stark quotes from</p><p>interviewees, such as “grow up in this culture and you’ll find that</p><p>small mistakes are not tolerated,” and “[you] don’t want to be too far</p><p>outside where management is thinking.”57</p><p>The relationship between the regulators and the bank managers</p><p>was singled out as especially fraught. For one, an information asym-</p><p>metry existed between the two groups that put the regulators at a</p><p>disadvantage. Because the regulators had to request information from</p><p>the banks, the banks could act as gatekeepers, in turn making the</p><p>regulators feel dependent on the bank’s willingness and good grace</p><p>for timely and useful information. This led, as Beim argued, reg-</p><p>ulators to adopt a nonconfrontational and often overly deferential</p><p>style to smooth their attempts to obtain information.58 Most criti-</p><p>cally, Beim reported that within three weeks of his investigation he</p><p>saw signs of regulatory capture, a phenomenon that journalist Ira Glass</p><p>later described as like “a watchdog who licks the face of an intruder</p><p>and plays catch with the intruder instead of barking at him.”59 The</p><p>68 Psychological Safety at Work</p><p>regulators were, in a sense, disabled from effectively carrying out their</p><p>regulatory duties by a culture of fear and deference.</p><p>What makes this dynamic especially frustrating is that the banks</p><p>were required by law to hand over whatever information the Feds</p><p>asked for. Carmen Segarra, who worked as a regulator after the Beim</p><p>investigation, said, “The Fed has both the power to get the informa-</p><p>tion and the power to punish a bank if it chooses to withhold it.”</p><p>When asked why she thought the regulators chose deference even</p><p>though they possessed this power, her answer was succinct: “they are</p><p>coming from a place of fear.”60</p><p>Could the colossal collapse of a financial system the likes of which</p><p>the world had not seen since the 1930s have been prevented had</p><p>the banks and regulators worked in a climate of psychological safety?</p><p>That may be a stretch. Lax regulations, greed, and faulty incentives</p><p>were certainly important contributing factors. However, we can say</p><p>that the culture of fear silenced or inhibited anyone who wanted to</p><p>ask questions or criticize, thereby squandering many opportunities to</p><p>catch and correct excessive risk-taking and other sources of economic</p><p>failure.</p><p>Avoiding Avoidable Failure</p><p>Volkswagen, Wells Fargo, Nokia, and the New York Federal Reserve</p><p>serve as vivid examples of organizations that boasted deep reservoirs</p><p>of expertise, driven, intelligent leaders, and clearly articulated goals.</p><p>None lacked capable employees in any of the relevant fields required</p><p>for the organization to succeed in its industry. In short, they had the</p><p>talent. What they lacked was the leadership needed to ensure that</p><p>a climate of psychological safety permeated the workplace, allowing</p><p>people to speak truth to power inside the company – and, in the case</p><p>of the Fed, to their industry partners. Chapter 7 will focus on what</p><p>leaders need to do to create and recover psychological safety; here,</p><p>I simply note that the kinds of large-scale business failures described</p><p>in this chapter are preventable.</p><p>Avoidable Failure 69</p><p>None of these failures occurred overnight or out of the blue.</p><p>Quite the opposite. The seeds of failure were taking root for months</p><p>or years while senior management remained blissfully unaware. In</p><p>many organizations, like those discussed in this chapter, countless</p><p>small problems routinely occur, presenting early warning signs that</p><p>the company’s strategy may be falling short and needs to be revisited.</p><p>Yet these signals are often squandered. Preventing avoidable failure</p><p>thus starts with encouraging people throughout a company to push</p><p>back, share data, and actively report on what is really happening in</p><p>the lab or in the market so as to create a continuous loop of learning</p><p>and agile execution.</p><p>Each of the stories in this chapter can be seen as a case of strategic</p><p>failure. What started as small gaps in execution spiraled into dramatic,</p><p>headline-making failures when new information created by actual</p><p>experience – whether of engineers or salespeople – was not captured</p><p>and put to good use in rethinking and redirecting company efforts.61</p><p>For instance, Wells Fargo’s cross-selling strategy bumped up against</p><p>customers’ real spending power, planting a seed of strategic failure.</p><p>But what cemented the failure was the salespeople’s belief that senior</p><p>managers would not tolerate underperformance. That they found it</p><p>easier to fabricate false accounts than to report what they were learn-</p><p>ing in the field is as powerful a signal of low psychological safety as</p><p>you can find.</p><p>In focusing our attention on psychological safety, I do not mean</p><p>to dismiss the ethical dimensions of any of these cases. Wells Fargo,</p><p>for instance. Yet to view the customer-accounts fraud as the result of</p><p>individually-corrupt salespeople does not square with the widespread</p><p>nature of the behavior in the company, which points to a system set</p><p>up to fail. Set up to fail by the pernicious combination of a top-down</p><p>strategy and insufficient psychological safety to encourage sharing bad</p><p>news up the hierarchy. A similar point can be made about the VW</p><p>and Fed cases. As argued earlier in this chapter, any explanation that</p><p>looks only for a corrupt or foolish individual or individuals will be</p><p>incomplete, given the complex dynamics at play. What is interesting</p><p>to consider, however, is the extent to which having information about</p><p>70 Psychological Safety at Work</p><p>shortcomings come to light earlier rather than later can nearly always</p><p>mitigate the size and impact of failures and sometimes prevent them</p><p>altogether.</p><p>Adopting an Agile Approach to Strategy</p><p>Taken together, these four cases suggest the necessity of adopting</p><p>alternate perspectives on strategy that are more in tune with the</p><p>nature of value creation in today’s VUCA world. Solvay Business</p><p>School Professor Paul Verdin and I developed a perspective that</p><p>frames an organization’s strategy as a hypothesis rather than a plan.62</p><p>Like all hypotheses, it starts with situation assessment and analysis –</p><p>strategy’s classic tools. Also, like all hypotheses, it must be tested</p><p>through action. When strategy is seen as a hypothesis to be con-</p><p>tinually tested, encounters with customers provide valuable data</p><p>of ongoing interest to senior executives. Imagine if Wells Fargo</p><p>had adopted an agile approach to strategy: the company’s top</p><p>management would then have taken repeated instances of missed</p><p>targets or false accounts as useful data to help it assess the efficacy</p><p>of the original cross-selling strategy. This learning would then have</p><p>triggered much-needed strategic adaptation.</p><p>Of course, sometimes, poor performance is simply poor perfor-</p><p>mance. People underperforming. Not trying hard enough. Some-</p><p>times, companies do in fact need to find ways to better motivate and</p><p>manage employees to help them reach desired performance standards.</p><p>However, in a VUCA world, this is not the only explanation for</p><p>missing a desired target; it is not even the most likely explanation.</p><p>Early signs of gaps between results and plans must be viewed first as</p><p>data – triggering analysis – before concluding that the gaps are clear</p><p>and obvious evidence of employee underperformance.</p><p>Cheating and covering up are natural by-products of a top-down</p><p>culture that does not accept “no” or “it can’t be done” for an answer.</p><p>But combining this culture with a belief that a brilliant strategy for-</p><p>mulated in the past will hold indefinitely into the future becomes a</p><p>Avoidable Failure 71</p><p>certain recipe for failure. At both VW and Wells Fargo, signs that</p><p>corners were being cut were repeatedly ignored. Thus, the illusion</p><p>that the top-down strategies were working persisted – for a while.</p><p>Particularly poignant is that disconfirming</p><p>data were available for a</p><p>surprisingly long time, but they were not put to good use.</p><p>Success in a VUCA world requires senior executives to engage</p><p>thoughtfully and frequently with company operations across all levels</p><p>and departments. The people on the front line who create and deliver</p><p>products and services are privy to the most important strategic data</p><p>the company has available. They know what customers want, what</p><p>competitors are doing, and what the latest technology allows. Orga-</p><p>nizational learning – championed by company leaders but enacted</p><p>by everyone – requires actively seeking deviations that challenge the</p><p>assumptions underpinning a current strategy. Then, of course, these</p><p>deviations must be welcomed because of their informative value for</p><p>adapting the original strategy. Ironically, pushing harder on “exe-</p><p>cution” in response to early signals of underperformance may only</p><p>aggravate the problem if shortcomings reveal that prior market intel-</p><p>ligence or assumptions about the business model were flawed.</p><p>Finally, as unfortunate as the business failures in this chapter may</p><p>have been, in many ways they pale in comparison to the human costs</p><p>of low psychological safety explored in Chapter 4. Here we will see</p><p>the even more vital role of speaking up to avoid preventable harm.</p><p>Chapter 3 Takeaways</p><p>◾ Leaders who welcome only good news create fear that blocks</p><p>them from hearing the truth.</p><p>◾ Many managers confuse setting high standards with good man-</p><p>agement.</p><p>◾ A lack of psychological safety can create an illusion of success</p><p>that eventually turns into serious business failures.</p><p>◾ Early information about shortcomings can nearly always miti-</p><p>gate the size and impact of future, large-scale failure.</p><p>72 Psychological Safety at Work</p><p>Endnotes</p><p>1. Vlasic, B. “Volkswagen Official Gets 7-Year Term in Diesel-Emissions</p><p>Cheating.” The New York Times. December 6, 2017. https://www</p><p>.nytimes.com/2017/12/06/business/oliver-schmidt-volkswagen.html</p><p>Accessed June 13, 2018.</p><p>2. Kwak, J. “How Not to Regulate.” The Atlantic. September 30, 2014.</p><p>https://www.theatlantic.com/business/archive/2014/09/how-not-</p><p>to-regulate/380919/ Accessed June 13, 2018.</p><p>3. The Volkswagen story in this chapter draws from new sources cited</p><p>individually and from the following academic case studies:</p><p>◾ Giolito, V., Verdin, P., Hamwi, M., & Oualadj, Y. Volkswagen: A</p><p>Global Champion in the Making? Case Study. Solvay Brussels School</p><p>Economics & Management, 2017; Lynch, L.J., Cutro, C., & Bird, E.</p><p>◾ The Volkswagen Emissions Scandal. Case Study. UVA No. 7245.</p><p>Charlottesville, VA. University of Virginia, Darden Business Pub-</p><p>lishing, 2016; and</p><p>◾ Schuetz, M. Dieselgate – Heavy Fumes Exhausting the Volkswagen</p><p>Group. Case Study. HK No. 1089. Hong Kong. The University of</p><p>Hong Kong Asia Case Research Center, 2016.</p><p>4. Ewing, J. “Volkswagen C.E.O. Martin Winterkorn Resigns Amid</p><p>Emissions Scandal.” The New York Times. September 23, 2015.</p><p>https://www.nytimes.com/2015/09/24/business/international/</p><p>volkswagen-chief-martin-winterkorn-resigns-amid-emissions-scandal</p><p>.html Accessed June 13, 2018.</p><p>5. Parloff, R. “How VW Paid $25 Billion for ‘Dieselgate’ – and Got Off</p><p>Easy.” Fortune Magazine. February 6, 2018. http://fortune.com/2018/</p><p>02/06/volkswagen-vw-emissions-scandal-penalties/ Accessed June 13,</p><p>2018.</p><p>6. Ibid.</p><p>7. Sorokanich, B. “Report: Bosch Warned VW About Diesel Emissions</p><p>Cheating in 2007.” Car and Driver. September 28, 2015. https://blog</p><p>.caranddriver.com/report-bosch-warned-vw-about-diesel-emissions-</p><p>cheating-in-2007/ Accessed June 13, 2018.</p><p>8. Hakim, D., Kessler A.M., & Ewing, J. “As Volkswagen Pushed to Be</p><p>No. 1, Ambitions Fueled a Scandal.” The New York Times, Septem-</p><p>ber 26, 2015. https://www.nytimes.com/2015/09/27/business/as-vw-</p><p>pushed-to-be-no-1-ambitions-fueled-a-scandal.html Accessed June 13,</p><p>2018.</p><p>https://www.nytimes.com/2017/12/06/business/oliver-schmidt-volkswagen.html</p><p>https://www.nytimes.com/2017/12/06/business/oliver-schmidt-volkswagen.html</p><p>https://www.theatlantic.com/business/archive/2014/09/how-not-to-regulate/380919</p><p>https://www.theatlantic.com/business/archive/2014/09/how-not-to-regulate/380919</p><p>https://www.nytimes.com/2015/09/24/business/international/volkswagen-chief-martin-winterkorn-resigns-amid-emissions-scandal.html</p><p>https://www.nytimes.com/2015/09/24/business/international/volkswagen-chief-martin-winterkorn-resigns-amid-emissions-scandal.html</p><p>https://www.nytimes.com/2015/09/24/business/international/volkswagen-chief-martin-winterkorn-resigns-amid-emissions-scandal.html</p><p>http://fortune.com/2018/02/06/volkswagen-vw-emissions-scandal-penalties</p><p>http://fortune.com/2018/02/06/volkswagen-vw-emissions-scandal-penalties</p><p>https://blog.caranddriver.com/report-bosch-warned-vw-about-diesel-emissions-cheating-in-2007</p><p>https://blog.caranddriver.com/report-bosch-warned-vw-about-diesel-emissions-cheating-in-2007</p><p>https://blog.caranddriver.com/report-bosch-warned-vw-about-diesel-emissions-cheating-in-2007</p><p>https://www.nytimes.com/2015/09/27/business/as-vw-pushed-to-be-no-1-ambitions-fueled-a-scandal.html</p><p>https://www.nytimes.com/2015/09/27/business/as-vw-pushed-to-be-no-1-ambitions-fueled-a-scandal.html</p><p>https://www.nytimes.com/2015/09/27/business/as-vw-pushed-to-be-no-1-ambitions-fueled-a-scandal.html</p><p>https://www.nytimes.com/2015/09/27/business/as-vw-pushed-to-be-no-1-ambitions-fueled-a-scandal.html</p><p>Avoidable Failure 73</p><p>9. Ewing, J. 2015, op cit.</p><p>10. Cremer, A. & Bergin, T. “Fear and Respect: VW’s culture under Win-</p><p>terkorn.” Reuters. October 10, 2015. https://www.reuters.com/article/</p><p>us-volkswagen-emissions-culture/fear-and-respect-vws-culture-under-</p><p>winterkorn-idUSKCN0S40MT20151010 Accessed June 13, 2018.</p><p>11. https://www.youtube.com/watch?v=YpPNVSQmR5c</p><p>12. Lutz, B. “One Man Established the Culture that Led to VW’s</p><p>Emission Scandal.” Road and Track. November 4, 2015. https://www</p><p>.roadandtrack.com/car-culture/a27197/bob-lutz-vw-diesel-fiasco/</p><p>Accessed June 13, 2018.</p><p>13. Ibid.</p><p>14. Kiley, D. Getting the Bugs Out: The Rise, Fall, and Comeback of Volkswagen</p><p>in America. John Wiley & Sons, 2002. 38–49. Print.</p><p>15. https://www.youtube.com/watch?v=DfGs2Y5WJ14.</p><p>16. Cremer, A. & Bergin, T, 2015, op cit.</p><p>17. Ibid.</p><p>18. Ibid.</p><p>19. Ibid.</p><p>20. Details on the Wells Fargo story come from Lynch, L.J., Coleman, A.R.,</p><p>& Cutro, C. The Wells Fargo Banking Scandal. Case Study. UVA No.</p><p>7267. Charlottesville, VA. University of Virginia, Darden Business Pub-</p><p>lishing, 2017.</p><p>21. Wells Fargo, 2015 annual report</p><p>22. Wells Fargo, 2010 annual report</p><p>23. Wells Fargo, 2015 annual report</p><p>24. Gonzales, R. “Wells Fargo CEO John Stumpf Resigns Amid Scandal.”</p><p>NPR, October 12, 2016. https://www.npr.org/sections/thetwo-way/</p><p>2016/10/12/497729371/wells-fargo-ceo-john-stumpf-resigns-amid-</p><p>scandal Accessed June 13, 2018.</p><p>25. Reckard, E.S. “Wells Fargo’s Pressure-Cooker Sales Culture Comes</p><p>at a Cost.” The Los Angeles Times, December 21, 2013. http://www</p><p>.latimes.com/business/la-fi-wells-fargo-sale-pressure-20131222-story</p><p>.html Accessed June 13, 2018.</p><p>26. Keller, L.J., Campbell, D., & Mehrotra, K. “While 5,000 Wells Fargo</p><p>Employees Got Fired, Their Bosses Thrived.” Bloomberg. November</p><p>3, 2016. https://www.bloomberg.com/news/articles/2016-11-03/</p><p>wells-fargo-s-stars-climbed-while-abuses-flourished-beneath-them</p><p>Accessed June 13, 2018.</p><p>27. Cao, A. “Lawsuit Alleges Exactly How Wells Fargo Pushed Employees</p><p>to Abuse Customers.” TIME. September 29, 2016. http://time.com/</p><p>https://www.reuters.com/article/us-volkswagen-emissions-culture/fear-and-respect-vws-culture-under-winterkorn-idUSKCN0S40MT20151010</p><p>https://www.youtube.com/watch?v=YpPNVSQmR5c</p><p>https://www.roadandtrack.com/car-culture/a27197/bob-lutz-vw-diesel-fiasco</p><p>https://www.roadandtrack.com/car-culture/a27197/bob-lutz-vw-diesel-fiasco</p><p>https://www.youtube.com/watch?v=DfGs2Y5WJ14</p><p>https://www.npr.org/sections/thetwo-way/2016/10/12/497729371/wells-fargo-ceo-john-stumpf-resigns-amid-scandal</p><p>https://www.npr.org/sections/thetwo-way/2016/10/12/497729371/wells-fargo-ceo-john-stumpf-resigns-amid-scandal</p><p>https://www.npr.org/sections/thetwo-way/2016/10/12/497729371/wells-fargo-ceo-john-stumpf-resigns-amid-scandal</p><p>http://www.latimes.com/business/la-fi-wells-fargo-sale-pressure-20131222-story.html</p><p>http://www.latimes.com/business/la-fi-wells-fargo-sale-pressure-20131222-story.html</p><p>http://www.latimes.com/business/la-fi-wells-fargo-sale-pressure-20131222-story.html</p><p>https://www.bloomberg.com/news/articles/2016-11-03/wells-fargo-s-stars-climbed-while-abuses-flourished-beneath-them</p><p>https://www.bloomberg.com/news/articles/2016-11-03/wells-fargo-s-stars-climbed-while-abuses-flourished-beneath-them</p><p>http://time.com/money/4510482/wells-fargo-fake-accounts-class-action-lawsuit</p><p>https://www.reuters.com/article/us-volkswagen-emissions-culture/fear-and-respect-vws-culture-under-winterkorn-idUSKCN0S40MT20151010</p><p>https://www.reuters.com/article/us-volkswagen-emissions-culture/fear-and-respect-vws-culture-under-winterkorn-idUSKCN0S40MT20151010</p><p>74 Psychological Safety at Work</p><p>money/4510482/wells-fargo-fake-accounts-class-action-lawsuit/</p><p>Accessed June 13, 2018.</p><p>28. Mehrotra, K. “Wells Fargo Ex-Managers’ Suit Puts Scandal Blame</p><p>Higher Up Chain.” Bloomberg. December 8, 2016. https://www</p><p>.bloomberg.com/news/articles/2016-12-08/wells-fargo-ex-managers-</p><p>suit-puts-scandal-blame-higher-up-chain Accessed June 13, 2018.</p><p>29. Reckard, E.S. December 21, 2013, op cit.</p><p>30. Cowley, S. “Voices From Wells Fargo: ‘I Thought I Was Having a</p><p>Heart Attack.’” The New York Times. October 20, 2016. https://www</p><p>.nytimes.com/2016/10/21/business/dealbook/voices-from-wells-</p><p>fargo-i-thought-i-was-having-a-heart-attack.html Accessed June 13,</p><p>2018.</p><p>31. Cao, A. September 29, 2016, op cit.</p><p>32. Cowley, S. October 20, 2016, op cit.</p><p>33. Glazer, E. & Rexrode, C. “Wells Fargo CEO Defends Bank Culture,</p><p>Lays Blame With Bad Employees.” The Wall Street Journal. September</p><p>13, 2016. https://www.wsj.com/articles/wells-fargo-ceo-defends-</p><p>bank-culture-lays-blame-with-bad-employees-1473784452 Accessed</p><p>June 13, 2018.</p><p>34. Egan, M. September 8, 2016, op cit.</p><p>35. Freed, D. & Reckhard, E.S. “Wells Fargo Faces Costly Overhaul of</p><p>Bankrupt Sales Culture.” Reuters, October 12, 2016.</p><p>36. Corkery, M. & Cowley, S. “Wells Fargo Warned Workers Against</p><p>Sham Accounts, but ‘They Needed a Paycheck.’” The New York</p><p>Times, September 16, 2016. https://www.nytimes.com/2016/09/</p><p>17/business/dealbook/wells-fargo-warned-workers-against-fake-</p><p>accounts-but-they-needed-a-paycheck.html Accessed June 13, 2018.</p><p>37. Ibid.</p><p>38. Consumer Financial Protection Bureau press release. “Consumer</p><p>Financial Protection Bureau Fines Wells Fargo $100 Million for</p><p>Widespread Illegal Practice of Secretly Opening Unauthorized</p><p>Accounts.” ConsumerFinance.gov, September 8, 2016. https://www</p><p>.consumerfinance.gov/about-us/newsroom/consumer-financial-</p><p>protection-bureau-fines-wells-fargo-100-million-widespread-illegal-</p><p>practice-secretly-opening-unauthorized-accounts/ Accessed June 13,</p><p>2018.</p><p>39. Egan, M. “Wells Fargo Admits to Signs of Worker Retaliation.”</p><p>CNN Money. January 23, 2017. http://money.cnn.com/2017/01/23/</p><p>investing/wells-fargo-retaliation-ethics-line/index.html Accessed June</p><p>13, 2018.</p><p>http://time.com/money/4510482/wells-fargo-fake-accounts-class-action-lawsuit</p><p>https://www.bloomberg.com/news/articles/2016-12-08/wells-fargo-ex-managers-suit-puts-scandal-blame-higher-up-chain</p><p>https://www.nytimes.com/2016/10/21/business/dealbook/voices-from-wells-fargo-i-thought-i-was-having-a-heart-attack.html</p><p>https://www.nytimes.com/2016/10/21/business/dealbook/voices-from-wells-fargo-i-thought-i-was-having-a-heart-attack.html</p><p>https://www.nytimes.com/2016/10/21/business/dealbook/voices-from-wells-fargo-i-thought-i-was-having-a-heart-attack.html</p><p>https://www.wsj.com/articles/wells-fargo-ceo-defends-bank-culture-lays-blame-with-bad-employees-1473784452</p><p>https://www.wsj.com/articles/wells-fargo-ceo-defends-bank-culture-lays-blame-with-bad-employees-1473784452</p><p>https://www.nytimes.com/2016/09/17/business/dealbook/wells-fargo-warned-workers-against-fake-accounts-but-they-needed-a-paycheck.html</p><p>https://www.nytimes.com/2016/09/17/business/dealbook/wells-fargo-warned-workers-against-fake-accounts-but-they-needed-a-paycheck.html</p><p>https://www.nytimes.com/2016/09/17/business/dealbook/wells-fargo-warned-workers-against-fake-accounts-but-they-needed-a-paycheck.html</p><p>http://consumerfinance.gov</p><p>https://www.consumerfinance.gov/about-us/newsroom/consumer-financial-protection-bureau-fines-wells-fargo-100-million-widespread-illegal-practice-secretly-opening-unauthorized-accounts</p><p>https://www.consumerfinance.gov/about-us/newsroom/consumer-financial-protection-bureau-fines-wells-fargo-100-million-widespread-illegal-practice-secretly-opening-unauthorized-accounts</p><p>https://www.consumerfinance.gov/about-us/newsroom/consumer-financial-protection-bureau-fines-wells-fargo-100-million-widespread-illegal-practice-secretly-opening-unauthorized-accounts</p><p>https://www.consumerfinance.gov/about-us/newsroom/consumer-financial-protection-bureau-fines-wells-fargo-100-million-widespread-illegal-practice-secretly-opening-unauthorized-accounts</p><p>http://money.cnn.com/2017/01/23/investing/wells-fargo-retaliation-ethics-line/index.html</p><p>http://money.cnn.com/2017/01/23/investing/wells-fargo-retaliation-ethics-line/index.html</p><p>https://www.bloomberg.com/news/articles/2016-12-08/wells-fargo-ex-managers-suit-puts-scandal-blame-higher-up-chain</p><p>https://www.bloomberg.com/news/articles/2016-12-08/wells-fargo-ex-managers-suit-puts-scandal-blame-higher-up-chain</p><p>Avoidable Failure 75</p><p>40. Edmondson, A.C. & Verdin, P.J. “Your Strategy Should Be a Hypothesis</p><p>You Constantly Adjust.” Harvard Business Review. November 9, 2017.</p><p>https://hbr.org/2017/11/your-strategy-should-be-a-hypothesis-you-</p><p>constantly-adjust Accessed June 13, 2018.</p><p>41. “Our History.” Nokia. https://www.nokia.com/en_int/about-us/</p><p>who-we-are/our-history Accessed June 7, 2018.</p><p>42. Nokia Corporation, 1998 annual report.</p><p>43. Huy, Q. & Vuori, T. “Who Killed Nokia? Nokia Did.” INSEAD</p><p>Knowledge. September 22, 2015. https://knowledge.insead.edu/</p><p>strategy/who-killed-nokia-nokia-did-4268 Accessed June 13, 2018.</p><p>44. Bass, D., Heiskanen, V., & Fickling, D. “Microsoft to Buy Nokia’s</p><p>Devices Unit for $7.2 Billion.” Bloomberg. September 3, 2013. https://</p><p>www.bloomberg.com/news/articles/2013-09-03/microsoft-to-buy-</p><p>nokia-s-devices-business-for-5-44-billion-euros Accessed June 13,</p><p>2018.</p><p>45. Huy, Q. & Vuori, T. September 22, 2015, op cit.</p><p>46. Ibid.</p><p>47. Vuori, T. & Huy, Q. “Distributed Attention and Shared Emotions in the</p><p>Innovation Process: How Nokia Lost the Smartphone Battle.” Admin-</p><p>istrative Science Quarterly 61.1 (2016): 23.</p><p>48. Ibid.</p><p>49. Ibid.</p><p>50. Ibid.</p><p>51. Ibid.</p><p>52. Vuori, T. & Huy, Q. (2016): 30.</p><p>53. Vuori, T. & Huy, Q. (2016): 32.</p><p>54. Protess, B. & Craig, S. “Harsh Words for Regulators in Crisis</p><p>Commission Report.” The New York Times. January 27, 2011.</p><p>https://dealbook.nytimes.com/2011/01/27/harsh-words-for-</p><p>regulators-in-crisis-commission-report/?mtrref=www.google.com&</p><p>gwh=54322022775D2A4C1766CE843F23C604&gwt=pay Accessed</p><p>June 13, 2018.</p><p>55. Beim, D. & McCurdy, C. “Report on Systemic Risk and Bank</p><p>Supervision” Federal Reserve Bank of New York Report. 2009. 1. https://</p><p>info.publicintelligence.net/FRBNY-BankSupervisionReport.pdf .</p><p>Accessed June 1, 2018.</p><p>56. Beim, D. & McCurdy, C. 2009: 9.</p><p>57. Ibid.</p><p>58. Beim, D. & McCurdy, C. 2009: 19.</p><p>https://hbr.org/2017/11/your-strategy-should-be-a-hypothesis-you-constantly-adjust</p><p>https://hbr.org/2017/11/your-strategy-should-be-a-hypothesis-you-constantly-adjust</p><p>https://www.nokia.com/en_int/about-us/who-we-are/our-history</p><p>https://www.nokia.com/en_int/about-us/who-we-are/our-history</p><p>https://knowledge.insead.edu/strategy/who-killed-nokia-nokia-did-4268</p><p>https://knowledge.insead.edu/strategy/who-killed-nokia-nokia-did-4268</p><p>https://www.bloomberg.com/news/articles/2013-09-03/microsoft-to-buy-nokia-s-devices-business-for-5-44-billion-euros</p><p>https://www.bloomberg.com/news/articles/2013-09-03/microsoft-to-buy-nokia-s-devices-business-for-5-44-billion-euros</p><p>https://www.bloomberg.com/news/articles/2013-09-03/microsoft-to-buy-nokia-s-devices-business-for-5-44-billion-euros</p><p>https://dealbook.nytimes.com/2011/01/27/harsh-words-for-regulators-in-crisis-commission-report/?mtrref=www.google.com&gwh=54322022775D2A4C1766CE843F23C604&gwt=pay</p><p>https://dealbook.nytimes.com/2011/01/27/harsh-words-for-regulators-in-crisis-commission-report/?mtrref=www.google.com&gwh=54322022775D2A4C1766CE843F23C604&gwt=pay</p><p>https://dealbook.nytimes.com/2011/01/27/harsh-words-for-regulators-in-crisis-commission-report/?mtrref=www.google.com&gwh=54322022775D2A4C1766CE843F23C604&gwt=pay</p><p>https://info.publicintelligence.net/FRBNY-BankSupervisionReport.pdf</p><p>https://info.publicintelligence.net/FRBNY-BankSupervisionReport.pdf</p><p>76 Psychological Safety at Work</p><p>59. “The Secret Recordings of Carmen Segarra.” This American Life.</p><p>September 26, 2014. https://www.thisamericanlife.org/536/the-</p><p>secret-recordings-of-carmen-segarra. Accessed June 1, 2018.</p><p>60. Ibid.</p><p>61. Edmondson, A.C. & Verdin, P.J. “The strategic imperative of psycho-</p><p>logical safety and organizational error management.” How could this hap-</p><p>pen? Managing errors in organizations. Ed. J. Hagen. Palgrave/MacMillan:</p><p>in press.</p><p>62. Edmondson, A.C. & Verdin, P.J. November 9, 2017, op cit.</p><p>https://www.thisamericanlife.org/536/the-secret-recordings-of-carmen-segarra</p><p>https://www.thisamericanlife.org/536/the-secret-recordings-of-carmen-segarra</p><p>4</p><p>Dangerous Silence</p><p>“Regret for the things we did can be tempered by time; it is regret for the things we</p><p>did not do that is inconsolable.”</p><p>—Sydney Harris1</p><p>More than just business failure is at stake when psychological safety</p><p>is low. In many workplaces, people see something physically unsafe</p><p>or wrong and fear reporting it. Or they feel bullied and intimidated</p><p>by someone but don’t mention it to supervisors or counselors. This</p><p>reticence unfortunately can lead to widespread frustration, anxiety,</p><p>depression, and even physical harm. In short, we live and work in</p><p>communities, cultures, and organizations in which not speaking up</p><p>can be hazardous to human health.</p><p>This chapter explores how silence at work leads to harm that</p><p>could have been prevented. You will read stories that come predom-</p><p>inantly, but not exclusively, from high-risk industries. In these cases,</p><p>employees find themselves unable to speak up; the ensuing silence</p><p>then creates conditions for physical and emotional harm. Although</p><p>77</p><p>78 Psychological Safety at Work</p><p>never easy, in some workplaces, as we will see in Chapter 5 and</p><p>Chapter 6, people do feel both safe and compelled to speak up. This</p><p>gives everyone the chance to develop constructive solutions and avoid</p><p>harmful outcomes.</p><p>We’ll start with stories of silence that gave rise to major accidents</p><p>in high-risk settings where risk and routine often exist in an uneasy</p><p>balance. The first two accidents take place in the air. From there, we’ll</p><p>move to a hospital bed, tsunami waves, and finally the volatile setting</p><p>of public opinion.</p><p>Failing to Speak Up</p><p>On February 1, 2003, NASA’s Space Shuttle Columbia experienced a</p><p>catastrophic reentry into the Earth’s atmosphere.2 All seven astronauts</p><p>perished. Although space travel is obviously risky and fatal accidents</p><p>seem part of the territory, this particular accident did not come “out</p><p>of the blue.” Two weeks earlier, a NASA engineer named Rodney</p><p>Rocha had watched launch-day video footage, a day after what had</p><p>seemed to be a picture-perfect launch on a sunny Florida morning.</p><p>But something seemed amiss. Rocha played the tape over and over.</p><p>He thought a chunk of insulating foam might have fallen off the shut-</p><p>tle’s external tank and struck the left wing of the craft. The video</p><p>images were grainy, shot from a great distance, and it was impossi-</p><p>ble to really tell whether or not the foam had caused damage, but</p><p>Rocha could not help worrying about the size and position of that</p><p>grainy moving dot he saw on the screen. To resolve the ambiguity,</p><p>Rocha wanted to get satellite photos of the Shuttle’s wing. But this</p><p>would require NASA higher ups to ask the Department of Defense</p><p>for help.</p><p>Rocha emailed his boss to see if he could get help authorizing a</p><p>request for satellite images. His boss thought it unnecessary and said</p><p>so. Discouraged, Rocha sent an emotional email to his fellow engi-</p><p>neers, later explaining that “engineers were . . . not to send messages</p><p>much higher than their own rung in the ladder.”3 Working with an</p><p>Dangerous Silence 79</p><p>ad hoc team of engineers to assess the damage, he was unable to resolve</p><p>his concern about possible damage without obtaining images. A week</p><p>later, when the foam strike possibility was briefly discussed by senior</p><p>managers in the formal mission management team meeting, Rocha,</p><p>sitting on the periphery, observed silently.</p><p>A formal investigation by experts would later conclude that a</p><p>large hole in the shuttle wing occurred when a briefcase-sized piece</p><p>of foam hit the leading edge of the wing, causing the accident.4</p><p>They also identified two, albeit difficult and highly-uncertain, res-</p><p>cue options that might have prevented the tragic deaths. Reporting</p><p>on the investigation, ABC News anchor Charlie Gibson asked Rocha</p><p>why he hadn’t spoken up in the meeting. The engineer replied, “I</p><p>just couldn’t do it. I’m too low down [in the organization] . . . and</p><p>she [meaning Mission Management Team Leader Linda Ham] is way</p><p>up here,” gesturing with his hand held above his head.5</p><p>Rocha’s statement captures a subtle but crucial aspect of the psy-</p><p>chology of speaking up at work. Consider his words carefully. He did</p><p>not say, “I chose not to speak,” or “I felt it was not right to speak.” He</p><p>said that he “couldn’t” speak. Oddly, this description is apt. The psy-</p><p>chological experience of having something to say yet feeling literally</p><p>unable to do so is painfully real for many employees and very com-</p><p>mon in organizational hierarchies, like that of NASA in 2003. We</p><p>can all recognize this phenomenon. We understand why his hands</p><p>spontaneously depicted that poignant vertical ladder. When probed,</p><p>as Rocha was by Gibson, many people report a similar experience</p><p>of feeling unable to speak up when hierarchy is made salient. Mean-</p><p>while, the higher ups in a position to listen and learn are often blind</p><p>to the silencing effects of their presence.</p><p>What Was Not Said</p><p>Twenty-six years earlier, workplace silence played a major role in</p><p>the collision of two Boeing 747 jets on an island runway in the</p><p>Canary Islands in March 1977.6 The crash ignited two jumbo jets</p><p>80 Psychological Safety at Work</p><p>into flames, and 583 people died. Subsequent investigations into what</p><p>has been called the Tenerife disaster, still considered the worst acci-</p><p>dent in the history of civil aviation, were among the first to study</p><p>the roles played by human factors in airline fatalities. The result-</p><p>ing changes made to aviation procedures and cockpit training laid</p><p>the groundwork for some of today’s most crucial psychological safety</p><p>measures.</p><p>Let’s look at what went wrong on that afternoon in late March</p><p>at the small Los Rodeos Airport on the island of Tenerife. The run-</p><p>way was covered in heavy fog and the airport was small, which made</p><p>it difficult for the pilots of both aircrafts to see the runway and one</p><p>another. An unexpected landing at Tenerife due to a bomb scare ear-</p><p>lier that day at nearby Las Palamas airport put extra stress on the crew,</p><p>intent on keeping to their scheduled flight arrival times. Air control</p><p>personnel may have been watching a sports game, distracting their</p><p>attention. However, these relatively common, if unfavorable, condi-</p><p>tions need not have resulted in tragedy. If we look more closely into</p><p>what was said in the aircraft cockpit – and more importantly, what</p><p>was not said, and why not – we can better understand the outsized role</p><p>played by psychological safety.</p><p>Captain Jacob Veldhuyzen van Zanten, one of the company’s most</p><p>senior pilots, chief flight trainer of most of the company’s 747 pilots,</p><p>and head of flight safety for Royal Dutch Airlines (KLM), piloted the</p><p>flight.7 Nicknamed “Mr. KLM,” van Zanten held the power to issue</p><p>pilots’ licenses and oversaw pilots’ six-month flight checks to deter-</p><p>mine whether licenses would be extended. His photograph, which</p><p>had just appeared in a KLM advertising spread, depicted a smiling</p><p>and confident man in</p><p>a white shirt sitting in front of a control panel.</p><p>He looked like a man who was comfortable being in charge.</p><p>Flying with van Zanten that day were two other top-notch and</p><p>highly-experienced pilots: First Officer Klaas Meurs, age 32, and</p><p>Flight Engineer Willem Schreuder, age 48. Importantly, two months</p><p>earlier, van Zanten had been Meur’s “check pilot,” testing his ability</p><p>to fly the Boeing 747.</p><p>Dangerous Silence 81</p><p>The crucial moments came as the KLM and the Pan Am flights</p><p>were preparing for takeoff. Immediately after lining up on the</p><p>runway, Captain van Zanten impatiently advanced the throttles and</p><p>the aircraft started to move forward. First Officer Meurs, implying</p><p>that van Zanten was moving too soon, then advised that air traffic</p><p>control (ATC) had not yet given them clearance.</p><p>Van Zanten, sounding irritated, responded: “No, I know that. Go</p><p>ahead, ask.”8</p><p>Following his captain’s request, Meurs then radioed the tower</p><p>that they were “ready for takeoff” and “waiting for our ATC</p><p>clearance.” The ATC then specified the route that the aircraft was</p><p>to follow after takeoff. Although the ATC used the word “takeoff,”</p><p>their communication did not include an explicit statement that KLM</p><p>was cleared for takeoff. Meurs began reading the flight clearance back</p><p>to the controller, but van Zanten interrupted with an imperative:</p><p>“We’re going.”</p><p>Given the captain’s authority, it was in this moment that Meurs</p><p>apparently did not feel safe enough to speak up. Meurs, in that split</p><p>second, did not open his mouth to say, “wait for clearance!”</p><p>Meanwhile, after the KLM plane had started its takeoff roll, the</p><p>tower instructed the Pan Am crew to “report when runway clear.” To</p><p>which the Pan Am crew replied, “OK, will report when we’re clear.”</p><p>On hearing this, Flight Engineer Schreuder expressed his concern</p><p>that Pan Am was not clear of the runway by asking, “is he not clear,</p><p>that Pan American?”</p><p>Van Zanten emphatically replied, “oh, yes,” and continued with</p><p>the takeoff.</p><p>And in this moment Schreuder did not say a thing. Although</p><p>he had correctly surmised that the Pan Am jet might be blocking</p><p>their way, Schreuder did not challenge Van Zanten’s confident retort.</p><p>He did not ask ATC to clarify or confirm by asking, for example,</p><p>“is Pan American on the runway?” His reticence indicates a lack</p><p>of the psychological safety that would make such a query all but</p><p>second nature.</p><p>82 Psychological Safety at Work</p><p>By then it was too late. The KLM Boeing was going too fast to</p><p>stop when van Zanten, Meurs, and Schreuder finally could see the</p><p>Pan Am jet blocking their way. The KLM’s left-side engines, lower</p><p>fuselage, and main landing gear struck the upper right side of the Pan</p><p>Am’s fuselage, ripping apart the center. The KLM plane remained</p><p>briefly airborne before going into a stall, rolling sharply, hitting the</p><p>ground, and igniting into a fireball.</p><p>Such is the inexorably psychological pull of hierarchy that even</p><p>when their own lives were at risk, not to mention the lives of oth-</p><p>ers, the first officer and the flight engineer did not push back on their</p><p>captain’s authority. In those moments where speaking up might make</p><p>sense, we all go through an implicit decision-making process, weigh-</p><p>ing the benefits and costs of speaking up. The problem, as explained</p><p>in Chapter 2, is that the benefits are often unclear and delayed (e.g.</p><p>avoiding a possible collision) while the costs are tangible and imme-</p><p>diate (van Zanten’s irritation and potential anger). As a result, we</p><p>consistently underweight the benefits and overweight the costs. In</p><p>the case of Tenerife, this biased process led to disastrous outcomes.</p><p>Many who analyze events leading up to tragic accidents such</p><p>as this one-which could have been avoided had the junior officer</p><p>spoken up-cannot help pointing out that people should demonstrate</p><p>a bit more backbone. Courage. It is impossible to disagree with this</p><p>assertion. Nonetheless, agreeing doesn’t make it effective. Exhorting</p><p>people to speak up because it’s the right thing to do relies on an ethical</p><p>argument but is not a strategy for ensuring good outcomes. Insisting</p><p>on acts of courage puts the onus on individuals without creating the</p><p>conditions where the expectation is likely to be met.</p><p>For speaking up to become routine, psychological safety – and</p><p>expectations about speaking up – must become institutionalized and</p><p>systematized. After Tenerife, cockpit training was changed to place</p><p>more emphasis on crew decision-making, encourage pilots to assert</p><p>their opinion when they believed something was wrong, and help</p><p>captains listen to concerns from co-pilots and crews.9 These measures</p><p>were a precursor to the official crew resource management (CRM)</p><p>training that all pilots must now undergo.</p><p>Dangerous Silence 83</p><p>Excessive Confidence in Authority</p><p>Medicine, like commercial aviation, is another profession where</p><p>authority is well understood and tightly linked to one’s place in a</p><p>strict hierarchy. A direct line of command, where everyone knows</p><p>his or her place, has its benefits. However, deference to others,</p><p>especially in the face of ambiguity, can become the default mode of</p><p>operation, leading everyone to believe that the person-on-top always</p><p>knows best. In some cases, an implicit belief that the person with the</p><p>highest place on the hierarchy must also be the authority can lead to</p><p>fatal consequences. In other cases, an implicit belief in the authority</p><p>of the medical system itself can be fatal.</p><p>On December 3, 1994, Betsy Lehman, a 39-year-old mother</p><p>of two and a healthcare columnist at The Boston Globe, died at the</p><p>Dana-Farber Cancer Institute while undergoing a third round of</p><p>high-dose chemotherapy for breast cancer.10 In part because of her</p><p>profession as a journalist, Lehman’s death was well publicized in the</p><p>media, especially once it was linked to a medical error.11</p><p>The Dana-Farber Cancer Institute where Lehman sought treat-</p><p>ment was renowned for its cancer research and its success in treating</p><p>complex and difficult cases. With only 57 inpatient beds, its patient</p><p>care was a kind of boutique unit that enabled informal information</p><p>sharing among physicians, nurses, and pharmacy staff rather than the</p><p>formal communications mechanisms that exist in a traditional hospital</p><p>setting. As Senior Oncologist Stephen Sallan noted, “our confidence</p><p>was based on the assumption that if we were all wonderful then our</p><p>pharmacy safety would be wonderful.”12 Unfortunately, this assump-</p><p>tion did not leave much room for questioning or routine checking.</p><p>The absence of a Director of Nursing at the time of Lehman’s admit-</p><p>tance, a post that had been vacant for over a year, also signals that the</p><p>medical and clinical teams did not adequately appreciate the interde-</p><p>pendence and complexity of their work.</p><p>Lehman was admitted to the Dana-Farber for the planned</p><p>chemotherapy on November 14, 1994. Although the chemother-</p><p>apy agent was the commonly used cyclophosphamide, the dose</p><p>84 Psychological Safety at Work</p><p>was especially high because Lehman’s treatment plan involved</p><p>a cutting-edge stem-cell transplant. The protocol called for the</p><p>chemotherapy to be infused over four days, with the amount given</p><p>during each 24-hour period to be “barely shy of lethal.”13 As part of</p><p>the clinical trial, Lehman was also given another drug, cimetidine,</p><p>which was supposed to boost the effect of the first drug.14</p><p>In routine cancer treatments, courses of chemotherapy doses are</p><p>typically standardized; however, in a research trial such as Lehman</p><p>was undergoing, upper limits could be ambiguous. At Dana-Farber,</p><p>where 30% of patients might be enrolled in a clinical trial at any</p><p>one time, staff members who administered chemotherapy were</p><p>accustomed to seeing unusual drug combinations and dosages.15</p><p>That may partly explain why no alarm bells went off even though</p><p>the prescription – written by a clinical research fellow in oncology,</p><p>copied into Lehman’s records by a nurse, and filled by three different</p><p>pharmacists – had mistakenly ordered the entire four-day dosage</p><p>for each day, providing Lehman with four times the dosage</p><p>she was</p><p>supposed to receive.</p><p>The treatment was expected to produce severe nausea and vom-</p><p>iting. However, over the next three weeks in the hospital, Lehman’s</p><p>symptoms were extraordinary. She had not been as sick during the</p><p>first two high-dose treatments. Now she was “grossly swollen” and</p><p>had abnormal blood and EKG tests.16 High-dose cyclophosphamide</p><p>was known to be toxic to the heart. Lehman’s husband reported that</p><p>she was “vomiting sheets of tissue. [The doctors] said this was the</p><p>worst they had ever seen. But the doctors said this was all normal with</p><p>bone marrow transplant.”17 At one point, Lehman asked a nurse, “Am</p><p>I going to die from vomiting?”18 Meanwhile, another patient, admit-</p><p>ted shortly before Lehman, given the same incorrect chemother-</p><p>apy dose, had suddenly collapsed and was rushed to the intensive</p><p>care unit.</p><p>The day before Lehman’s discharge, her symptoms seemed to be</p><p>abating. And there were signs that the experimental stem cell trans-</p><p>plant was proceeding successfully. An EKG, however, was abnormal.</p><p>On December 3, the day of her discharge and the day she died of</p><p>Dangerous Silence 85</p><p>heart failure, the last people she spoke to – a friend, a social worker,</p><p>and a nurse – confirmed that she was very upset, frightened, and felt</p><p>that something “was wrong.”19 We do not know whether or not she</p><p>had voiced this concern as distinctly or coherently in the previous</p><p>weeks. Surely, she must have wondered. Of course, an extremely ill</p><p>patient is usually not in a position to assertively question her treatment</p><p>plan, especially one that is experimental.</p><p>The medical error was not discovered until three months later – by</p><p>a routine data check rather than by a clinical inquiry. As part of</p><p>its corrective actions, Dana-Farber instituted automated medication</p><p>checks into its chemotherapy procedures. Ultimately, Lehman’s death</p><p>became a catalyst for hospital and healthcare institutions in the US to</p><p>craft policy to help reduce medical errors, including more systemic</p><p>checking of routine procedures throughout a patient’s treatment pro-</p><p>cess and more reporting provisions for caregivers, regardless of their</p><p>professional status.</p><p>From the perspective of psychological safety, however, the bigger</p><p>question that remains is why, given Lehman’s extreme physical dis-</p><p>tress, did no one deeply and persistently question whether something</p><p>had gone profoundly wrong? Did Lehman and her husband place</p><p>too much trust in the highly regarded medical institution? Similarly,</p><p>why did pharmacists not question the extraordinary fourfold dosage</p><p>of the already high-dose chemotherapy agent? The same can be asked</p><p>about the nurses. Perhaps their implicit trust in the expertise of the</p><p>physician-researchers left them incurious. Or, they may have been</p><p>reluctant to speak up to inquire into rationale for the treatment plan</p><p>only to be put down by their higher-status colleagues. We don’t know</p><p>whether the nurses and physicians who observed Lehman’s symp-</p><p>toms assigned too little significance to the type of side effects the</p><p>high-dose chemotherapy was supposed to induce. No one involved</p><p>seemed to accurately assess the gravity of her condition. Ultimately,</p><p>Betsy Lehman’s mother, Mildred K. Lehman, was the one who con-</p><p>cisely summed up the problem: “Betsy’s life might have been saved</p><p>if staff had stepped forward to attend to the multiple signs that her</p><p>treatment was far off course.”20</p><p>86 Psychological Safety at Work</p><p>What is important to take away from this story, and what most</p><p>hospitals today work hard to avoid, is that a climate in which people</p><p>err on the side of silence – implicitly favoring self-protection and</p><p>embarrassment avoidance over the possibility that one’s input may</p><p>be desperately needed in that moment – is a serious risk factor. It</p><p>is clearly far better for people to ask questions or raise concerns and</p><p>be wrong than it is for them to hold back, but most people don’t</p><p>consciously recognize that fact. Raising concerns that turn out to be</p><p>unfounded presents a learning opportunity for the person speaking up</p><p>and for those listening who thereby glean crucial information about</p><p>what others understand or don’t understand about the situation or</p><p>the task.</p><p>A Culture of Silence</p><p>Cassandra, one of the most tragic characters in classical Greek mythol-</p><p>ogy, was given the gift of prophecy along with the curse that she</p><p>would never be believed. Low levels of psychological safety can create</p><p>a culture of silence. They can also create a Cassandra culture – an envi-</p><p>ronment in which speaking up is belittled and warnings go unheeded.</p><p>Especially when speaking up entails drawing attention to unpleasant</p><p>outcomes, as was the case for Cassandra in her prediction of war, it’s</p><p>easy for others not to listen or believe. A culture of silence is thus not</p><p>only one that inhibits speaking up but one in which people fail to</p><p>listen thoughtfully to those who do speak up – especially when they</p><p>are bringing unpleasant news.</p><p>Consider the Challenger shuttle explosion back in 1986. Unlike</p><p>Rodney Rocha’s silence in a crucial workplace moment, Roger</p><p>Boisjoly, an engineer at NASA contractor Morton-Thiokol, did</p><p>speak up. The night before the disastrous launch, Boisjoly raised his</p><p>concern that unusually cold temperatures might cause the O-rings</p><p>that connected segments of the shuttle to malfunction. His data were</p><p>incomplete and his argument vague, but the assembled group could</p><p>have readily resolved the ambiguity with some simple analyses and</p><p>Dangerous Silence 87</p><p>experiments had they listened intensely and respectfully. In short, for</p><p>voice to be effective requires a culture of listening.</p><p>Let’s take a look at a more recent example of what can happen</p><p>when the listening culture is weak.</p><p>Dismissing Warnings</p><p>On March 11, 2011, a 9.0 magnitude earthquake occurred off the</p><p>northeastern coast of Japan. The quake, later dubbed the “Great</p><p>East Japanese Earthquake,” created tsunami waves up to 45 feet</p><p>high that struck the Fukushima Daiichi Nuclear Power Plant.21</p><p>Waves of mythic proportions leapt easily over the plant’s undersized</p><p>sea walls, flooding the site and completely destroying emergency</p><p>generators, seawater cooling pumps, and the electric wiring system.</p><p>Without power to cool down the nuclear reactors, three of the</p><p>reactors overheated, resulting in multiple explosions that injured</p><p>workers on the ground. Most alarmingly, nuclear fuel was released</p><p>into the ocean, and radionuclides were released from the plant into</p><p>the atmosphere. As a result of the nuclear meltdown, hundreds</p><p>of thousands of Japanese were forced to flee their homes to avoid</p><p>radiation exposure. Most will be unlikely to ever return home, as it’s</p><p>estimated the cleanup will take between 30 and 40 years.22</p><p>Although the earthquake itself, the most powerful ever recorded</p><p>in Japan’s history, wreaked unpreventable catastrophic damage that</p><p>killed an estimated 15,000 people,23 it’s now universally accepted</p><p>that the corollary disaster at the nuclear power plant was in fact</p><p>preventable. By the summer of 2012, an independent investigation,</p><p>released after having conducted 900 hours of hearings, interviews</p><p>with over a thousand people, 9 plant tours, 19 committee meetings,</p><p>and 3 town halls, concluded that “the accident was clearly man-</p><p>made” and the “direct causes of the accident were all foreseeable.”24</p><p>Examining the evidence, it becomes clear that in the years leading</p><p>up to the disaster at the Daiichi Nuclear Power Plant, more than</p><p>one Cassandra-like figure spoke up more than once to warn of such</p><p>88 Psychological Safety at Work</p><p>an accident. Recommendations were made for reasonable safety</p><p>measures that would likely have prevented or mitigated the plant’s</p><p>destruction. But each time, the warnings were dismissed or not</p><p>believed. The question is, why?</p><p>In 2006, Katsuhiko Ishibashi, a professor at the Research Center</p><p>for Urban Safety and Security at Kobe University, was appointed to</p><p>a Japanese subcommittee tasked with revising the national guidelines</p><p>on the earthquake-resistance of the country’s nuclear power plants.</p><p>Ishibashi proposed</p><p>that the group review the standards for surveying</p><p>active fault lines and criticized the government’s record of allowing</p><p>the construction of power plants, like Fukushima Daiichi, in areas</p><p>with the potential for such high seismic activity. But the rest of the</p><p>committee, the majority of which consisted of advisors with ties to</p><p>the power companies, rejected his proposal and downplayed his con-</p><p>cerns.25</p><p>The following year, Ishibashi spoke up again, publishing a pre-</p><p>scient article titled Why Worry? Japan’s Nuclear Plants at Grave Risk</p><p>from Quake Damage, with the claim that Japan had been lulled into a</p><p>false sense of confidence after many years of relatively quiet seismic</p><p>activity. An expert on seismicity and plate tectonics in and around</p><p>the Japanese islands, he believed that tectonic plates followed regular</p><p>schedules and that the area in question was overdue for an earth-</p><p>quake. His warning was explicit: “unless radical steps are taken now</p><p>to reduce the vulnerability of nuclear power plants to earthquakes,</p><p>Japan could experience a true nuclear catastrophe in the near future,”</p><p>including one caused by tsunamis.26 Unfortunately, others dismissed</p><p>Ishibashi’s warnings. For instance, Haruki Madarame, a nuclear reg-</p><p>ulator and chairman of Japan’s Nuclear Safety Commission during</p><p>the Fukushima disaster, told the Japanese legislature not to worry, as</p><p>Ishibashi was a “nobody.”27</p><p>If Madarame was harsh in his condemnation of Ishibashi as a</p><p>“nobody,” it’s true that, as an academic rather than an industry or gov-</p><p>ernment official, he was an outsider. He was, perhaps, not as tightly</p><p>bound to the dominant post–World War II push for Japan to become</p><p>independent from its historical dependence on energy imports. Since</p><p>Dangerous Silence 89</p><p>the mid-fifties, the island, which has few fossil fuels in the ground,</p><p>had invested heavily in nuclear energy to diversify its energy supply</p><p>from oil and achieve greater energy security.28 For the next 40 years,</p><p>following the 1970s “oil shocks,” and despite the highly publicized</p><p>1979 Three Mile Island and 1986 Chernobyl accidents, Japan had</p><p>worked doggedly and ferociously to develop its own domestic nuclear</p><p>power production capacity.29 For instance, the government had pro-</p><p>vided subsidies and other incentives for rural towns to build plants. It</p><p>even conducted public relations campaigns to convince citizens that</p><p>nuclear power was safe.30 Even so, public opinion surrounding nuclear</p><p>power remained mixed to negative, with several anti-nuclear demon-</p><p>strations and the abandonment of several plans to build more plants.31</p><p>Given this political context, Ishibashi’s safety concerns may have been</p><p>perceived as unpatriotic or meddlesome.</p><p>A 2000 in-house study by Tokyo Electric Power Company</p><p>(TEPCO), the country’s biggest electric company and the owner</p><p>of the Fukushima Daiichi plant, did acknowledge the possibility</p><p>that Japan could experience a tsunami of as high as 50 feet. In fact,</p><p>the report recommended that measures be taken to provide better</p><p>protection from the risks of flooding. However, nothing was ever</p><p>done because TEPCO thought the risk of such a low probability</p><p>event was unrealistic.32 Japanese regulators like the Nuclear and</p><p>Industrial Safety Agency (NISA) also may have hesitated from</p><p>policing the utilities because, by then, nuclear energy had become</p><p>even more of a strategic priority for Japan, and increased nuclear</p><p>power generation was required to reach the greenhouse gas emission</p><p>goals laid out by the Kyoto protocol. A dozen new plants were</p><p>slated to be built by 2011.33 Prior to the Fukushima disaster, Japan</p><p>was generating 30% of its electricity via nuclear reactors, and the</p><p>government planned to increase that percentage to 40% in the years</p><p>to come.34</p><p>Although safety issues were ostensibly part of the nuclear power</p><p>expansion plans, retrospective investigations demonstrate that the</p><p>government and industry culture had not given due credence or</p><p>consideration to the gravity of existing threats. For example, in a</p><p>90 Psychological Safety at Work</p><p>June 2009 meeting held by NISA specifically to discuss the readiness</p><p>of Fukushima Daiichi to withstand a natural disaster, tsunamis were</p><p>not even on the agenda. The agency simply did not see them as</p><p>likely enough in the Fukushima region to warrant consideration. In</p><p>creating safety guidelines for Fukushima, the panel thus used data</p><p>from the biggest earthquake on record in the area, a 1938 earthquake</p><p>that measured only 7.9 in magnitude and caused only a small</p><p>tsunami. Because the reactors at Fukushima Daiichi were located</p><p>near the sea, TEPCO constructed a seawall – one just tall enough to</p><p>stop a tsunami similar to the one in 1938 from hitting it. The panel</p><p>assumed that the wall was tall enough to stop any future tsunami and</p><p>thus focused mainly on preparing the plant for earthquakes.</p><p>Another Cassandra-like figure spoke up at that June meeting. Dr.</p><p>Yukinobi Okamura, the director of Japan’s Active Fault and Earth-</p><p>quake Research Center, told the panel he disagreed with TEPCO’s</p><p>decision.35 He did not think the 1938 quake was big enough to serve</p><p>as the basis for the Daiichi guidelines and instead brought up a much</p><p>earlier example, the Jogan tsunami, which occurred in AD 869 after</p><p>a massive earthquake. TEPCO representatives, wishing to discredit</p><p>Okamura, minimize his concern, or both, claimed the Jogan earth-</p><p>quake “did not cause much damage.” Okamura insisted otherwise.</p><p>The Jogan tsunami had destroyed castles and killed at least a thou-</p><p>sand people. Historical writings compared the tsunami’s fury to waves</p><p>that “raged like nightmares and immediately reached the city center.”</p><p>Okamura told the panel that he was worried that a tsunami like Jogan</p><p>could overwhelm the Fukushima region and was confused that the</p><p>panel was not using all of the available data.</p><p>Instead of listening and taking Okamura’s concerns seriously,</p><p>as might occur in a culture where psychological safety was high, a</p><p>TEPCO executive countered that it didn’t make sense to base the</p><p>safety recommendations on a legendary earthquake that wasn’t mea-</p><p>sured by contemporary tools and techniques. Besides, this meeting</p><p>was to discuss the risks from earthquakes, rather than tsunamis. The</p><p>meeting moved on, with TEPCO executives saying they would try</p><p>to learn more. The next meeting, Okamura again tried to convince</p><p>Dangerous Silence 91</p><p>the panel of the severity of the threat. He described the predictive</p><p>models his institute had created to show that the current seawall</p><p>would not be high enough for anything above an 8.4 magnitude</p><p>earthquake, and the detailed surveys they’d performed on the sand</p><p>left behind by the Jogan tsunami. In the end, however, the panel did</p><p>not listen.</p><p>Going Along to Get Along</p><p>A culture of silence can thus be understood as a culture in which</p><p>the prevailing winds favor going along rather than offering one’s</p><p>concerns. It is based on the assumption that most people’s voices</p><p>do not offer value and thus will not be valued. Perhaps the most</p><p>cogent indictment of how a culture of silence perpetuated a set of</p><p>attitudes that enabled the Daiichi plant disaster was articulated by</p><p>Kiyoshi Kurokawa, the Chairman of the NAIIC, who wrote at the</p><p>beginning of the English version of the report that</p><p>For all the extensive detail it provides, what this report cannot fully</p><p>convey – especially to a global audience – is the mindset that supported</p><p>the negligence behind this disaster. What must be admitted – very</p><p>painfully – is that this was a disaster “Made in Japan.” Its fundamental</p><p>causes are to be found in the ingrained conventions of Japanese culture: our</p><p>reflexive obedience; our reluctance to question authority; our devotion</p><p>to “sticking with the program”; our groupism; and our insularity.36</p><p>Japanese culture does not have a monopoly on any of the</p><p>ingrained conventions that Kurokawa lists. Each one is endemic of</p><p>a culture with low levels of psychological safety where the internal</p><p>reluctance to speak up or push back combines with a very strong</p><p>desire to look good to the outside world. Concern</p><p>with reputation</p><p>can silence employees’ voices internally as well as externally. Resis-</p><p>tance to warnings about the safety about the Fukushima Daiichi</p><p>plant – and what it would take to install better safety measures – were</p><p>bound up in national aspirations for nuclear energy.</p><p>92 Psychological Safety at Work</p><p>Similar to what we learned about the FRBNY in Chapter 3,</p><p>where another powerful set of institutional bodies tacitly colluded</p><p>to silence the few who dared to speak up, push back, or disagree,</p><p>Japan’s nuclear power industry suffered regulatory capture. Accord-</p><p>ing to Kurokawa, Japan’s long-held policy goal to achieve national</p><p>energy security via nuclear energy became “such a powerful man-</p><p>date, [that] nuclear power became an unstoppable force, immune</p><p>to scrutiny by civil society. Its regulation was entrusted to the same</p><p>government bureaucracy responsible for its promotion.”37 This blind-</p><p>ing need and ambition helped create a culture where “it became</p><p>accepted practice to resist regulatory pressure and cover up small-scale</p><p>accidents . . . that led to the disaster at the Fukushima Daiichi Nuclear</p><p>Plant.”38</p><p>In 2013, a Stanford study concluded that a mere $50 million could</p><p>have financed a wall high enough to prevent the disaster.39 Yet, the</p><p>case shows how very challenging it can be to be heard – to have</p><p>voice welcomed, explored, and sometimes acted upon – when the</p><p>dominant culture does not want to hear the message.</p><p>Silence in the Noisy Age of Social Media</p><p>On October 15, 2017, actress Alyssa Milano tapped fewer than 140</p><p>characters into her personal device: “If you’ve been sexually harassed</p><p>or assaulted write ‘me too’ as a reply to this tweet.” Within 24 hours,</p><p>the hashtag #MeToo had been tweeted nearly half a million times.40</p><p>Although the MeToo movement had been created 10 years earlier</p><p>by Tarana Burke,41 Milano’s tweet, posted in the context of a slew</p><p>of recent and highly publicized sexual harassment accusations leveled</p><p>against celebrities, ignited a social media activism campaign. The goal:</p><p>the simple act of speaking up. Women and men from all walks of life</p><p>who had suffered myriad types of unwanted sexual attention, often</p><p>egregious and persistent, the majority afraid to tell even their closest</p><p>relations, were emboldened to tweet, post, and message about their</p><p>experiences in what became a public forum.</p><p>Dangerous Silence 93</p><p>Milano’s tweet was hardly the first act of speaking up. Nine</p><p>months earlier, on February 19, 2017, the social media landscape</p><p>was emblazoned by a 3000-word blog post written by a young</p><p>software engineer.42 Susan Fowler, who had recently left her job</p><p>as a site-reliability engineer at the ride-sharing company Uber,</p><p>was exercising her right to candor on her personal website. The</p><p>specificity and honesty with which she described her experience,</p><p>which she called “a strange, fascinating, and slightly horrifying</p><p>story,” reveals much about how mechanisms of power and silence</p><p>can perpetuate a psychologically unsafe culture. Fowler’s voice,</p><p>echoed by some of her colleagues, amplified by social media, and</p><p>made louder still by mainstream press, tells us how an unsafe culture</p><p>can ultimately become unsustainable.</p><p>On her first day at the company, Fowler’s manager sent her a series</p><p>of inappropriate messages over the company’s chat system. The man-</p><p>ager told her “he was looking for women to have sex with.” Fowler</p><p>said, “It was clear that he was trying to get me to have sex with</p><p>him . . . ” She took screenshots of the messages and reported the man-</p><p>ager to HR. But things didn’t go as she expected. Both HR and upper</p><p>management informed Fowler that it was “this man’s first offense, and</p><p>that they wouldn’t feel comfortable giving him anything other than a</p><p>warning and a stern talking-to” because he “was a high performer.”</p><p>Fowler was given the choice of either finding another team to work</p><p>on or remaining on her present team with the understanding that her</p><p>manager would “most likely give [her] a poor performance review</p><p>when review time came around, and there was nothing they could do</p><p>about that.” Fowler tried to protest this “choice,” but got nowhere,</p><p>and ultimately ended up switching teams.</p><p>Over the next few months, Fowler met other women engineers</p><p>who had similar experiences of sexual harassment at Uber. They had</p><p>also reported these to HR and gotten nowhere. Some of the women</p><p>even reported having similar interactions with the same manager as</p><p>Fowler. All were told it was his first offense. In each case, nothing</p><p>was done. Fowler and her colleagues, feeling unheard, fell silent –</p><p>for a while.</p><p>94 Psychological Safety at Work</p><p>Ironically, as reported in her blog post, Fowler had been initially</p><p>excited about joining Uber back in November 2015, citing that she</p><p>had “the rare opportunity to choose whichever team was working on</p><p>something that I wanted to be part of.”</p><p>Promoted and Protected</p><p>Uber Technologies, Inc., founded in 2009 by serial entrepreneurs and</p><p>friends Garrett Camp and Travis Kalanick, had launched in San Fran-</p><p>cisco in 2011 with funding from prominent Silicon Valley venture</p><p>capital firms.43 As Uber grew, so did its reputation as an aggressive,</p><p>fast-moving, in-your-face company, not inconsistent with its overt</p><p>intention to disrupt the long-established taxicab industry, replacing</p><p>it with a ride-sharing economy.44 Top employees were “promoted</p><p>and protected” – as long as they could hit or exceed their numbers,</p><p>they were rewarded.45 After Fowler’s post broke, current and former</p><p>employees came forward to describe Uber’s culture as “unrestrained,”</p><p>a “Hobbesian environment . . . in which workers are sometimes pit-</p><p>ted against one another and where a blind eye is turned to infractions</p><p>from top performers.”46 Fowler’s manager had merely been a case in</p><p>point.</p><p>Fowler, like other new Uber hires, had been advised of the</p><p>company’s core values.47 Several of those values were likely to have</p><p>contributed to a psychologically unsafe environment. For example,</p><p>“super-pumpedness,” especially central to the company, involved a</p><p>can-do attitude and doing whatever it took to move the company</p><p>forward. This often meant working long hours, not in itself a</p><p>hallmark of a psychologically unsafe environment; Fowler seems to</p><p>have relished the intellectual challenges and makes a point to say that</p><p>she is “proud” of the engineering work she and her team did. But</p><p>super-pumpedness, with its allusions to the sports arena and male</p><p>hormones, seems to have been a harbinger of the bad times to come.</p><p>Dangerous Silence 95</p><p>Another core value was to “make bold bets,” which was interpreted</p><p>as asking for forgiveness rather than permission. In other words, it</p><p>was better to cross a line, be found out wrong, and ask for forgiveness</p><p>than it was to ask permission to transgress in the first place. Another</p><p>value, “meritocracy and toe-stepping,” meant that employees were</p><p>incented to work autonomously, rather than in teams, and cause</p><p>pain to others to get things done and move forward, even if it meant</p><p>damaging some relationships along the way.48</p><p>You may ask, so what? The same company that silenced, hurt,</p><p>and eventually lost hardworking and talented engineers such as Susan</p><p>Fowler was still tremendously successful in getting millions of people</p><p>to speak with a new vocabulary word – “to uber.” The company’s</p><p>growth was exponential and as of early 2018 is valued at north of $70</p><p>billion.49 Maybe a bit of super-pumpedness and a little toe-stepping</p><p>is just what it takes today to get ahead?</p><p>One problem is that social media enables a new kind of speaking</p><p>up that makes it that much harder for companies to actively and</p><p>shamelessly advocate for a psychologically unsafe culture. Fowler’s</p><p>exposé sent reporters running to investigate. The New York Times</p><p>interviewed over 30 current and former Uber employees and</p><p>reported on numerous incidents of harassment, some as egregious</p><p>as an Uber manager who “groped female co-workers’ breasts at</p><p>a company retreat in Las Vegas” and “a director [who] shouted a</p><p>homophobic slur at a subordinate during a heated confrontation</p><p>in a meeting.”50 According to Fowler, when she joined Uber,</p><p>the engineering site reliability organization was over 25% women,</p><p>but before she left it had dropped to 6%. In the aftermath and</p><p>reckoning that followed Fowler’s blog, multiple lawsuits ensued,</p><p>massive numbers of employees at all levels were either fired or left of</p><p>their own accord, and the company’s valuation and reputation fell far</p><p>and fast.51 A second problem is that people suffer unnecessary harm.</p><p>On June 21, 2017, Travis Kalanick stepped down as Uber’s</p><p>CEO after five of its major shareholders demanded his resignation.52</p><p>96 Psychological Safety at Work</p><p>Although Fowler petitioned the United States Supreme Court to</p><p>consider her experience at Uber in its decision on whether employ-</p><p>ees can forfeit rights to collective litigation in their employment</p><p>contracts, the proposal was later voted down.53 That year, she was</p><p>featured on the cover of TIME Magazine as one of its “Person(s) of the</p><p>Year” as one of five “Silence Breakers” who spoke out about sexual</p><p>harassment in 2017.54 She was also named The Financial Times “Per-</p><p>son of the Year 2017,”55 one of Vanity Fair’s “New Establishments,”56</p><p>and No. 2 on Recode’s Top 100, behind only Jeff Bezos.57</p><p>Susan Fowler at Uber is just one example of how social media</p><p>has enabled the speaking of truth to power in the workplace. In</p><p>2017, thousands of women spoke up to say, “Me Too,” to workplace</p><p>harassment, and hundreds of men in high-profile positions suffered</p><p>the consequences of behavior that had, in many cases, worked for</p><p>awhile – decades, or even entire careers. Communication technology</p><p>gave social media movements such as MeToo and Black Lives Matter</p><p>the power to ignite and move with rapidity into mainstream media,</p><p>public opinion, and in some cases, into the legal courts. Such move-</p><p>ments raise the sense of urgency to create and maintain organizations</p><p>where psychological safety supports people to do their best work.</p><p>When Uber’s new CEO, Dara Khosrowshahi, first came on board</p><p>in August 2017, one of his priorities was to meet with women engi-</p><p>neers. Alert to the damage done to the company’s culture, he began</p><p>by laying the groundwork for a psychologically safe workplace. As</p><p>Jessica Bryndza, Uber’s Global Director of People Experience, com-</p><p>mented, “He [Khosrowshahi] didn’t come in guns blazing. He came</p><p>in listening.”58</p><p>The operative word here is “listening.” In the Chapters 5 and 6,</p><p>you will read about eight flourishing organizations where leaders have</p><p>created the conditions to make listening and speaking up the norm,</p><p>not the exception. In these fearless workplaces, it’s far less likely that</p><p>employees will refrain from sharing valuable information, insights, or</p><p>questions and far more likely that leaders will listen to rather than</p><p>dismiss bad news or early warnings.</p><p>Dangerous Silence 97</p><p>Chapter 4 Takeaways</p><p>◾ When people fail to speak up with their concerns or ques-</p><p>tions, the physical safety of customers or employees is at risk,</p><p>sometimes leading to tragic loss of life.</p><p>◾ Excessive confidence in authority is a risk factor in psycholog-</p><p>ical and physical safety.</p><p>◾ A culture of silence is a dangerous culture.</p><p>Endnotes</p><p>1. Harris. S.J. “Syd Cannot Stand Christmas Neckties.” The Akron</p><p>Beacon Journal. January 5, 1951, pp. 6. https://www.newspapers.com/</p><p>newspage/147433987/ Accessed July 23, 2018</p><p>2. Roberto, M.A, Edmondson, A.C., &. Bohmer, R.J., Columbia’s Final</p><p>Mission. Case Study. HBS No. 304-090. Boston, MA: Harvard Busi-</p><p>ness School Publishing, 2004.</p><p>3. Whitcraft, D., Katz, D., & Day, T. (Producers). “Columbia: Final Mis-</p><p>sion,” ABC Primetime. New York: ABC News, 2003.</p><p>4. National Aeronautics and Space Administration. Columbia Acci-</p><p>dent Investigation Board: Report Volume 1. Washington, D.C.: U.S.</p><p>Government Printing Office, 2003.</p><p>5. Whitcraft, D. et al. 2003, op cit.</p><p>6. The story of the disaster on Tenerife in this chapter draws on a number</p><p>of sources produced by Jan Hagen and his colleagues, including:</p><p>◾ Schafer, U., Hagen, J., & Burger, C. Mr. KLM (A): Jacob Veld-</p><p>huyzen. Case Study. ESMT No. 411-0117. Berlin, Germany: Euro-</p><p>pean School of Management and Technology, 2011.</p><p>◾ Schafer, U., Hagen, J., & Burger, C. Mr. KLM (B): Captain van Zan-</p><p>ten. Case Study. ESMT No. 411-0118. Berlin, Germany: European</p><p>School of Management and Technology, 2011.</p><p>◾ Schafer, U., Hagen, J., & Burger, C. Mr. KLM (C): Jaap. Case Study.</p><p>ESMT No. 411-0119. Berlin, Germany: European School of Man-</p><p>agement and Technology, 2011.</p><p>◾ Hagen, J.U. Confronting Mistakes: Lessons From The Aviation Industry</p><p>When Dealing with Error. United Kingdom: Palgrave Macmillan UK,</p><p>2013. Print.</p><p>https://www.newspapers.com/newspage/147433987/</p><p>https://www.newspapers.com/newspage/147433987/</p><p>98 Psychological Safety at Work</p><p>7. Royal Dutch Airlines is Koninklijke Luchtvaart Maatschappij in Dutch,</p><p>abbreviated as KLM.</p><p>8. The dialogue reported in this story was captured by the cockpit voice</p><p>recorders of both planes involved in the collision and reported in</p><p>Appendix 6 of the following investigation report: Air Line Pilots</p><p>Association. Aircraft accident report: Human factors report on the Tenerife</p><p>accident, Tenerife, Canary Islands, March 27, 1977. Washington D.C.:</p><p>Engineering and Air Safety, 1977.</p><p>9. For history and background on CRM, refer to Alan Diehl’s book on air</p><p>safety: Diehl, A.E. Air Safety Investigators: Using Science to Save Lives – One</p><p>Crash at a Time. United States: XLIBRIS, 2013. Print.</p><p>10. The story of Betsy Lehman’s death at the Dana-Farber Cancer Institute</p><p>in this chapter draws on information from a case study by my colleague</p><p>Richard Bohmer: Bohmer, R. & Winslow, A. The Dana-Farber Cancer</p><p>Institute. Case Study. HBS Case No. 699-025. Boston, MA: Harvard</p><p>Business School Publishing, 1999.</p><p>11. The Boston Globe broke the Lehman story and continued to follow it</p><p>closely in the months and years that followed. Richard Knox, who was</p><p>later sued for his coverage of the incident, wrote the first article about</p><p>the error: Knox, R.A. “Doctor’s Orders Killed Cancer Patient.” The</p><p>Boston Globe, March 23, 1995.</p><p>12. Bohmer, R. & Winslow, A. 1999: 8.</p><p>13. Gorman, C. & Mondi, L. “The disturbing case of the cure that killed</p><p>the patient.” TIME Magazine. April 3, 1995: 60. http://content</p><p>.time.com/time/magazine/article/0,9171,982768,00.html Accessed</p><p>June 14, 2018.</p><p>14. Bohmer, R. & Winslow, A. 1999, op cit.</p><p>15. Ibid.</p><p>16. Knox, March 23, 1995, op cit.</p><p>17. Ibid.</p><p>18. Ibid.</p><p>19. Ibid.</p><p>20. Knox, R.A. “Dana-Farber puts focus on mistakes in overdoses.” The</p><p>Boston Globe. October 31, 1995. https://www.highbeam.com/doc/</p><p>1P2-8310418.html Accessed June 12, 2018.</p><p>21. Details on the disaster at Fukushima Daiichi come from multiple reports:</p><p>◾ Fukushima Nuclear Accident Independent Investigation Commis-</p><p>sion (NAIIC). “Official Report of the Fukushima Nuclear Accident</p><p>http://content.time.com/time/magazine/article/0,9171,982768,00.html</p><p>http://content.time.com/time/magazine/article/0,9171,982768,00.html</p><p>https://www.highbeam.com/doc/1P2-8310418.html</p><p>https://www.highbeam.com/doc/1P2-8310418.html</p><p>Dangerous Silence 99</p><p>Independent Investigation Commission: Executive Summary.”</p><p>National Diet of Japan. 2012. https://www.nirs.org/wp-content/</p><p>uploads/fukushima/naiic_report.pdf Accessed June 12, 2018.</p><p>◾ Amano, Y. “The Fukushima Daiichi Accident: Report by the</p><p>Director General.” International Atomic Energy Agency Report. 2015.</p><p>https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1710-</p><p>ReportByTheDG-Web.pdf Accessed June 12, 2018.</p><p>22. Amano, Y. 2015, op cit.</p><p>23. Ibid.</p><p>24. Fukushima NAIIC. 2012: 16.</p><p>25. Clenfield, J. & Sato, S. “Japan Nuclear Energy Drive Compromised</p><p>by Conflicts of Interest.” Bloomberg. December 12, 2007. http://www</p><p>.bloomberg.com/apps/news?pid=newsarchive&sid=awR8KsLlAcSo</p><p>Accessed June 12, 2018.</p><p>26. Ishibashi, K. “Why Worry? Japan’s Nuclear Plants at Grave Risk From</p><p>Quake Damage.” The Asia-Pacific Journal. August 1, 2007. https://apjjf</p><p>.org/-Ishibashi-Katsuhiko/2495/article.html Accessed June 12, 2018.</p><p>27. Clenfield, J. “Nuclear Regulator Dismissed</p><p>Seismologist on Japan</p><p>Quake Threat.” Bloomberg.com. November 21, 2011. https://www</p><p>.bloomberg.com/news/articles/2011-11-21/nuclear-regulator-</p><p>dismissed-seismologist-on-japan-quake-threat Accessed June 12,</p><p>2018.</p><p>28. World Nuclear Association. “Nuclear Power in Japan.” World-Nuclear.org</p><p>www.world-nuclear.org/information-library/country-profiles/</p><p>countries-g-n/japan-nuclear-power.aspx. Accessed June 4, 2018.</p><p>29. Ibid.</p><p>30. Aldrich, D.P. “With a Mighty Hand.” The New Republic. March 19,</p><p>2011. https://newrepublic.com/article/85463/japan-nuclear-power-</p><p>regulation Accessed June 11, 2018.</p><p>31. See, for instance: BBC News. “Japan cancels nuclear power plant.” BBC</p><p>News. February 22, 2000. http://news.bbc.co.uk/2/hi/asia-pacific/</p><p>652169.stm Accessed June 10, 2018.</p><p>32. Tokyo Electric Power Company. “Fukushima Nuclear Accident</p><p>Summary & Nuclear Safety Reform Plan” Tokyo Electric Power</p><p>Company, Inc. March 29, 2013: 19. As the company wrote in this</p><p>report after the Fukushima disaster: “in June and July of [2000], the</p><p>cost of constructing flooding embankment to protect against tsunami</p><p>and the impact on surrounding areas were evaluated. The reliability</p><p>https://www.nirs.org/wp-content/uploads/fukushima/naiic_report.pdf</p><p>https://www.nirs.org/wp-content/uploads/fukushima/naiic_report.pdf</p><p>https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1710-ReportByTheDG-Web.pdf</p><p>https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1710-ReportByTheDG-Web.pdf</p><p>http://www.bloomberg.com/apps/news?pid=newsarchive&sid=awR8KsLlAcSo</p><p>http://www.bloomberg.com/apps/news?pid=newsarchive&sid=awR8KsLlAcSo</p><p>https://apjjf.org/-Ishibashi-Katsuhiko/2495/article.html</p><p>https://apjjf.org/-Ishibashi-Katsuhiko/2495/article.html</p><p>https://www.bloomberg.com/news/articles/2011-11-21/nuclear-regulator-dismissed-seismologist-on-japan-quake-threat</p><p>https://www.bloomberg.com/news/articles/2011-11-21/nuclear-regulator-dismissed-seismologist-on-japan-quake-threat</p><p>https://www.bloomberg.com/news/articles/2011-11-21/nuclear-regulator-dismissed-seismologist-on-japan-quake-threat</p><p>www.world-nuclear.org/information-library/country-profiles/countries-g-n/japan-nuclear-power.aspx</p><p>www.world-nuclear.org/information-library/country-profiles/countries-g-n/japan-nuclear-power.aspx</p><p>https://newrepublic.com/article/85463/japan-nuclear-power-regulation</p><p>https://newrepublic.com/article/85463/japan-nuclear-power-regulation</p><p>http://news.bbc.co.uk/2/hi/asia-pacific/652169.stm</p><p>http://news.bbc.co.uk/2/hi/asia-pacific/</p><p>http://news.bbc.co.uk/2/hi/asia-pacific/652169.stm</p><p>http://Bloomberg.com</p><p>http://World-Nuclear.org</p><p>100 Psychological Safety at Work</p><p>of the computational result was also discussed.” But they ultimately</p><p>concluded that the “technological validity” of such a model could not</p><p>be verified, and did nothing more.</p><p>33. World Nuclear Association. “Nuclear Power in Japan,” op cit.</p><p>34. Ibid.</p><p>35. All information from the Okamura story is from Clarke, R. & Eddy,</p><p>R.P. Warnings: Finding Cassandras to Stop Catastrophes. HarperCollins</p><p>Publishing, 2017, Chapter 5, pp. 75-98.</p><p>36. Fukushima NAIIC. 2012: 9</p><p>37. Ibid.</p><p>38. Ibid.</p><p>39. Lipscy, P.Y., Kushida, K.E., & Incerti, T. “The Fukushima Disaster</p><p>and Japan’s Nuclear Plant Vulnerability in Comparative Perspective.”</p><p>American Chemical Society: Environmental Science & Technology, (2013): 47,</p><p>6082–6088.</p><p>40. Gilbert, S. “The Movement of #MeToo: How a Hashtag Got Its</p><p>Power.” The Atlantic. October 16, 2017. https://www.theatlantic</p><p>.com/entertainment/archive/2017/10/the-movement-of-metoo/</p><p>542979/ Accessed June 14, 2018.</p><p>41. Garcia, S.E. “The Woman Who Created #MeToo Long Before</p><p>Hashtags.” The New York Times. October 20, 2017. https://www</p><p>.nytimes.com/2017/10/20/us/me-too-movement-tarana-burke.html</p><p>Accessed June 13, 2018.</p><p>42. Fowler, S. “Reflecting on One Very, Very Strange Year at Uber.” Susan</p><p>Fowler personal site. February 19, 2017. https://www.susanjfowler</p><p>.com/blog/2017/2/19/reflecting-on-one-very-strange-year-at-uber</p><p>Accessed June 5, 2018</p><p>43. Several details on Uber were taken from a case written by my friend Jay</p><p>Lorsch and colleagues: Srinivasan, S., Lorsch, J.W., & Pitcher, Q. Uber</p><p>in 2017: One Bumpy Ride. Case Study. HBS No. 117-070. Boston,</p><p>MA: Harvard Business School Publishing, 2017.</p><p>44. Isaac, M. “Inside Uber’s Aggressive, Unrestrained Workplace Culture.”</p><p>The New York Times. February 22, 2017. https://www.nytimes.com/</p><p>2017/02/22/technology/uber-workplace-culture.html Accessed June</p><p>13, 2018.</p><p>45. Isaac, M. “Uber’s C.E.O. Plays With Fire.” The New York Times. April</p><p>23, 2017. https://www.nytimes.com/2017/04/23/technology/travis-</p><p>kalanick-pushes-uber-and-himself-to-the-precipice.html Accessed</p><p>June 13, 2018.</p><p>46. Isaac, M. February 22, 2017, op cit.</p><p>https://www.theatlantic.com/entertainment/archive/2017/10/the-movement-of-metoo/542979/</p><p>https://www.theatlantic.com/entertainment/archive/2017/10/the-movement-of-metoo/542979/</p><p>https://www.theatlantic.com/entertainment/archive/2017/10/the-movement-of-metoo/542979/</p><p>https://www.nytimes.com/2017/10/20/us/me-too-movement-tarana-burke.html</p><p>https://www.nytimes.com/2017/10/20/us/me-too-movement-tarana-burke.html</p><p>https://www.susanjfowler.com/blog/2017/2/19/reflecting-on-one-very-strange-year-at-uber</p><p>https://www.susanjfowler.com/blog/2017/2/19/reflecting-on-one-very-strange-year-at-uber</p><p>https://www.nytimes.com/2017/02/22/technology/uber-workplace-culture.html</p><p>https://www.nytimes.com/2017/02/22/technology/uber-workplace-culture.html</p><p>https://www.nytimes.com/2017/04/23/technology/travis-kalanick-pushes-uber-and-himself-to-the-precipice.html</p><p>https://www.nytimes.com/2017/04/23/technology/travis-kalanick-pushes-uber-and-himself-to-the-precipice.html</p><p>Dangerous Silence 101</p><p>47. Quora. “What Are Uber’s 14 Cultural Values?” Quora, https://www</p><p>.quora.com/What-are-Ubers-14-core-cultural-values</p><p>48. Ibid.</p><p>49. Schleifer, T. “Uber’s latest valuation: $72 billion.” Recode. February</p><p>9, 2018. https://www.recode.net/2018/2/9/16996834/uber-latest-</p><p>valuation-72-billion-waymo-lawsuit-settlement Accessed June 13,</p><p>2018.</p><p>50. Isaac, M. February 22, 2017, op cit.</p><p>51. Srinivasan, S., Lorsch, J.W., & Pitcher, Q. Uber in 2017: One Bumpy</p><p>Ride. Case Study. HBS No. 117-070. Boston, MA: Harvard Business</p><p>School Publishing, 2017.</p><p>52. Isaac, M. “Uber Founder Travis Kalanick Resigns as C.E.O.” The New</p><p>York Times. June 21, 2017. https://www.nytimes.com/2017/06/21/</p><p>technology/uber-ceo-travis-kalanick.html Accessed June 13, 2018.</p><p>53. Blumberg, P. “Ex-Uber Engineer Asks Supreme Court to Learn From</p><p>Her Ordeal.” Bloomberg.Com. August 24, 2017; Hurley, L. “Companies</p><p>win big at U.S. top court on worker class-action curbs.” Reuters. May</p><p>21, 2018.</p><p>54. Kim, L. “Two Bay Area Women on Time Cover for ‘Person of the</p><p>Year.’” ABC7 San Francisco. December 7, 2017.</p><p>55. Hook, L. “FT Person of the Year: Susan Fowler.” Financial Times.</p><p>December 12, 2017.</p><p>56. Morse, B. “Elon Musk, Susan Fowler, and Mark Zuckerberg Join Tech’s</p><p>Biggest Names in ‘New Establishment’ List.” Inc.com. October 2, 2017.</p><p>https://www.inc.com/brittany-morse/elon-musk-susan-fowler-and-</p><p>markzerberg-join-big-tech-names-in-new-establishment-list.html</p><p>Accessed June 8, 2018.</p><p>57. Bhuiyan, J. “With Just Her Words, Susan Fowler Brought Uber to Its</p><p>Knees.” Recode, December 6, 2017. https://www.recode.net/2017/</p><p>12/6/16680602/susan-fowler-uber-engineer-recode-100-diversity-</p><p>sexual-harassment Accessed June 12, 2018.</p><p>58. Kerr, D. “Uber’s U-Turn: How the New CEO Is Cleaning House after</p><p>Scandals and Lawsuits.” C-NET. April 27, 2018. https://www.cnet</p><p>.com/news/ubers-u-turn-how-ceo-dara-khosrowshahi-is-cleaning-</p><p>up-after-scandals-and-lawsuits/ Accessed June 14, 2018.</p><p>https://www.quora.com/What-are-Ubers-14-core-cultural-values</p><p>https://www.quora.com/What-are-Ubers-14-core-cultural-values</p><p>https://www.recode.net/2018/2/9/16996834/uber-latest-valuation-72-billion-waymo-lawsuit-settlement</p><p>https://www.recode.net/2018/2/9/16996834/uber-latest-valuation-72-billion-waymo-lawsuit-settlement</p><p>https://www.nytimes.com/2017/06/21/technology/uber-ceo-travis-kalanick.html</p><p>https://www.nytimes.com/2017/06/21/technology/uber-ceo-travis-kalanick.html</p><p>showed up unexpectedly – in what I would later describe as a blind-</p><p>ing flash of the obvious – to explain some puzzling results in my data.</p><p>Today, studies of psychological safety can be found in sectors ranging</p><p>from business to healthcare to K–12 education. Over the past 20 years,</p><p>a burgeoning academic literature has taken shape on the causes and</p><p>consequences of psychological safety in the workplace, some of which</p><p>is my own work but a great deal of which has been done by other</p><p>researchers. We have learned a lot about what psychological safety is,</p><p>how psychological safety works, and why psychological safety mat-</p><p>ters. I’ll summarize key findings from these studies in this book.</p><p>Recently, the concept of psychological safety has taken hold</p><p>among practitioners as well. Thoughtful executives, managers,</p><p>consultants, and clinicians in a variety of industries are seeking</p><p>xviii Introduction</p><p>to help their organizations make changes to create psychological</p><p>safety as a strategy to promote learning, innovation, and employee</p><p>engagement. Psychological safety received a significant boost in</p><p>popularity in the managerial blogosphere after Charles Duhigg</p><p>published an article in the New York Times Magazine in February</p><p>2016, reporting on a five-year study at Google that investigated</p><p>what made the best teams.8 The study examined several possibilities:</p><p>Did it matter if teammates have similar educational backgrounds?</p><p>Was gender balance important? What about socializing outside of</p><p>work? No clear set of parameters emerged. Project Aristotle, as the</p><p>initiative was code-named, then turned to studying norms; that is,</p><p>the behaviors and unwritten rules to which a group adheres often</p><p>without much conscious attention. Eventually, as Duhigg wrote,</p><p>the researchers “encountered the concept of psychological safety</p><p>in academic papers [and] everything suddenly fell into place.”9</p><p>They concluded, “psychological safety was far and away the most</p><p>important of the five dynamics we found.”10 Other behaviors were</p><p>also important, such as setting clear goals and reinforcing mutual</p><p>accountability, but unless team members felt psychologically safe,</p><p>the other behaviors were insufficient. Indeed, as the study’s lead</p><p>researcher, Julia Rozovsky, wrote, “it’s the underpinning of the other</p><p>four.”11 Reflecting her wonderfully concise conclusion, Chapter 1</p><p>of this book is titled “The Underpinning.”</p><p>Overview of the Book</p><p>This book is divided into three parts. Part I: The Power of Psychological</p><p>Safety consists of two chapters that introduce the concept of psycho-</p><p>logical safety and offer a brief history of the research on this important</p><p>workplace phenomenon. We’ll look at why psychological safety mat-</p><p>ters, as well as why it’s not the norm in many organizations.</p><p>Chapter 1, “The Underpinning,” opens with a disguised true</p><p>story taking place in a hospital that shows at once the ordinariness</p><p>of an employee holding back at work – not sharing a concern or</p><p>Introduction xix</p><p>a question – as well as the profound implications this human reflex</p><p>can have for the quality of work in almost any organization. I will</p><p>also recall the story of how I stumbled into psychological safety by</p><p>accident early in my academic career.</p><p>Chapter 2, “The Paper Trail,” presents key findings from a</p><p>systematic review of academic research on psychological safety.</p><p>I don’t provide many details of individual studies but rather give</p><p>an overview of how research on psychological safety has provided</p><p>evidence supporting the central argument in this book – that no</p><p>twenty-first century organization can afford to have a culture of fear.</p><p>The Fearless Organization is not only a better place for employees, it’s</p><p>also a place where innovation, growth, and performance take hold. If</p><p>readers want to skim this evidence and move quickly to Part II, they</p><p>will be rewarded by a series of case studies that clearly illuminate first</p><p>the costs of not having psychological safety and next the rewards of</p><p>investing in building it.</p><p>The four chapters in Part II: Psychological Safety at Work present</p><p>real-world case studies of workplaces in both private and public-sector</p><p>organizations to show how psychological safety (or its absence) shapes</p><p>business results and human safety performance.</p><p>Chapter 3, “Avoidable Failure,” digs into cases in which</p><p>workplace fear allowed an illusion of business success, postponing</p><p>inevitable discoveries of underlying problems that had gone unre-</p><p>ported and unaddressed for a period of time. Here we will see iconic</p><p>companies that appeared to be industry stars only to suffer dramatic</p><p>and highly-publicized falls from grace. Chapter 4, “Dangerous</p><p>Silence,” highlights workplaces where employees, customers, or</p><p>communities suffered avoidable physical or emotional harm because</p><p>employees, living in a culture of fear, were reluctant to speak up, ask</p><p>questions, or get help.</p><p>Chapters 5 and 6 take us into organizations that have worked</p><p>diligently to create an environment where speaking up is enabled</p><p>and expected. These organizational portraits allow us to see what a</p><p>fearless organization looks and feels like. They are strikingly different</p><p>from those highlighted in Chapters 3 and 4, but importantly they are</p><p>xx Introduction</p><p>also very different from each other. There is more than one way to be</p><p>fearless! Chapter 5 (“The Fearless Workplace”) presents companies</p><p>(like Pixar) where creative work is directly and obviously critical</p><p>to business performance and where leaders understood the need to</p><p>create psychological safety early in their tenure, as well as companies</p><p>like Barry-Wehmilller, an industrial equipment manufacturer that</p><p>underwent a transformational journey to discover that the business</p><p>thrives when employees thrive. Chapter 6 (“Safe and Sound”)</p><p>examines workplaces where psychological safety helps to ensure</p><p>employee and client safety and dignity.</p><p>Part III: Creating a Fearless Organization presents two chapters that</p><p>build on the stories and research presented so far to focus on the</p><p>question of what leaders must do to create a fearless organization – an</p><p>organization where everyone can bring his or her full self to work,</p><p>contribute, grow, thrive, and team up to produce remarkable results.</p><p>Chapter 7, “Making It Happen,” tackles the question of what you</p><p>need to do to build psychological safety – and how to get it back if it’s</p><p>lost. It contains the leader’s tool kit. I present a framework with three</p><p>simple (but not always easy) activities that leaders – at the top and</p><p>throughout an organization – can use to create a more engaged and</p><p>vital workforce. We’ll see that creating psychological safety takes effort</p><p>and skill, but the effort pays off when expertise or collaboration matter</p><p>to the quality of the work. We will also see that the leader’s work</p><p>is never done. It’s not a matter of checking the psychological safety</p><p>box and moving on. Building and reinforcing the work environment</p><p>where people can learn, innovate, and grow is a never-ending job,</p><p>but a deeply meaningful one. Chapter 8, “What’s Next,” concludes</p><p>the book, updates a few stories, and offers answers to some of the</p><p>questions I am most frequently asked by people in companies around</p><p>the world.</p><p>*****</p><p>In an era when no individual can know or do everything needed</p><p>to carry out the work that serves customers, it’s more important than</p><p>ever for people to speak up, share information, contribute expertise,</p><p>Introduction xxi</p><p>take risks, and work with each other to create lasting value. Yet, as</p><p>Edmund Burke wrote more than 250 years ago, fear limits our abil-</p><p>ity for effective thought and action – even for the most talented of</p><p>employees. Today’s leaders must be willing to take on the job of driv-</p><p>ing fear out of the organization to create the conditions for learning,</p><p>innovation, and growth. I hope this book will help you do just that.</p><p>Endnotes</p><p>1. Burke, E. A Philosophical Inquiry into the Origin of Our Ideas of the Sublime</p><p>and Beautiful. Dancing Unicorn Books, 2016. Print.</p><p>2. Selingo, J.J. “Wanted: Factory Workers, Degree Required.” The New</p><p>York Times.</p><p>https://www.inc.com/brittany-morse/elon-musk-susan-fowler-and-markzerberg-join-big-tech-names-in-new-establishment-list.html</p><p>https://www.inc.com/brittany-morse/elon-musk-susan-fowler-and-markzerberg-join-big-tech-names-in-new-establishment-list.html</p><p>https://www.recode.net/2017/12/6/16680602/susan-fowler-uber-engineer-recode-100-diversity-sexual-harassment</p><p>https://www.recode.net/2017/12/6/16680602/susan-fowler-uber-engineer-recode-100-diversity-sexual-harassment</p><p>https://www.recode.net/2017/12/6/16680602/susan-fowler-uber-engineer-recode-100-diversity-sexual-harassment</p><p>https://www.cnet.com/news/ubers-u-turn-how-ceo-dara-khosrowshahi-is-cleaning-up-after-scandals-and-lawsuits/</p><p>https://www.cnet.com/news/ubers-u-turn-how-ceo-dara-khosrowshahi-is-cleaning-up-after-scandals-and-lawsuits/</p><p>https://www.cnet.com/news/ubers-u-turn-how-ceo-dara-khosrowshahi-is-cleaning-up-after-scandals-and-lawsuits/</p><p>http://Bloomberg.com</p><p>http://Inc.com</p><p>5</p><p>The Fearless</p><p>Workplace</p><p>The only thing we have to fear is fear itself.</p><p>—Franklin D. Roosevelt1</p><p>Perhaps the truly fearless workplace is an impossibility. People are</p><p>naturally averse to losing their standing in the eyes of peers and bosses.</p><p>Nonetheless, a growing number of organizations are making the fear-</p><p>less workplace an aspiration. Leaders of these organizations recognize</p><p>that psychological safety is mission critical when knowledge is a cru-</p><p>cial source of value. In that sense, the fearless organization is some-</p><p>thing to continually strive toward rather than to achieve once and for</p><p>all. It’s a never-ending and dynamic journey.</p><p>In this chapter I describe the practices and culture that a handful</p><p>of successful companies have worked hard to create - to show how</p><p>psychological safety works. When people speak up, ask questions,</p><p>debate vigorously, and commit themselves to continuous learning and</p><p>improvement, good things happen. It’s not that it’s easy, or always</p><p>enjoyable, but as you will see in the pages ahead, investing the effort</p><p>103</p><p>104 Psychological Safety at Work</p><p>and living with the challenges pays off. Workplaces where employees</p><p>know that their input is valued create new possibilities for authentic</p><p>engagement and stellar performance.</p><p>The organizations profiled in this chapter thus provide a glimpse</p><p>into what psychologically safe workplaces look like; they show what</p><p>happens – for the quality of the product, for customers, and for share-</p><p>holders – when employees are freed up to express their ideas, ques-</p><p>tions, and concerns. Fewer in number than their more fearful coun-</p><p>terparts, these organizations boast a hidden source of competitive</p><p>advantage, which plays out in a variety of ways, depending on the</p><p>industry, the company leaders, and the nature of the work.</p><p>As we will see, there is more than one way in which psycholog-</p><p>ical safety manifests in the workplace. When a team, department, or</p><p>organization gets psychological safety right, it can seem remarkably</p><p>straightforward, especially when compared to the stories of people</p><p>navigating the interpersonal and conversational complexities created</p><p>by fear and distrust. For this reason, you may notice the relative sim-</p><p>plicity of these “good news” stories. You’ll hear more from leaders, in</p><p>their own words, in this chapter, about their visions and philosophies</p><p>about effective workplaces in a fast-paced world. This is because the</p><p>individuals you’ll meet in the pages ahead tended to have thought</p><p>deeply to inform conscious decisions about creating workplaces to</p><p>bring out the best in people.</p><p>The companies profiled in this chapter range from the creative</p><p>fields of film and fashion to high-tech computing and finance to</p><p>machine manufacturing. Yet, for all the striking differences, each of</p><p>the companies profiled relies on employee learning, ingenuity and</p><p>engagement for its success.</p><p>Making Candor Real</p><p>If you were over the age of three in 1995, chances are you were</p><p>aware – or would soon become aware – of a movie called Toy Story,</p><p>the first computer animated feature film released by a company named</p><p>The Fearless Workplace 105</p><p>Pixar. That year, Toy Story would become the highest grossing film</p><p>and Pixar the largest initial public offering.2 The rest, as they say, is</p><p>history. Pixar Animation Studios has since produced 19 feature films,</p><p>all of which have been commercial and critical triumphs. This is a</p><p>remarkable statement in an industry where hits are prized but rare, and</p><p>a series of hits without fail from a single company is all but unheard</p><p>of. How do they do it? Through leadership that creates the conditions</p><p>where both creativity and criticism can flourish. Pixar may be in the</p><p>business of creating and animating stories, but the way the company</p><p>works offers lessons about psychological safety that, much like their</p><p>movies, are universal.</p><p>Pixar co-founder Ed Catmull credits the studio’s success, in part,</p><p>to candor. His definition of candor as forthrightness or frankness3 and</p><p>his insight that we associate the word “candor” with truth-telling and</p><p>a lack of reserve support psychological safety’s tenets. When candor</p><p>is part of a workplace culture, people don’t feel silenced. They don’t</p><p>keep their thoughts to themselves. They say what’s on their minds</p><p>and share ideas, opinions, and criticisms. Ideally, they laugh together</p><p>and speak noisily. Catmull encourages candor by looking for ways to</p><p>institutionalize it in the organization – most notably, in what Pixar</p><p>calls its “Braintrust.”</p><p>A small group that meets every few months or so to assess a movie</p><p>in process, provide candid feedback to the director, and help solve</p><p>creative problems, the Braintrust was launched in 1999, when Pixar</p><p>was rushing to save Toy Story 2, which had gone off the rails. The</p><p>Braintrust’s recipe is fairly simple: a group of directors and storytellers</p><p>watches an early run of the movie together, eats lunch together, and</p><p>then provides feedback to the director about what they think worked</p><p>and what did not. But the recipe’s key ingredient is candor. And can-</p><p>dor, though simple, is never easy.</p><p>Embracing the bad on the journey to good</p><p>As Catmull candidly admits, “ . . . early on, all of our movies suck.”4</p><p>In other words, it would have been easy to make Toy Story a movie</p><p>106 Psychological Safety at Work</p><p>about the secret life of toys that was sappy and boring. But the creative</p><p>process, innately iterative, relies on feedback that is truly honest. If</p><p>the people in the Braintrust room had murmured words of polite</p><p>praise for early screenings rather than feeling safe enough to candidly</p><p>say what they felt was wrong, missing, or unclear or made no sense,</p><p>chances are that Toy Story and Toy Story 2 would not have soared into</p><p>the cinematic stratosphere.</p><p>Pixar’s Braintrust has rules. First, feedback must be construc-</p><p>tive – and about the project, not the person. Similarly, the filmmaker</p><p>cannot be defensive or take criticism personally and must be ready</p><p>to hear the truth. Second, the comments are suggestions, not</p><p>prescriptions. There are no mandates, top-down or otherwise; the</p><p>director is ultimately the one responsible for the movie and can take</p><p>or leave solutions offered. Third, candid feedback is not a “gotcha”</p><p>but must come from a place of empathy. It helps that the directors</p><p>have often already gone through the process themselves. Praise and</p><p>appreciation, especially for the director’s vision and ambition, are</p><p>doled out in heaping measures. Catmull, again: “The Braintrust</p><p>is benevolent. It wants to help. And it has no selfish agenda.”5</p><p>The Braintrust, seen as a neutral and free-floating “it” rather than</p><p>as a fearsome “them,” is perceived as more than the sum of its</p><p>individual members. When people feel psychologically safe enough</p><p>to contribute insight, opinion, or suggestion, the knowledge in the</p><p>room thereby increases exponentially. This is because individual</p><p>observations and suggestions build on each other, taking new shape</p><p>and creating new value, especially compared to what happens when</p><p>individual feedback is collected separately.</p><p>Braintrusts – groups of people with a shared</p><p>agenda who offer</p><p>candid feedback to their peers – are subject to individual personali-</p><p>ties and chemistries. In other words, they can easily go off the rails if</p><p>the process isn’t well led. To be effective, managers have to monitor</p><p>dynamics continually over time. It helps enormously if people respect</p><p>each other’s expertise and trust each other’s opinions. Pixar director</p><p>Andrew Stanton offers advice for how to choose people for an effec-</p><p>tive feedback group. They must, he says, “make you think smarter and</p><p>The Fearless Workplace 107</p><p>put lots of solutions on the table in a short amount of time.”6 Stan-</p><p>ton’s point about having people around who make us “think smarter”</p><p>gets to the heart of why psychological safety is essential to innovation</p><p>and progress. We can only think smarter if others in the room speak</p><p>their minds.</p><p>Sadly, a caveat is necessary here. In late 2017, Ed Catmull’s</p><p>co-founder and Pixar’s chief creative officer, John Lasseter, stepped</p><p>down for behavioral misconduct and apologized in an email to</p><p>“anyone who has ever been on the receiving end of an unwanted</p><p>hug or any other gesture they felt crossed the line in any way, shape</p><p>or form.”7 Complaints by individual Pixar employees about Lasseter’s</p><p>harassment soon followed. Lasseter’s behavior and consequent outing,</p><p>part of the MeToo movement, which I will discuss in Chapter 6,</p><p>underscores the fragile and temporal nature of psychological safety.</p><p>Unwanted physical attention easily undermines hard-earned trust.</p><p>The Braintrust resembles what the academic community calls</p><p>peer review – a process by which other experts in the field read</p><p>and offer constructive criticism on a colleague’s article draft or book</p><p>in-progress. This can be invaluable input for improvement, and</p><p>it’s almost always the case that a published article is vastly better</p><p>than the original submitted manuscript. However, academic peer</p><p>review also can be competitive and unfriendly – especially when</p><p>anonymous – and these are attributes that the Braintrust, at its best,</p><p>defiantly lacks. Pixar’s method also resembles “art crits” (critiques),</p><p>in which a group of art students, usually led by a professor or</p><p>professional artist, offers candid critical comments on one another’s</p><p>work. Although art crits – like any group process – can veer into</p><p>a domain of low psychological safety when the honesty becomes</p><p>destructive and is not accompanied by empathic support,8 this is not</p><p>necessarily The case; peer feedback is valuable enough for young</p><p>artists to self-organize.9 Imagine if the ill-fated Volkswagen diesel</p><p>engine had been subject to a braintrust of engineers who could have</p><p>offered candid feedback on its feasibility rather than a secretive group</p><p>who worked in fear of failure. Things might have turned out quite</p><p>differently.</p><p>108 Psychological Safety at Work</p><p>Freedom to Fail</p><p>Failure is another ingredient Catmull cites as crucial to Pixar’s expo-</p><p>nential numbers at the box office. That might sound odd, in that the</p><p>last thing Pixar wants is a box office flop. But avoiding that outcome</p><p>is understood to be dependent on embracing failure earlier in the cre-</p><p>ative journey. The Braintrust views risk and failure as a necessary part</p><p>of the creative process. In its early stages a film will “suck” according</p><p>to Catmull. Stanton compares the process of moviemaking to that</p><p>of learning to ride a bicycle; no one learns how to pedal gracefully</p><p>without falling over a few times.10 Catmull believes that without the</p><p>freedom to fail people “will seek instead to repeat something safe</p><p>that’s been good enough in the past. Their work will be derivative,</p><p>not innovative.”11 As in so many other contexts, experimentation and</p><p>its inevitable trial-and-error process are necessary to innovation.</p><p>Catmull is honest and human in acknowledging that failure hurts.</p><p>Embracing failure is far easier to say than to actually put into practice!</p><p>“To disentangle the good and bad parts of failure,” he says, “we have</p><p>to recognize both the reality of the pain and the benefit of the result-</p><p>ing growth.”12 He points out that it’s not enough to simply accept</p><p>failure when it happens and move on, more or less hoping to avoid it</p><p>going forward. We need to understand failure not as something to fear</p><p>or try to avoid, but as a natural part of learning and exploration. Just</p><p>as learning to ride a bike entails the physical discomfort of skinned</p><p>knees or bruised elbows, creating a stunningly original movie requires</p><p>the psychological pain of failure. Moreover, trying to avoid the pain</p><p>of failure in learning will lead to far worse pain. Catmull: “for lead-</p><p>ers especially, this strategy – trying to avoid failure by outthinking</p><p>it – dooms you to fail.”13</p><p>Failure can, of course, be costly, and Pixar is strategic in seeking</p><p>to have failures occur early in the process by, for example, allowing</p><p>directors to spend years in the development phase, which involves</p><p>expenditures of salaries but limits excess production costs. How</p><p>do you know when failure isn’t productive? When is it better to</p><p>cut losses and give up? According to Catmull, when a project isn’t</p><p>The Fearless Workplace 109</p><p>working out, the only reason Pixar will fire a director is if the director</p><p>has clearly lost the confidence of his or her team or has received</p><p>constructive feedback in a Braintrust meeting and refused to act on</p><p>it for a prolonged period. In this way, Pixar tries to institutionalize</p><p>what Catmull calls “uncouple[ing] fear and failure”14 by creating</p><p>an environment where psychological safety is high enough that a</p><p>“making mistakes doesn’t strike terror into employees’ hearts.” Of</p><p>course, Pixar is not alone in embracing candor and failure. In fact, it’s</p><p>likely that any successful creative endeavor does this, either implicitly</p><p>or explicitly. The enormously successful (and controversial) Ray</p><p>Dalio of Bridgewater Associates, one of the world’s largest hedge</p><p>funds, provides another example.</p><p>Extreme Candor</p><p>In 1975, a twentysomething Ray Dalio founded Bridgewater Asso-</p><p>ciates in his two-bedroom New York City apartment. Since then,</p><p>the firm has grown to over 1500 employees, earned consistently</p><p>high returns (even during the 2008–2009 financial crisis), and been</p><p>the recipient of dozens of industry awards. Dalio has been on the</p><p>Forbes 400 list and TIME Magazine’s 100 most influential people. He</p><p>attributes Bridgewater’s success to its culture of “valuing meaningful</p><p>work and meaningful relationships,” which has been achieved</p><p>through “radical truth and transparency.”15 In 2011–2012, as part</p><p>of a plan to preserve the firm’s culture, Dalio created a document</p><p>titled Principles to record the tried-and-true ideas, methods, and</p><p>processes that he’d developed.16 Now a best-selling book,17 Principles</p><p>provides a detailed and extensive guide to one way – by no means the</p><p>only way – that psychological safety can work to promote learning,</p><p>innovation, and growth.</p><p>Dalio’s extreme candor begins with his principle that leaders must</p><p>“create an environment in which . . . no one has the right to hold a</p><p>critical opinion without speaking up about it.”18 Note the use of the</p><p>word “right.” The framing here is an ethical one. At Bridgewater,</p><p>110 Psychological Safety at Work</p><p>if you think it, you must say it. No holding back. In Dalio’s view,</p><p>candor is always in service to the truth, no matter how painful,</p><p>because only by facing the truth can you take effective action to</p><p>produce good outcomes. By way of example, he points out that if a</p><p>person has a terminal illness, it’s better to know the truth, no matter</p><p>how frightening, because only then can one figure out what to do.19</p><p>In framing silence as an unethical choice, Dalio is taking a more</p><p>extreme stance than I have adopted. But it’s worth reflecting on this</p><p>idea, which to me implies that you owe your colleagues the expression</p><p>of your opinion or ideas; in a sense, those ideas belong to the collective</p><p>enterprise, and you therefore don’t have the right to hoard them.</p><p>Candid feedback at Bridgewater is thus constant and detailed.</p><p>Every employee is required to keep an Issue Log,</p><p>which records</p><p>individual mistakes, strengths and weaknesses, and a “pain button,”</p><p>which records the employee’s reaction to specific criticisms as well as</p><p>their changes in behavior to remedy weaknesses, and whether those</p><p>changes were effective.</p><p>Transparency Libraries</p><p>Radical transparency and extreme candor go hand in hand at Bridge-</p><p>water. There’s even a prohibition on talking about people who are</p><p>not present and thus cannot learn from what’s being said. Managers</p><p>are not supposed to talk about their supervisees if the person is not</p><p>in the room. In Dalio’s words, “If you talk behind people’s backs</p><p>at Bridgewater you are called a slimy weasel.”20 A tally of ongoing</p><p>assessment statistics for each employee are kept on “baseball cards,”</p><p>publicly available to everyone in the firm, and used by managers for</p><p>making decisions around compensation, incentives, promotions, and</p><p>firing. No one at the firm, including Dalio, can hide behind opacity.</p><p>A “transparency library” containing videos of every executive meet-</p><p>ing, is available for viewing in case employees want to see how policies</p><p>or initiatives were discussed.</p><p>The Fearless Workplace 111</p><p>Dalio’s views on the need for error and smart failures as a part of</p><p>the learning process are consistent with what we know about how</p><p>growth and innovation occur. He believes that “our society’s ‘mis-</p><p>takephobia’ is crippling”21 because, beginning in elementary school,</p><p>we are taught to seek the right answer instead of learning to learn</p><p>from mistakes as a pathway to innovative and independent thinking.</p><p>Early on, he says he “learned that everyone makes mistakes and has</p><p>weaknesses and that one of the most important things that differen-</p><p>tiates people is their approach to handling them.” For that reason, at</p><p>Bridgewater, “it is okay to makes mistakes, but unacceptable not to</p><p>identify, analyze, and learn from them.”22</p><p>Productive Conflict</p><p>Candor, transparency, and learning from error – a psychological safety</p><p>triad – are emphasized in Dalio’s Principles as scaffolding for both his</p><p>life and his company. To that list we can add conflict resolution, an</p><p>important input to innovation and good decision-making for which</p><p>psychological safety is sorely needed. Conflict, in the Bridgewater</p><p>culture, is conducted in the service of finding “what is true and what</p><p>to do about it.”23 It involves having task-based conversations about</p><p>who will do what, as well as exchanging alternate points of view</p><p>and overcoming differences or misunderstandings. Recognizing the</p><p>innate human tendency to treat a conflict as a contest, Dalio offers</p><p>up advice, such as, “don’t try to ‘win’ the argument. Finding out</p><p>that you are wrong is even more valuable than being right, because</p><p>you are learning.”24 It’s important to know when to move on from</p><p>a disagreement and not spend too much time on trivial details.</p><p>He concedes that “open-minded disagreements” are frequent at</p><p>Bridgewater, and, naturally, people sometimes do get angry. (Not</p><p>surprisingly, new employees at Bridgewater have a high attrition</p><p>rate; the culture is not for everybody). Managers are advised to</p><p>“enforce the logic of conversations” when people’s emotions get too</p><p>112 Psychological Safety at Work</p><p>hot to handle; this is best done by remaining “calm and analytical in</p><p>listening to others’ points of view.”25</p><p>Dalio distinguishes between three categories of conversa-</p><p>tion – debate, discussion, and teaching – and advises that managers</p><p>evaluate explicitly which method of discourse is most appropriate</p><p>for the issue at hand. Discussion, according to Dalio, is an open</p><p>exploration of ideas and possibilities and involves people with varying</p><p>levels of experience and authority in the organization. In a discus-</p><p>sion, everyone is encouraged to ask questions, offer opinions, and</p><p>make suggestions. All views are welcomed and considered. Debate,</p><p>however, takes place between “approximate equals,” and teaching</p><p>takes place between people with “different levels of understanding.”</p><p>While the boundaries between debate, discussion, and teaching</p><p>may often be fluid in a fearless organization – communications may</p><p>combine all three categories – these three categories offer useful</p><p>ways of thinking about and structuring how to speak to one another</p><p>in a psychologically safe environment.</p><p>We see here that explicit hierarchy and psychological safety are not</p><p>mutually exclusive in a fearless organization. While the Bridgewater</p><p>environment is clearly one where people must get used to speaking up</p><p>often and openly, speaking up coexists with a hierarchy that is based in</p><p>part on individual track records. But decision-making is not by con-</p><p>sensus. Like Pixar’s Brainstrusts, open debate’s purpose is to provide</p><p>the lead decision-maker with alternative perspectives to help him or</p><p>her figure out the best outcome. And in a culture that likely pres-</p><p>elects for opinionated, self-assured personalities, Dalio warns against</p><p>arrogance. “Ask yourself whether you have earned the right to have</p><p>an opinion,” he says.26 Such a right is earned through successful track</p><p>records and proven responsibility. Dalio compares this to skiing down</p><p>a difficult slope; if you can’t successfully manage such a feat, you</p><p>shouldn’t tell others how to do it.27 For their part, managers must</p><p>distinguish between opinions that have the most merit – because they</p><p>draw on a person’s experience – and those that are merely conjecture.</p><p>Although a leader nearing the end of a successful career, Dalio</p><p>tempers the dangers of over-confidence by including among his own</p><p>The Fearless Workplace 113</p><p>most valued principles “the power of knowing how to deal with not</p><p>knowing.”28 He attributes his success in part to having recognized and</p><p>adhered to this principle, because its power has enabled him to ask</p><p>questions, seek advice, and find the best answers to difficult questions.</p><p>Surprisingly, this hard-driving financier shares a belief in not knowing</p><p>with a soft-spoken designer of women’s fashion, Eileen Fisher, who</p><p>otherwise bears very little resemblance to Dalio.</p><p>Be a Don’t Knower</p><p>Eileen Fisher is among those leaders who calls herself a “don’t</p><p>knower.”29 She began her now-celebrated clothing brand in 1984,</p><p>at the age of 34, when she did not know how to sew and knew</p><p>little about either fashion or business. Today, as a leader, Fisher</p><p>models vulnerability and humility, which unsurprisingly helps to</p><p>create psychological safety in the workplace, as we will explore</p><p>further in Chapter 7. She speaks honestly about her struggles and</p><p>fears. Painfully shy when she was younger, she was afraid to go into</p><p>Bloomingdale’s with her first clothing designs because she was afraid</p><p>of being rejected. Inspired by the kimonos she’d seen while working</p><p>as a graphic designer in Japan and with access to one friend’s booth</p><p>at the Boutique Show – a kind of arts and crafts fair – and another</p><p>friend’s skill with a sewing machine, Fisher launched her company</p><p>by designing first four and then eight pieces of clothing for the</p><p>borrowed booth. On the first go-around she received orders from</p><p>buyers for $3000, and for the second show, she was surprised to find</p><p>buyers lining up to orders totaling $40 000.30</p><p>Today, Eileen Fisher, the company, operates nearly 70 retail</p><p>stores, which generated between $400 and $500 million in revenue</p><p>in 2016.31 It’s a supplier to many other clothing retailers and has</p><p>consistently been recognized as one of the best companies to work</p><p>for. Unlike the businesses featured in Chapter 3 that faced enormous</p><p>failures, the company has enjoyed continuous growth and thoughtful,</p><p>productive change, unblemished by financial, legal, or safety failures.</p><p>114 Psychological Safety at Work</p><p>Its management practices and governance structures have created a</p><p>showcase for psychological safety.</p><p>Humble Listening</p><p>Fisher calls herself a natural listener, which helps to make “not know-</p><p>ing” a positive trait. When first setting up her company, she found</p><p>the combination of these two traits to be an advantage. As she says,</p><p>“when you don’t know and you’re really listening intently,</p><p>people</p><p>want to help you. They want to share.”32 Evidently, she’s managed</p><p>to maintain the vulnerability and receptivity of her original “I don’t</p><p>know,” even as she’s become a seasoned leader of an enduring brand</p><p>in the fashion industry. One of the outcomes of managing by not</p><p>knowing is, as Fisher says, that “people feel safe to explore their own</p><p>ideas instead of feeling like they just need to do what you tell them</p><p>to do.”33</p><p>Eileen Fisher clothing is structured along simple lines and</p><p>fluid designs. The same could be said for the way the company</p><p>conducts its meetings. People sit in a circle, with the intention of</p><p>de-emphasizing hierarchies and instead encouraging what’s called</p><p>“a leader in every chair.”34 To create the mindfulness and focus</p><p>conducive to an environment where everyone collaborates and</p><p>contributes, meetings begin with a minute of silence. Sometimes an</p><p>object, such as a gourd, is passed from person to person; the idea</p><p>is the person is allowed and expected to speak when the object is</p><p>in hand.35 The point is that Fisher, like the other leaders discussed</p><p>in this chapter, has institutionalized very specific processes that help</p><p>create psychological safety.</p><p>Among the things that Fisher does know is what it’s like to feel</p><p>unsafe to speak up. In school she felt that speaking up meant risking</p><p>criticism, humiliation, and embarrassment; consequently, it was, she</p><p>felt, “safer to say nothing than to figure out what you think and what</p><p>you want to say.”36 Perhaps that’s partly why she’s so consciously and</p><p>carefully created an environment where employees feel safe speaking</p><p>The Fearless Workplace 115</p><p>their minds. Fisher, again: “My inclination is to ask questions, to get</p><p>the right people in the conversation and let everyone have a voice.</p><p>The collective and collaborative process produces a lot of energy – it’s</p><p>the source of creativity and innovation.”37 Interestingly, Fisher, as a</p><p>clothing designer, is not looking for “right answers” but for the mul-</p><p>tiplicity of voices that produce a collaborative process and creative</p><p>energy. She’s framing success as a certain kind of energy rather than</p><p>an immediate result.</p><p>Permission to Care</p><p>When Fisher describes how projects and initiatives come about in her</p><p>organization, she emphasizes encouraging employees to be passion-</p><p>ate and giving them “permission to care.”38 For example, an assistant,</p><p>Amy Hall, rose in the company to become Director of Social Con-</p><p>sciousness by following her passion for how the company was running</p><p>its factories and treating its factory workers, eventually becoming</p><p>involved in setting standards for how factories operate worldwide.</p><p>In 2013, at a four-day off-site company sustainability conference, the</p><p>staff made a commitment to produce only environmentally sustain-</p><p>able clothing by the year 2020. Although the idea had not originally</p><p>come from Fisher, she wanted to lend her support and realized the</p><p>importance of simply saying, “yes.” Although she doesn’t call herself</p><p>a CEO, she realized that “saying yes gives people permission” to go</p><p>forward.39</p><p>Like any company, Eileen Fisher has had to change and grow.</p><p>Fisher rejected offers to become a public company, as well as an offer</p><p>to sell to Liz Claiborne, a larger women’s clothing company, because</p><p>she didn’t feel that they were passionate enough about her company’s</p><p>clothing and vision. Instead, in 2005, Fisher decided to pass part of the</p><p>company ownership to her employees. In 2009, the brand underwent</p><p>a major change in its marketing and product lines to appeal to younger</p><p>women in addition to the loyal customer base that had aged along</p><p>with Fisher. More recently, Fisher sees empowering women and girls</p><p>116 Psychological Safety at Work</p><p>as part of the company mission, and to that end she has founded</p><p>the Eileen Fisher Leadership Institute. The company also gives grants</p><p>to women entrepreneurs and to nonprofits that foster leadership in</p><p>women and girls.40</p><p>As it turns out, Fisher does know. As she says, “I’ve learned over</p><p>time that I actually have a lot to say, particularly around issues like</p><p>sustainability and business as a movement. My voice matters.”41 It</p><p>may be that Fisher herself is the last to know the strength of her own</p><p>voice. For as the president of Macy’s North, Frank Gazetta, said about</p><p>the seasonal product lines with which he stocks his stores, “the voice</p><p>of Eileen is always there.”42</p><p>Ultimately, Eileen’s voice has been widely heard (and seen) in</p><p>the fashion industry because she was willing to take risks, willing</p><p>to fail. In any creative industry, failure is a fact of life. Most design</p><p>ideas never come to fruition. Similarly, most film footage hits the</p><p>cutting room floor, and many financial bets will fail before you hit a</p><p>winner. Indeed, more and more people in leading companies around</p><p>the world are embracing the notion of failing well to succeed sooner.</p><p>But as appealing and logical as the idea of learning from failure may</p><p>be, the truth is no one really wants to fail.</p><p>When Failure Works</p><p>A team of smart, motivated people in Palo Alto had worked for two</p><p>full years on an innovation project. The goal was to develop a process</p><p>to turn seawater into an affordable fuel. You might think achieving</p><p>such a goal would be impossible. But, scientists had already figured</p><p>out the necessary technology to make it work in very small quantities.</p><p>The challenge for Project Foghorn, as the endeavor was called, was</p><p>to assess if the process could be commercially viable on a massive</p><p>scale. After two years of hard work, however, the team reluctantly</p><p>admitted that it could not get production costs low enough to produce</p><p>an economically competitive fuel, especially since by then the price</p><p>of oil had fallen. They decided to terminate the project.</p><p>The Fearless Workplace 117</p><p>Was the team fired? Humiliated? Did team members hang their</p><p>heads for weeks? Far from it. Every member of the Foghorn team</p><p>received a bonus from the company.43</p><p>Make It Safe to Fail</p><p>The company was Google X, an invention and innovation lab</p><p>that operates as an independent entity within Google’s parent</p><p>company, Alphabet. The mission of X, as it’s come to be called,</p><p>is to launch “moonshot” technologies that will make the world a</p><p>better place.44 The explicit goal is to develop and commercialize</p><p>radical, world-changing solutions to big problems, to produce the</p><p>kind of breakthroughs that could eventually become as big as the</p><p>next Google.45 Intelligent failure is especially integral to success at</p><p>X, and for this reason we can learn a lot about what makes it work</p><p>and the mindsets that leaders encourage to make failure acceptable</p><p>in their organizations.</p><p>Although the idea of rewarding people for failing may seem to</p><p>create a problematic incentive, if we look closely enough we can</p><p>see its business logic, especially for a research organization that pur-</p><p>sues big, audacious ideas. Astro Teller, CEO at X – or “Captain of</p><p>Moonshots,” to be precise – believes that it’s a superior economic</p><p>strategy to reward people for killing unpromising projects than it is</p><p>to let unworkable ideas languish in purgatory for years and soak up</p><p>resources.46 In other words, you have to fail at many attempts before</p><p>coming up with a success. X considers over 100 ideas for moonshots</p><p>each year, in areas ranging from clean energy to sustainable farming to</p><p>artificial intelligence. However, only a handful of these ideas become</p><p>projects with full-time staff working on them.47</p><p>Teller explained in his 2016 TED talk why and how X “make[s]</p><p>it safe to fail.”</p><p>You cannot yell at people and force them to fail fast. People resist. They</p><p>worry. “What will happen to me if I fail? Will people laugh at me?</p><p>118 Psychological Safety at Work</p><p>Will I be fired? . . . The only way to get people to work on big, risky</p><p>things – audacious ideas – and have them run at all the hardest parts of</p><p>the problem first is if you make that the path of least resistance for them.</p><p>We work hard at X to make it safe to fail. Teams kill their ideas as soon</p><p>as the evidence is on the table because they’re rewarded for it.</p><p>They get</p><p>applause from their peers. Hugs and high fives from their manager, me</p><p>in particular. They get promoted for it. We have bonused every single</p><p>person on teams that ended their projects, from teams as small as two to</p><p>teams of more than 30.48</p><p>Teller highlights how unpleasant it feels for us to fail, especially</p><p>at work. It’s natural to worry what other people will think and about</p><p>losing our job. That’s why, unless a leader expressly and actively makes</p><p>it psychologically safe to do so, people will seek to avoid failure.</p><p>Rapid Evaluation</p><p>Just as vital as creating a psychologically safe environment for</p><p>smart failure is constructing a specific process for handling failure.</p><p>Teller and X pursue the mission through a process of disciplined</p><p>experimentation. Just as scientists seek to find evidence that rejects</p><p>their hypotheses, the company seeks to find evidence that its most</p><p>optimistic and idealistic ideas will not work so it can kill off these</p><p>ideas sooner rather than later and move onto other ones.49 Project</p><p>proposals can come from anyone inside or outside the company.</p><p>To make sure that X only works on the most promising ideas, the</p><p>company has a “Rapid Evaluation” team that processes proposals,</p><p>vets ideas, and promotes only those that seem achievable. This team,</p><p>which consists of a combination of senior managers and inventors,</p><p>first runs a pre-mortem, trying to come up with as many reasons</p><p>as possible why the idea could fail.50 “Rapid Eval,” as the team is</p><p>known, considers the problem’s scale, feasibility, and technological</p><p>risks. During this iterative stage, issues are questioned, changed, and</p><p>refined by engaging in candid conversation that’s not unlike Pixar’s</p><p>Braintrust.</p><p>The Fearless Workplace 119</p><p>Very few ideas make it past this Rapid Eval stage.51 If an idea is</p><p>deemed promising, its team must develop a crude prototype, ideally in</p><p>a few days. X has a “Design Kitchen” in one of its buildings equipped</p><p>with tools and materials to create such physical prototypes.52 If Rapid</p><p>Eval is convinced by the prototype, it runs the idea by a second busi-</p><p>ness group called “Foundry,” which asks, “Should this solution exist?</p><p>Is there a business case to be made for the proposed solution? If we</p><p>can build it, will people actually use it?”</p><p>The company honors smart failures in other ways, too. Prototypes</p><p>that never made it past the Foundry stage, and thus were dropped, are</p><p>showcased in the Palo Alto office.53 Since November 2016, X has</p><p>held an annual celebration to hear testimonials about failed projects.</p><p>(Failed relationships and personal tragedies are also welcomed.) Failed</p><p>prototypes are placed on a small altar, and people say a few words</p><p>about what the project meant to them. Employees feel that this ritual</p><p>helps remove some of the emotional baggage they still carry from</p><p>investing themselves into something that never came to be.54</p><p>Failing to Fail Is the Real Failure</p><p>For X, then, failing is not taboo. In fact, as Teller told BBC News</p><p>in 2014, “real failure is trying something, learning it doesn’t work,</p><p>then continuing to do it anyway.”55 Real failure is defined as not</p><p>learning, or not taking enough risks to fall flat on your face. Teller and</p><p>X embrace failure so much that they don’t talk about succeeding on</p><p>their projects at all; instead, they speak of “failing to fail.”56 Successful</p><p>failure is an art. It helps if you can fail at the right time and for the</p><p>right reasons. In Chapter 7, we’ll see other ways organizations make</p><p>use of and institutionalize failure.</p><p>Caring for Employees</p><p>The power of psychological safety is not reserved for creative indus-</p><p>tries such as film, fashion, and cutting-edge technology. The global</p><p>120 Psychological Safety at Work</p><p>equipment and engineering company Barry-Wehmiller demonstrates</p><p>that psychological safety brings immense rewards in a manufacturing</p><p>setting. These rewards come in both economic and human develop-</p><p>ment forms.57</p><p>Founded in St. Louis in the mid-1880s as a machine manufac-</p><p>turer for the brewing industry, Barry-Wehmiller today is a $3 billion</p><p>organization that employs 12 000 people at 100-plus locations</p><p>in 28 countries.58 In 2015, CEO Bob Chapman and co-author</p><p>Raj Sisodia published Everybody Matters: The Extraordinary Power</p><p>of Caring for Your People Like Family, a book whose title concisely</p><p>declares the company’s mission to “measure success by the way</p><p>we touch the lives of people.” Caring for employees – “team</p><p>members” in Barry-Wehmiller-speak – using tangible measures of</p><p>employee well-being has proved to be a sure recipe for establishing a</p><p>psychologically safe workplace where learning and growth thrive.</p><p>The Great Recession of 2007–2009 presented a dramatic oppor-</p><p>tunity for Barry-Wehmiller to make good on its promise to care for</p><p>people like family. When new equipment orders declined consider-</p><p>ably and layoffs seemed inevitable, Chapman instead initiated a pro-</p><p>gram of shared sacrifice. Following his principle that in a caring family</p><p>“all the family members would absorb some pain so that no mem-</p><p>ber of the family had to experience a dramatic loss,”59 there were no</p><p>layoffs. Instead, all employees, no matter their position, took a manda-</p><p>tory unpaid furlough of four weeks at the time of their choosing.</p><p>Cost-cutting in the form of shared sacrifice manifested in other ways</p><p>as well. Chapman reduced his salary to $10 500, suspended executive</p><p>bonuses, halted contributions to retirement accounts, and reduced</p><p>travel expenses. What was the result? Unions supported the program.</p><p>Team members created a market to help each other; those who could</p><p>afford to take more than a month off voluntarily traded with those</p><p>who could not. Barry-Wehmiller rallied from the economic down-</p><p>turn relatively easily and by 2010 reported record financial results. In</p><p>other words, by continuing to make its team members feel safe and</p><p>cared for during a crisis, the company created a win-win situation for</p><p>everyone.</p><p>The Fearless Workplace 121</p><p>Barry-Wehmiller has developed a rigorous and well-documented</p><p>approach to systematizing its values and methods, which create psy-</p><p>chological safety as a by-product. That may be because the company</p><p>has flourished by acquiring poorly performing companies and turning</p><p>them profitable since the mid-1980s. The majority were companies</p><p>that provided equipment and services to industries such as packaging</p><p>or paper manufacturing. Each acquisition – as of this writing, there</p><p>are over 100 – has been another opportunity to articulate and develop</p><p>Barry-Wehmiller’s culture and vision.60</p><p>Its internal “Guiding Principles of Leadership” document, for-</p><p>mulated with employee input, is meant to, among other things, create</p><p>an environment of trust, meaning, and pride that celebrates and brings</p><p>out the best in each person.61 Shortly after the document was drafted,</p><p>Chapman traveled to various units and sat down with small groups of</p><p>people to listen to their feelings about the Principles. He learned</p><p>that trust – employees feeling trusted by management – was key, and</p><p>that time clocks, break bells, and locking inventory in cages inhibited</p><p>that trust. Chapman describes immediately getting rid of what he</p><p>calls “trust-destroying and demeaning practices”62 inappropriate for</p><p>responsible adults. Listening sessions, as they are called, have since</p><p>become institutionalized times where team members are asked to</p><p>speak their minds.</p><p>Barry-Wehmiller University was founded in 2008 to impart</p><p>the company’s distinct leadership practices and vision. Instructors</p><p>are mostly recruited and trained from within the organization, are</p><p>encouraged to impart insight rather than information, and make use</p><p>of storytelling to share experiences and emotions. Chapman says</p><p>the company’s practice is to “Treat people superbly and compensate</p><p>them fairly.”63 For example, when the company instituted health-</p><p>care policies that included checks into employee well-being and</p><p>habits, which contributed to a 5% reduction in healthcare costs for</p><p>Barry-Wehmiller, team members were given a free month on paying</p><p>their premiums.</p><p>Because</p><p>most of their work involves the repetitive but intricate</p><p>process-laden work that’s germane to assembly factories – see</p><p>122 Psychological Safety at Work</p><p>Chapter 7 for more about the implications of different types of work</p><p>for psychological safety and learning – process improvements or their</p><p>opposite (stuck processes) have enormous consequences for perfor-</p><p>mance. No one wants to institute changes to workplace processes</p><p>that make a job more difficult and create employee resentment,</p><p>but too often memos handed down from the top do just that. Far</p><p>more reasonable is to have the people who are actually doing the</p><p>work design and redesign the process. In the fearless organization,</p><p>suggestions for improvement (kaizen) are actively recruited and</p><p>instituted when apt.</p><p>Asking for Input</p><p>Bob Chapman tells the story of setting up a machine shop in Green</p><p>Bay, Wisconsin. Ten divisional presidents first spent a week on how to</p><p>improve the process of getting spare parts orders entered, completed,</p><p>and shipped to customers. Analyses were run and reports generated,</p><p>only to realize that the plan wasn’t going to work in practice. Another</p><p>leadership team met, spent another week analyzing and projecting,</p><p>this time also looking at how manufacturing space might be laid</p><p>out. Still, no one felt confident enough to proceed. Finally, a third</p><p>improvement event was held, this time with two senior leaders and</p><p>ten people who were actually going to do the work: forklift drivers,</p><p>assemblers, pickers, packers, and clerical staff. Now, suddenly, the way</p><p>forward was clear. In Chapman’s telling:</p><p>They [the workers] took cardboard cutouts onto the floor of the factory</p><p>and measured what they would need to bring different carts and forklifts</p><p>through. They could see the different clearance issues and recognized that</p><p>work from one area often flowed to another. Lighter parts would be easier</p><p>to carry a farther distance. They looked at how many steps it took, how</p><p>safe it was to have a forklift in an area, or whether it could come around</p><p>the outside in a safer configuration.64</p><p>The Fearless Workplace 123</p><p>This is a prime example of asking people for input and of the</p><p>benefits of doing so. Even better than to, for example, open an online</p><p>portal to invite employee suggestions is to invite the responsible par-</p><p>ties to the meeting! In Dalio’s terms, it’s the forklift operators them-</p><p>selves who have earned the “right to have an opinion” on whether</p><p>or not there’s enough clearance for their trucks to pass through an</p><p>area. Contrast Barry-Wehmiller’s approach with the factory fellow</p><p>from Chapter 2 who had an idea for improvement and could point</p><p>to no good reason for not offering it up. Had he been given a seat at</p><p>the table, chances are that management could have benefitted from</p><p>his idea.</p><p>Chapman reports that the solution the assembly workers devised</p><p>was still in place five years later. They were, he says, “able to share to</p><p>improve the process and create a meaningful, lasting, and more human</p><p>process for everybody in that organization.”65 What’s important to</p><p>note is just how much it can take on the part of everyone involved to</p><p>create a fearless organization. Top management had to spend consid-</p><p>erable time and have the good sense to recognize that its ideas would</p><p>not succeed. Factory workers had to be explicitly involved in the</p><p>process of designing process. I don’t mean to imply that working in</p><p>a fearless organization takes more effort or a tremendously difficult</p><p>undertaking. It doesn’t. But initially, when we’ve been entrenched</p><p>in fear and its attendant mental frameworks, it’s not always obvious.</p><p>Barry-Wehmiller leaders are superb practitioners of an essential psy-</p><p>chological safety building practice I call Inviting Participation, to be</p><p>discussed in Chapter 7.</p><p>Learning from Psychologically Safe Work</p><p>Environments</p><p>Barry Wehmiller, Google X, Eileen Fisher, Bridgewater, and Pixar</p><p>have little in common on the surface. Yet they have managed to create</p><p>124 Psychological Safety at Work</p><p>work environments characterized by unusual levels of candor, engage-</p><p>ment, collaboration, and risk-taking, all of which have contributed</p><p>to the creation of successful businesses – in strikingly varied ways.</p><p>Chapter 6 highlights a few other unusual organizations and leaders.</p><p>But this time our focus will be on efforts to promote or improve</p><p>human health, dignity, or safety.</p><p>Chapter 5 Takeaways</p><p>◾ Workplaces characterized by candor can offer immense benefits</p><p>for creativity, learning, and innovation.</p><p>◾ Leaders who are willing to say “I don’t know” play a sur-</p><p>prisingly powerful role in engaging the hearts and minds of</p><p>employees.</p><p>◾ Creating an environment that values employees yields benefits</p><p>in engagement, problem solving, and performance.</p><p>Endnotes</p><p>1. Franklin Delano Roosevelt. Presidential Inaugural Address. History.</p><p>March 4, 1933. https://www.history.com/speeches/franklin-d-</p><p>roosevelts-first-inaugural-address Accessed June 7, 2018</p><p>2. “Our Story.” Pixar Animation Studios, https://www.pixar.com/our-</p><p>story-1#our-story Accessed June 7, 2018.</p><p>3. Catmull, E. & Wallace, A. Creativity, Inc.: Overcoming the Unseen Forces</p><p>That Stand in the Way of True Inspiration. New York: Random House,</p><p>2013. Print.</p><p>4. Catmull, E. & Wallace, A. 2013: 90.</p><p>5. Catmull, E. & Wallace, A. 2013: 95.</p><p>6. Catmull, E. & Wallace, A. 2013: 105.</p><p>7. Barnes, B. “John Lasseter, a Pixar Founder, Takes Leave After ‘Mis-</p><p>steps.’” The New York Times, January 20, 2018. https://www.nytimes</p><p>.com/2017/11/21/business/media/john-lasseter-pixar-disney-leave</p><p>.html Accessed July 25, 2018.</p><p>8. Finkel, J. “Tales From the Crit: For Art Students, May Is the Cruelest</p><p>Month.” The New York Times. April 30, 2006. https://www.nytimes</p><p>https://www.history.com/speeches/franklin-d-roosevelts-first-inaugural-address</p><p>https://www.history.com/speeches/franklin-d-roosevelts-first-inaugural-address</p><p>https://www.pixar.com/our-story-1#our-story</p><p>https://www.pixar.com/our-story-1#our-story</p><p>https://www.nytimes.com/2017/11/21/business/media/john-lasseter-pixar-disney-leave.html</p><p>https://www.nytimes.com/2017/11/21/business/media/john-lasseter-pixar-disney-leave.html</p><p>https://www.nytimes.com/2017/11/21/business/media/john-lasseter-pixar-disney-leave.html</p><p>https://www.nytimes.com/2006/04/30/arts/design/tales-from-the-crit-for-art-students-may-is-the-cruelest-month.html</p><p>The Fearless Workplace 125</p><p>.com/2006/04/30/arts/design/tales-from-the-crit-for-art-students-</p><p>may-is-the-cruelest-month.html Accessed June 13, 2018.</p><p>9. For more on art crits, see http://bushwickartcritgroup.com/.</p><p>10. Catmull, E. & Wallace, A. 2013. 109</p><p>11. Catmull, E. & Wallace, A. 2013: 111.</p><p>12. Catmull, E. & Wallace, A. 2013: 108–109.</p><p>13. Catmull, E. & Wallace, A. 2013: 109.</p><p>14. Catmull, E. & Wallace, A. 2013: 123.</p><p>15. Dalio, R. “How to Build a Company Where the Best Ideas Win.”</p><p>TED. 2017. https://www.ted.com/talks/ray_dalio_how_to_build_a_</p><p>company_where_the_best_ideas_win Accessed June 12, 2018.</p><p>16. Dalio, R. “Principles.” Ray Dalio. 2011. https://docs.google.com/</p><p>viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxlYm9va3</p><p>Nkb3dubG9hZG5vdzIwMTZ8Z3g6MjY3NGU2Njk5N2QxNjViMg</p><p>Accessed June 13, 2018.</p><p>17. Dalio, R. Principles, Vol. 1: Life & Work. New York: Simon & Schuster,</p><p>2017. Print.</p><p>18. Dalio, R. 2011: 88.</p><p>19. Ibid.</p><p>20. Dalio, R. 2011: 89.</p><p>21. Dalio, R. 2011: 17.</p><p>22. Dalio, R. 2011: 88.</p><p>23. Dalio, R. 2011: 19.</p><p>24. Dalio, R. 2011: 96.</p><p>25. Dalio, R. 2011: 105.</p><p>26. Dalio, R. 2011: 102.</p><p>27. Dalio, R. 2011: 190.</p><p>28. Dalio, R. 2011: 189.</p><p>29. Tenney, M. “Be a Don’t Knower: One of Eileen Fisher’s Secrets</p><p>to Success.” The Huffington Post. May 15, 2015. https://www</p><p>.huffingtonpost.com/matt-tenney/be-a-dont-knower-one-of-e_b_</p><p>7242468.html Accessed June 12, 2018.</p><p>30. Malcolm, J. “Nobody’s Looking At You: Eileen Fisher and the art</p><p>of understatement.” The New Yorker. September 23, 2013. https://</p><p>www.newyorker.com/magazine/2013/09/23/nobodys-looking-at-</p><p>you Accessed June 12, 2018.</p><p>31. Fernandez, C. “Eileen Fisher Makes Strides Towards Circularity</p><p>With ‘Tiny Factory.’” The Business of Fashion. December</p><p>6, 2017.</p><p>https://www.businessoffashion.com/articles/intelligence/eileen-</p><p>fisher-makes-strides-towards-circularity-with-tiny-factory Accessed</p><p>June 8, 2018.</p><p>https://www.nytimes.com/2006/04/30/arts/design/tales-from-the-crit-for-art-students-may-is-the-cruelest-month.html</p><p>https://www.nytimes.com/2006/04/30/arts/design/tales-from-the-crit-for-art-students-may-is-the-cruelest-month.html</p><p>http://bushwickartcritgroup.com</p><p>https://www.ted.com/talks/ray_dalio_how_to_build_a_company_where_the_best_ideas_win</p><p>https://www.ted.com/talks/ray_dalio_how_to_build_a_company_where_the_best_ideas_win</p><p>https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxlYm9va3Nkb3dubG9hZG5vdzIwMTZ8Z3g6MjY3NGU2Njk5N2QxNjViMg</p><p>https://www.huffingtonpost.com/matt-tenney/be-a-dont-knower-one-of-e_b_7242468.html</p><p>https://www.huffingtonpost.com/matt-tenney/be-a-dont-knower-one-of-e_b_7242468.html</p><p>https://www.huffingtonpost.com/matt-tenney/be-a-dont-knower-one-of-e_b_7242468.html</p><p>https://www.newyorker.com/magazine/2013/09/23/nobodys-looking-at-you</p><p>https://www.newyorker.com/magazine/2013/09/23/nobodys-looking-at-you</p><p>https://www.newyorker.com/magazine/2013/09/23/nobodys-looking-at-you</p><p>https://www.businessoffashion.com/articles/intelligence/eileen-fisher-makes-strides-towards-circularity-with-tiny-factory</p><p>https://www.businessoffashion.com/articles/intelligence/eileen-fisher-makes-strides-towards-circularity-with-tiny-factory</p><p>http://bushwickartcritgroup.com/</p><p>https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxlYm9va3Nkb3dubG9hZG5vdzIwMTZ8Z3g6MjY3NGU2Njk5N2QxNjViMg</p><p>126 Psychological Safety at Work</p><p>32. Tenney, M. May 15, 2015, op cit.</p><p>33. Ibid.</p><p>34. According to Janet Malcolm, Fisher subscribes to the philosophy artic-</p><p>ulated in a 2010 book called The Circle Way: A Leader in Every Chair</p><p>by Ann Linnea and Christina Baldwin (published by Barret-Koehler)</p><p>which posits circle leadership as both a paradigm shift for group col-</p><p>laboration and a practice that draws upon the circle “lineage” derived</p><p>from cultures, such as Native American and Aboriginal.</p><p>35. Malcolm, J. September 23, 2013, op cit.</p><p>36. Ibid.</p><p>37. Dunbar, M.F. “Designer Eileen Fisher on how Finding Purpose</p><p>Changed Her Company. Conscious Company Media. July 4, 2015.</p><p>https://consciouscompanymedia.com/sustainable-business/designer-</p><p>eileen-fisher-on-how-finding-purpose-changed-her-company/</p><p>Accessed June 8, 2018.</p><p>38. Ibid.</p><p>39. Ibid.</p><p>40. “Business as a Movement.” Eileen Fisher. https://www.eileenfisher</p><p>.com/business-as-a-movement/business-as-a-movement Accessed</p><p>June 8, 2018.</p><p>41. “Eileen Fisher, No Excuses.” A Green Beauty. December 7, 2016.</p><p>https://agreenbeauty.com/fashion/eileen-fisher-no-excuses Accessed</p><p>June 8, 2018.</p><p>42. Beckett, W. “Eileen Fisher: A Pocket of Prosperity.” Women’s Wear</p><p>Daily. October 17, 2007.</p><p>43. Thompson, D. “Google X and the Science of Radical Creativity.” The</p><p>Atlantic. November 2017. https://www.theatlantic.com/magazine/</p><p>archive/2017/11/x-google-moonshot-factory/540648/ Accessed June</p><p>8, 2018.</p><p>44. “What We Do.” X. https://x.company/about/ Accessed June 8, 2018.</p><p>45. Thompson, D. November, 2017, op cit.</p><p>46. Ibid.</p><p>47. Ibid.</p><p>48. Teller, A. “The Unexpected Benefit of Celebrating Failure.” TED.</p><p>2016. https://www.ted.com/talks/astro_teller_the_unexpected_benefit_</p><p>of_celebrating_failure Accessed June 8, 2018.</p><p>49. “Celebrating Failure Fuels Moonshots.” Stanford ECorner, April 20,</p><p>2016. https://ecorner.stanford.edu/podcast/celebrating-failure-fuels-</p><p>moonshots/ Accessed June 8, 2018.</p><p>50. Thompson, D. November 2017, op cit.</p><p>https://consciouscompanymedia.com/sustainable-business/designer-eileen-fisher-on-how-finding-purpose-changed-her-company</p><p>https://consciouscompanymedia.com/sustainable-business/designer-eileen-fisher-on-how-finding-purpose-changed-her-company</p><p>https://www.eileenfisher.com/business-as-a-movement/business-as-a-movement</p><p>https://www.eileenfisher.com/business-as-a-movement/business-as-a-movement</p><p>https://agreenbeauty.com/fashion/eileen-fisher-no-excuses</p><p>https://www.theatlantic.com/magazine/archive/2017/11/x-google-moonshot-factory/540648</p><p>https://www.theatlantic.com/magazine/archive/2017/11/x-google-moonshot-factory/540648</p><p>https://x.company/about</p><p>https://www.ted.com/talks/astro_teller_the_unexpected_benefit_of_celebrating_failure</p><p>https://ecorner.stanford.edu/podcast/celebrating-failure-fuels-moonshots</p><p>https://ecorner.stanford.edu/podcast/celebrating-failure-fuels-moonshots</p><p>https://www.ted.com/talks/astro_teller_the_unexpected_benefit_</p><p>https://www.ted.com/talks/astro_teller_the_unexpected_benefit_of_celebrating_failure</p><p>The Fearless Workplace 127</p><p>51. Gertner, J. “The Truth About Google X: An Exclusive Look</p><p>Behind The Secretive Lab’s Closed Doors.” Fast Company. April 15,</p><p>2014. https://www.fastcompany.com/3028156/the-google-x-factor</p><p>Accessed June 13, 2018.</p><p>52. Ibid.</p><p>53. Thompson, D. November 2017, op cit.</p><p>54. Ibid.</p><p>55. Wakefield, D. “Google boss on why it is OK to fail.” BBC News.</p><p>February 16, 2016. http://www.bbc.com/news/technology-</p><p>35589220 Accessed June 14, 2018.</p><p>56. Dougherty, C. “They Promised Us Jet Packs. They Promised the</p><p>Bosses Profit.” The New York Times. July 23, 2016. https://www</p><p>.nytimes.com/2016/07/24/technology/they-promised-us-jet-packs-</p><p>they-promised-the-bosses-profit.html Accessed June 14, 2018.</p><p>57. Information on Bob Chapman and Barry-Wehmiller comes from</p><p>Chapman’s book Everybody Matters and a case study conducted by my</p><p>HBS colleague Jan Rivkin:</p><p>◾ Chapman, B. & Sisodia, R. Everybody Matters: The Extraordinary</p><p>Power of Caring for Your People Like Family. US: Penguin-Random</p><p>House, 2015. Print.</p><p>◾ Minor, D. & Rivkin, J. Truly Human Leadership at Barry-Wehmiller.</p><p>Case Study. HBS No. 717-420. Boston, MA: Harvard Business</p><p>School Publishing, 2016.</p><p>58. “Surpassing 100 acquisitions, Barry-Wehmiller looks to the future.”</p><p>Barry-Wehmiller. February 6, 2016. https://www.barrywehmiller</p><p>.com/docs/default-source/pressroom-library/pr_bw_100acquisitions_</p><p>020618_final.pdf?sfvrsn=2 Accessed June 8, 2018.</p><p>59. Chapman, B. & Sisodia, R. 2015: 101.</p><p>60. “Surpassing 100 acquisitions, Barry-Wehmiller looks to the future.”</p><p>February 6, 2016, op cit.</p><p>61. Chapman, B. & Sisodia, R. 2015: 53.</p><p>62. Chapman, B. & Sisodia, R. 2015: 59.</p><p>63. Chapman, B. & Sisodia, R. 2015: 53.</p><p>64. Chapman, B. & Sisodia, R. 2015: 170</p><p>65. Ibid.</p><p>https://www.fastcompany.com/3028156/the-google-x-factor</p><p>http://www.bbc.com/news/technology-35589220</p><p>http://www.bbc.com/news/technology-35589220</p><p>https://www.nytimes.com/2016/07/24/technology/they-promised-us-jet-packs-they-promised-the-bosses-profit.html</p><p>https://www.nytimes.com/2016/07/24/technology/they-promised-us-jet-packs-they-promised-the-bosses-profit.html</p><p>https://www.nytimes.com/2016/07/24/technology/they-promised-us-jet-packs-they-promised-the-bosses-profit.html</p><p>https://www.barrywehmiller.com/docs/default-source/pressroom-library/pr_bw_100acquisitions_020618_final.pdf?sfvrsn=2</p><p>https://www.barrywehmiller.com/docs/default-source/pressroom-library/pr_bw_100acquisitions_020618_final.pdf?sfvrsn=2</p><p>https://www.barrywehmiller.com/docs/default-source/pressroom-library/pr_bw_100acquisitions_020618_final.pdf?sfvrsn=2</p><p>6</p><p>Safe and Sound</p><p>“It is not death that a man should fear, but he should fear never beginning to live.”</p><p>—Marcus Aurelius1</p><p>“Birds,” said Captain Chesley “Sully” Sullenberger III.</p><p>“Whoa,” said First Officer Jeffrey Skiles.</p><p>The two pilots, side by side nearly three thousand feet above</p><p>Manhattan on a cold, clear day in January 2009, both knew that this</p><p>deceptively simple word – birds – could spell disaster. Sullenberger,</p><p>age 57, and Skiles, age 49, had met for the first time just hours earlier.</p><p>Both were highly-experienced pilots, well-versed in the clipped</p><p>verbal exchanges of cockpit communications.2 For the next few</p><p>seconds they watched as Canadian geese filled the windscreen, heard</p><p>a loud thudding as the large birds were ingested into the Airbus’</p><p>engines, and then smelled burning feathers and flesh. The lives of</p><p>150 passengers and five crew, including their own, would depend on</p><p>how the two pilots, the crew,</p><p>and the air traffic controller handled the</p><p>next three minutes. What would become a miraculous, zero-fatality</p><p>129</p><p>130 Psychological Safety at Work</p><p>landing on the Hudson River drew on aviation training, navigation</p><p>skills, old-fashioned luck, and that extra, less tangible quality that</p><p>knowledge workers today must acquire: the ability to team by</p><p>communicating fearlessly. Fearless communication is vital input into</p><p>making complex decisions, often quickly, that have no precedent</p><p>and bring serious consequences.</p><p>Use Your Words</p><p>We have many examples of how even brief verbal exchanges can</p><p>be thwarted by a lack of psychological safety. The nurse who hes-</p><p>itates to speak up to a surgeon about a possible procedural error</p><p>because past exchanges led her to think this would bother him; the</p><p>new engineer on a project who doesn’t ask a question because she</p><p>fears looking stupid; and the boss who doesn’t listen to ideas from</p><p>employees because he thinks it will make him appear weak. We have</p><p>fewer examples of the nuanced exchanges that occur in situations</p><p>of high psychological safety, especially those with high stress, and of</p><p>the positive outcomes that ensue. But those excruciating few minutes</p><p>of cockpit conversation, recorded that January afternoon, are worth</p><p>deconstructing. Each of the small team of key participants felt safe</p><p>enough with one another to become heroes together.</p><p>The bird strike took place about 90 seconds after Flight 1549’s</p><p>takeoff from New York City’s LaGuardia airport. The immediate</p><p>problem: dual engine failure. The next problem: dual engine fail-</p><p>ure was classified as a “non-normal situation,” and was not included</p><p>in the automated systems that warn pilots of system failures and dis-</p><p>play instructions on the monitor for handling the failure.3 In short,</p><p>dual engine failure from bird strikes was exceedingly rare – bordering</p><p>on unheard of. Airline policy asked captains “to use common sense</p><p>and good judgment, especially in those situations not specifically cov-</p><p>ered.”4 In other words, they were on their own.</p><p>Immediately, Sullenberger, or “Sully” as he has been immor-</p><p>talized in the eponymous Hollywood film, who had been serving</p><p>Safe and Sound 131</p><p>as copilot, took over the controls from Skiles. “My aircraft,” said</p><p>Sullenberger, using aviation coded shorthand, as he put his hands on</p><p>the controls.</p><p>Although almost instinctive, the decision was driven by good rea-</p><p>soning: Sully had logged far more hours flying the A320 than had</p><p>Skiles. Perhaps most important, from where he sat, Sullenberger could</p><p>see the cityscape and George Washington Bridge out his left viewing</p><p>window, while Skiles could not. Also relevant: Skiles was the pilot</p><p>who was more familiar with emergency procedures and could thus</p><p>better manage the landing equipment.</p><p>“Your aircraft,” replied Skiles.</p><p>That was all it took. There was no hesitancy, fear, apology, or</p><p>disagreement from either man.</p><p>Sullenberger had long played a major role in training other pilots</p><p>in Cockpit Resource Management (CRM) at US Airways.5 Passion-</p><p>ately committed to the program, which emphasizes interpersonal</p><p>communication, leadership, and decision-making under pressure, it’s</p><p>hard to imagine any pilot with a better understanding of the need</p><p>for crew members to feel able to speak up than Sully. Both he and</p><p>Skiles felt they were operating in a psychologically safe environment.</p><p>But the cockpit pilots were not the only members of that intensely</p><p>high-performing team that day.</p><p>Next, Sullenberger informed Patrick Harten, the air traffic</p><p>controller who worked out of the large Long Island center that</p><p>controls arrivals and departures out of the greater New York area,</p><p>that they’d hit birds and were turning back to LaGuardia. “Mayday,</p><p>mayday, mayday,” said Sullenberger, citing the universal message for</p><p>life-threatening distress. Harten took the necessary measures, which</p><p>included calling the LaGuardia control tower to tell them to prepare</p><p>for an emergency landing.</p><p>A Virtual Team in the Learning Zone</p><p>Meanwhile, Skiles was unsuccessful in his attempts to restart the</p><p>engines, in part because the plane was not moving fast enough.</p><p>132 Psychological Safety at Work</p><p>“We don’t have that,” he told Sullenberger, referring to the plane’s</p><p>speed. Sullenberger agreed, and then was silent. He was mentally</p><p>calculating whether they’d have a better chance trying to make it to</p><p>an airport runway or to land on the river below. Although Harten</p><p>tried several times to direct the Airbus toward a nearby airport from</p><p>the control tower, each time Sullenberger replied that he was “un-</p><p>able.” He then reported he would be taking the riskiest but, to him,</p><p>most feasible option: landing in the Hudson River. It was also the</p><p>option that would minimize chances of harming bystanders on the</p><p>ground in the densely populated city below. Harten, dumbfounded</p><p>and believing landing in the water would almost certainly result in</p><p>the pilots’ deaths, asked Sullenberger to repeat his intention. This</p><p>was as much a trained reflex as a conscious request. As we saw in the</p><p>1977 Tenerife disaster when a Royal Dutch Airlines (KLM) captain</p><p>misunderstood the instructions of an air traffic controller – who said</p><p>he was not cleared for takeoff – and proceeded to speed down a foggy</p><p>runway and collide with another plane, the tiniest break in clarity</p><p>can result in hundreds of needless deaths. Harten was well trained.</p><p>Soon – no more than a minute later – it was time for the cockpit to</p><p>alert the rest of the flight crew and the passengers. Again, Sullenberger</p><p>communicated deliberately and carefully in the way he thought most</p><p>likely to achieve a good outcome. Afraid of how hard the plane might</p><p>hit the water, he chose not to tell the flight crew to prepare for a</p><p>water landing – in which case he knew they would instruct passengers</p><p>to don life jackets, consuming valuable time. Instead, he broadcast,</p><p>“This is the captain. Brace for impact.” The three flight attendants</p><p>then shouted at the passengers to put their heads down and grab their</p><p>legs, as directed by emergency landing protocol. Sullenberger steered</p><p>the airplane to a perfect, if unavoidably violent, landing, while Skiles</p><p>called out altitude and speed. Some passengers suffered injuries, most</p><p>relatively minor, but not a single life was lost in this almost miraculous</p><p>outcome. Soon, nearby boats swarmed to area and rescued passengers</p><p>before anyone suffered hypothermia.</p><p>Safe and Sound 133</p><p>Using Time Well</p><p>Let’s look more closely at what was accomplished here with very few,</p><p>very precise words. Although clearly an extreme case, the human</p><p>interactions in this extraordinary situation provide a compelling</p><p>demonstration that clarity and candor do not necessarily mean</p><p>getting bogged down in endless discussions. Psychological safety</p><p>does not imply excessive talking and over-processing. Psychologically</p><p>safe meetings do not have to take longer. Conversely, I’ve studied</p><p>management team meetings where low psychological safety gave</p><p>rise to indirectness of argument that consumed far more time than</p><p>necessary. Worse, key decisions were often postponed due to evident</p><p>conflict that was not effectively discussed, making the discussions</p><p>and the total decision time (in months) take far more time than</p><p>necessary.6</p><p>Learning from Other Industries</p><p>What we can learn from this extreme case, as well as from many cases</p><p>of normal business conversation, is that psychological safety must be</p><p>paired with discipline to achieve optimal results efficiently. Consider</p><p>that, for his part, Harten asked only essential questions; also, he kept</p><p>the phone lines open as he spoke to the other air controllers, so that</p><p>Sullenberger could hear those conversations at the same time, again</p><p>saving valuable time because Harten did not have to repeat them. Sul-</p><p>lenberger later wrote about Harten, “his words let me know that he</p><p>understood that these hard choices were mine to make, and it wasn’t</p><p>going to help if he tried to dictate a plan to me.”7 And then there</p><p>was what was not said. For many of those crucial seconds, Sullen-</p><p>berger and Skiles</p><p>silently concentrated on their respective tasks and</p><p>kept an eye on each other for the visual clues that kept them working</p><p>as a coordinated team.</p><p>134 Psychological Safety at Work</p><p>Flight 1549’s experienced flight crew was well trained in stan-</p><p>dard aviation equipment protocols and procedures. Equally impor-</p><p>tant, they were trained in threat and error management (TEM) and</p><p>CRM (also sometimes called Crew Resource Management). Both</p><p>programs teach ways of thinking and decision-making. CRM – a</p><p>program that, among other skills, instructs aviation crews to speak</p><p>up to their captain when they feel something is wrong and likewise</p><p>instructs captains to listen to crew concerns – is especially well suited</p><p>to creating environments of psychological safety. CRM training, now</p><p>required for all pilots, was first begun in response to Tenerife and</p><p>other similarly tragic accidents, such as the 1982 Air Florida fatal</p><p>landing in the Potomac in which a copilot could not bring him-</p><p>self to insist that the captain turn back in the face of freezing rain</p><p>and incomplete de-icing, and the 2013 Asiana Airlines crash at the</p><p>San Francisco airport, when a copilot was afraid to warn his captain</p><p>about a low-speed landing.8</p><p>Training modeled after CRM has also spread to medical envi-</p><p>ronments. The goal has been to increase patient safety by promoting</p><p>better communication and teamwork.9 In one study, a CRM-like</p><p>training in communication and teamwork was shown to produce bet-</p><p>ter outcomes in the delivery room for both mothers and babies. The</p><p>program also led to greater patient and staff satisfaction.10</p><p>It can be tempting to discount the value of the Hudson Miracle</p><p>in demonstrating psychological safety and teaming in action because</p><p>of the role played by emergency protocols in shaping the response.</p><p>However, as we have seen far too often in aviation, as well as in other</p><p>highly-protocolized settings like the operating room, the existence of</p><p>procedures does not ensure their use. Without psychological safety,</p><p>micro-assessments of interpersonal risk tend to crowd out proper</p><p>responses. We simply fail to recognize the implications of our hesi-</p><p>tation or silence in the moments in which we could have spoken up.</p><p>Psychological safety can thus be seen as a precondition for the</p><p>effective use of emergency protocols. But, as we will see in the next</p><p>case, emergencies are not the only context where a psychologically</p><p>safe work environment can foster human health and safety.</p><p>Safe and Sound 135</p><p>One for All and All for One</p><p>What does a leading provider of kidney dialysis services for 200 000</p><p>patients around the world have in common with a nineteenth century</p><p>historical novel?11 Answer: a swashbuckling hero who brandishes a</p><p>sword and lives by the motto “one for all and all for one.”</p><p>At DaVita Kidney Care, the swashbuckler is CEO and Chairman</p><p>Kent Thiry.12 Thiry is known to leap about the stage brandishing</p><p>a sword while wearing full musketeer regalia in front of hundreds</p><p>of frontline employees – patient care technicians, nurses, and social</p><p>workers – in attendance for the regularly offered two-day DaVita</p><p>Academy program, one of the foundational seminars for new employ-</p><p>ees put on by the DaVita University. Thiry’s unusual choice of persona</p><p>and costume, along with frequent high-fives and other high-intensity</p><p>interactions, seem to reflect his comfort bringing his whole self to</p><p>the workplace, so as to signal to others that they can do so too.</p><p>The program offers many team-building and socializing activities for</p><p>attendees that include songs, skits, games, storytelling, refreshments,</p><p>music, and dancing and is intended to introduce employees to the</p><p>DaVita culture. Thiry also leads a town hall question and answer</p><p>session, where he is willing to be vulnerable (often admitting, for</p><p>example, that he doesn’t know the answer to a question) and open,</p><p>entertaining direct questions about wages and promotions. The “One</p><p>for All and All for One” slogan conveys a company core value – the</p><p>idea of shared obligations and responsibility. All Davita workers are</p><p>called upon to contribute their best to the company; likewise, the</p><p>company is responsible for helping individuals develop and succeed.</p><p>Attendance at the Academy program is voluntary, but the company’s</p><p>data shows that people who do attend have a turnover rate of about</p><p>12% compared to the 28% who do not attend.13</p><p>Hired in 1999 to rescue the company from the brink of ruin,</p><p>Thiry is credited with having turned it around by building a set of</p><p>values and a culture that combine to create a high level of psycholog-</p><p>ical safety. Much like Bob Chapman at Barry-Wehmiller, discussed</p><p>in Chapter 5, Thiry believes in fostering a community where people</p><p>136 Psychological Safety at Work</p><p>on every level of the organization have a voice and are developed as</p><p>leaders. As part of giving people a voice, Thiry decided to involve</p><p>them in creating a list of core values, which were then voted on by</p><p>600 of the company’s clinician-managers. Employees (called team-</p><p>mates) were asked to vote to find the new name, DaVita, when Thiry</p><p>wanted to rename the company, previously called Total Renal Care.</p><p>To help prepare frontline employees for their responsibilities as team-</p><p>mates, and to support them in taking on administrative roles, DaVita</p><p>University provides many leadership development programs, with an</p><p>emphasis on management and team skills, along with programs on</p><p>quality improvement.</p><p>Thiry refers to himself as the “mayor” of DaVita “village”</p><p>and emphasizes that “building a successful company is a means to</p><p>the end of building a healthy community.”14 Also in support of</p><p>a healthy community, the DaVita Village Network fund exists to</p><p>help teammates who may encounter unexpected medical expenses</p><p>or have other financial difficulties. This is part of the “all for one”</p><p>philosophy. The company matches donations teammates make into</p><p>the fund. Although the majority of teammates are low-skilled, hourly</p><p>workers, DaVita offers comprehensive health and welfare benefits,</p><p>including provisions for healthcare, retirement, tuition reimburse-</p><p>ments, and, most surprisingly, stock options and profit sharing.</p><p>These incentives help support Thiry’s demand that teammates come</p><p>to work “intending not only to do a solid day’s work, but also to</p><p>strive to make DaVita a special place.”15</p><p>Kidney dialysis patients, the majority of whom are suffering from</p><p>end-stage renal condition, are especially in need of the combined</p><p>efforts of a medical team that is “all for one.” Patients typically</p><p>visit a local clinic three to four times per week and are hooked</p><p>up to the dialysis machine for about four hours at a time – for</p><p>the rest of what they know is likely to be a shortened life. They</p><p>must endure the poke of needles and sit quietly while the machine</p><p>draws out and cleans the blood that their failed kidneys can no</p><p>longer process. They must adhere to a strict diet and often suffer</p><p>from other chronic conditions, such as diabetes and heart disease.</p><p>Safe and Sound 137</p><p>Unsurprisingly, some become depressed, or worse, stop coming</p><p>to the clinic for treatments, which leads soon to death. It’s emo-</p><p>tionally difficult to care for dialysis patients. Up to 25% will die</p><p>each year. Given these morale-lowering conditions, the excessively</p><p>upbeat tone of the DaVita Academy sessions begins to make</p><p>more sense.</p><p>Most importantly, DaVita consistently delivers top clinical out-</p><p>comes in its industry. That’s because good clinical outcomes in large</p><p>part depend on the quality of care delivered by the staff at the out-</p><p>patient dialysis clinics where most patients are treated. Although a</p><p>technician’s job is ostensibly practical – to connect and disconnect the</p><p>patient to the machine and monitor the ongoing treatment – much</p><p>can also depend on the relationships technicians establish with both</p><p>the patient and other caregivers. Patients who feel comfortable and</p><p>trusting – psychologically safe – with the clinic staff are more likely</p><p>to comply with a rigorous treatment plan. To encourage these pos-</p><p>itive feelings, DaVita centers</p><p>are often decorated with photographs</p><p>of patients and their families, as well as by drawings made by them,</p><p>their children, and their grandchildren. As one DaVita administra-</p><p>tor said, “it’s important that the teammates like their jobs and smile</p><p>and relate in a compassionate way to patients, because that makes</p><p>the patients feel better about being here.”16 In other words, clinic</p><p>staff who themselves feel supported by high levels of psychological</p><p>safety are able to support and bond with patients, which contributes</p><p>to positive clinical outcomes.</p><p>As we have seen in other healthcare settings, speaking up and feel-</p><p>ing psychologically safe enough to communicate across boundaries</p><p>and well-established medical hierarchies also contributes to positive</p><p>clinical outcomes. In 2017, DaVita successfully participated in a pilot</p><p>program run by the Centers for Medicare and Medicaid Services</p><p>(CMS) to institute integrated care for dialysis patients – specifically</p><p>for nurses, social workers, and technicians to communicate regu-</p><p>larly with nephrologists about individual patients. As Roy Marcus,</p><p>a medical director and participating nephrologist put it, “DaVita’s</p><p>integrated care team regularly communicates with nephrologists to</p><p>138 Psychological Safety at Work</p><p>better address gaps in care that extend beyond dialysis. This frequent</p><p>communication means I have the time and details I need to provide</p><p>better, more holistic care to my patients.”17</p><p>Kidney dialysis treatment is especially well suited to follow the</p><p>Institute for Healthcare Improvement’s triple aim for healthcare:</p><p>improving patient experience, improving population health, and</p><p>reducing cost per patient.18 Here, as in other industries, making</p><p>dramatic, systemic change happen is highly-dependent on building</p><p>the psychological safety that allows employees to speak up with their</p><p>concerns and ideas for improvement, as well as to experiment in</p><p>small ways to figure out what works best.</p><p>Speaking Up for Worker Safety</p><p>By now you’re well aware that speaking up is easier said than done.</p><p>There’s no switch to flip that will instantaneously turn an organization</p><p>accustomed to silence and fear into one where people speak candidly.</p><p>Instead, creating a psychologically safe workplace, as we’ll explore in</p><p>depth in Chapter 7, requires a lot of effort to alter systems, structures,</p><p>and processes. Ultimately, it means that deep-seated entrenched orga-</p><p>nizational norms and attitudes must change. And it begins with what</p><p>I call “stage setting.” Let’s look at how Anglo American, one of the</p><p>world’s largest mines, headquartered in South Africa, prepared for and</p><p>then institutionalized speaking up.</p><p>When Cynthia Carroll was appointed in 2007, with much fan-</p><p>fare, as the first female CEO of an international mining company,</p><p>she was appalled by the number of worker fatalities been occurring</p><p>in the company – nearly 200 in the 5 years prior to her arrival.19</p><p>Realizing that she was “in an unprecedented position to influence</p><p>change” as both an American/outsider in a foreign country and as</p><p>a woman where “until very recently women hadn’t been allowed to</p><p>visit underground at mines in South Africa, let alone work there,”20</p><p>she immediately used her position to speak up and demand a policy</p><p>of zero fatalities or serious injuries.</p><p>Safe and Sound 139</p><p>At first, others in the company, especially members of the old</p><p>guard who saw themselves as upholding tradition, refused to take</p><p>Carroll seriously. At least one executive responded by saying that</p><p>zero harm “will never happen in our lifetime.”21 Likewise, when</p><p>Carroll visited individual mines, the local managers tried to make</p><p>her understand that while safety was important, her demands were</p><p>unrealistic. Serious injuries and deaths were considered an inevitable</p><p>hazard, part of mining’s dangerous physical demands. Furthermore it</p><p>was not uncommon to blame errors on the workers themselves. The</p><p>prevailing attitude in South Africa, according to Anglo American’s</p><p>chairman, Sir Mark Moody-Stuart, who was instrumental in hiring</p><p>Carroll, was that workers who suffered injuries “took shortcuts, did</p><p>not always follow the rules; they were stupid.”22</p><p>Carroll’s response to the resistance could not have been more</p><p>unambiguous. She shut down one of the most problematic and dan-</p><p>gerous mines. Rustenburg, located about 60 miles from Johannes-</p><p>burg, was the world’s foremost supplier of platinum and generated</p><p>about $8 million in revenue per day. Shutting down the mine was</p><p>both bold and unprecedented. It immediately got everyone’s atten-</p><p>tion. Even more shocking, Carroll insisted that before the mine could</p><p>restart, she wanted to find out what the workers were thinking, and</p><p>she intended to get input from every single worker about how to</p><p>improve safety. This, she knew, was a direct challenge to Anglo Amer-</p><p>ican’s strict hierarchical culture and rigid, top-down management</p><p>style, which had begun with the mine’s founding in 1917 and was</p><p>further strengthened by South Africa’s apartheid history.</p><p>Here’s where things get interesting. After shutting down the</p><p>mine, Anglo American executives gathered 3000 to 4000 workers at</p><p>a time in a stadium and spoke about the importance of safety. Because</p><p>the workers spoke a range of languages and literacy rates were low,</p><p>the company used visuals to illustrate safety and hired a theater group</p><p>to role-play safety interactions between workers and supervisors.</p><p>Employees were then divided into groups of 40 to 50 and asked to</p><p>speak up about their safety concerns and opinions. Understandably,</p><p>the workers were reluctant to do so, having historically had no say.</p><p>140 Psychological Safety at Work</p><p>As Carroll observed, “I wondered how much authority someone</p><p>who is underground for hours on end, with a shift supervisor right</p><p>behind him, really has. I questioned whether a line worker had the</p><p>power to put up his hand and say, ‘I’m not going to do this, because it</p><p>is unsafe.’”23 In other words, the workers had to feel psychologically</p><p>safe in order to speak up about their physical safety.</p><p>Psychological safety had to be created in the mines by finding a</p><p>culturally appropriate approach. With help from the unions, Anglo</p><p>American leadership adopted a traditional South African method of</p><p>conducting village assemblies, called lekgotla. As you will see, lekgotla</p><p>seems to echo tenets and practices of psychological safety. Tradition-</p><p>ally, in these assemblies (somewhat like meetings at Eileen Fisher),</p><p>everyone sits in a circle and has a chance to speak without being inter-</p><p>rupted or criticized; conversation continues for as long as it takes to</p><p>reach consensus on whatever issue is at stake.24</p><p>During Anglo American’s lekgotla, senior managers reframed the</p><p>initial question. Instead of asking workers to give their opinions</p><p>directly about safety issues, they asked, “what do we need to do to</p><p>create a work environment of care and respect?” That was when</p><p>workers started to feel safe enough to speak up about specific</p><p>concerns. One group said that they’d like hot water at their work</p><p>site to clean up and make tea. (Management complied with this</p><p>request.) The dialogue continued until each group had developed a</p><p>contract stating what specific actions were needed to maximize safety.</p><p>In a powerful symbolic gesture of shared commitment, workers</p><p>and Anglo American executives both signed the contract. As Judy</p><p>Ndlovu, an Anglo American executive said about this process, “the</p><p>real change was listening to the workers . . . Cynthia challenged</p><p>management to understand what the employees were thinking, what</p><p>they felt when they went into the mine each day.”25 Previously, for</p><p>an individual miner to speak up would have taken courage but might</p><p>very well have been a foolish act if not well received by management.</p><p>Once psychological safety started to take root in the culture, miners</p><p>could then speak up to help insure physical safety.</p><p>Safe and Sound 141</p><p>When the mines reopened, more than 30,000 workers were</p><p>retrained to comply with the newly agreed-upon safety protocols.</p><p>Top leadership met with managers</p><p>January 30, 2017. https://www.nytimes.com/2017/01/</p><p>30/education/edlife/factory-workers-college-degree-apprenticeships</p><p>.html Accessed June 13, 2018.</p><p>3. Cross, R., Rebele, R., & Grant, A. “Collaborative Overload.”</p><p>Harvard Business Review. January 1, 2016. https://hbr.org/2016/01/</p><p>collaborative-overload Accessed June 13, 2018.</p><p>4. Edmondson, A.C. “Teamwork on the fly.” Harvard Business Review</p><p>90.4, April 2012. 72–80. Print.</p><p>5. Edmondson, A.C. Teaming: How Organizations Learn, Innovate, and</p><p>Compete in the Knowledge Economy. San Francisco: Jossey-Bass, 2012.</p><p>Print.</p><p>6. Gallup. State of the American Workplace Report. Gallup: Washington,</p><p>D.C, 2017. http://news.gallup.com/reports/199961/state-american-</p><p>workplace-report-2017.aspx Accessed June 13, 2018.</p><p>7. Gallup, State of the American Workplace Report. 2012: 112</p><p>8. Duhigg, C. “What Google Learned From Its Quest to Build the Per-</p><p>fect Team” The New York Times Magazine. February 25, 2016. https://</p><p>www.nytimes.com/2016/02/28/magazine/what-google-learned-</p><p>from-its-quest-to-build-the-perfect-team.html Accessed June 13,</p><p>2018.</p><p>9. Ibid.</p><p>10. Rozovsky, J. “The five keys to a successful Google team.” re:Work</p><p>Blog. November 17, 2015. https://rework.withgoogle.com/blog/five-</p><p>keys-to-a-successful-google-team/ Accessed June 13, 2018.</p><p>11. Ibid.</p><p>https://www.nytimes.com/2017/01/30/education/edlife/factory-workers-college-degree-apprenticeships.html</p><p>https://www.nytimes.com/2017/01/30/education/edlife/factory-workers-college-degree-apprenticeships.html</p><p>https://www.nytimes.com/2017/01/30/education/edlife/factory-workers-college-degree-apprenticeships.html</p><p>https://hbr.org/2016/01/collaborative-overload</p><p>http://news.gallup.com/reports/199961/state-american-workplace-report-2017.aspx</p><p>http://news.gallup.com/reports/199961/state-american-workplace-report-2017.aspx</p><p>https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html</p><p>https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team</p><p>https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team</p><p>https://hbr.org/2016/01/</p><p>https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html</p><p>https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html</p><p>https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html</p><p>https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html</p><p>https://hbr.org/2016/01/collaborative-overload</p><p>PART</p><p>I The Power of</p><p>Psychological Safety</p><p>1</p><p>The Underpinning</p><p>“Psychological safety was by far the most important of the five key dynamics we</p><p>found. It’s the underpinning of the other four.”</p><p>—Julia Rozovsky,</p><p>“The five keys to a successful Google team.”1</p><p>The tiny newborn twins seemed healthy enough, but their early</p><p>arrival at only 27 weeks’ gestation meant they were considered</p><p>“high risk.” Fortunately, the medical team at the busy urban hospital</p><p>where the babies were delivered included staff from the Neonatal</p><p>Intensive Care Unit (NICU): a young Neonatal Nurse Practitioner</p><p>named Christina Price∗ and a silver-haired neonatologist named</p><p>Dr. Drake. As Christina looked at the babies, she was concerned.</p><p>Her recent training had included, as newly established best practice,</p><p>administering a medicine that promoted lung development as soon</p><p>as possible for a high-risk baby. Babies born very prematurely often</p><p>arrive with lungs not quite ready for fully independent breathing</p><p>∗Names in this story are pseudonyms.</p><p>3</p><p>4 The Power of Psychological Safety</p><p>outside the womb. But the neonatologist had not issued an order</p><p>for the medicine, called a prophylactic surfactant. Christina stepped</p><p>forward to remind Dr. Drake about the surfactant and then caught</p><p>herself. Last week she’d overheard him publicly berate another nurse</p><p>for questioning one of his orders. She told herself that the twins</p><p>would probably be fine – after all, the doctor probably had a reason</p><p>for avoiding the surfactant, still considered a judgment call – and she</p><p>dismissed the idea of bringing it up. Besides, he’d already turned on</p><p>his heel, off for his morning rounds, white coat billowing.</p><p>Unconscious Calculators</p><p>In hesitating and then choosing not to speak up, Christina was</p><p>making a quick, not entirely conscious, risk calculation – the kind</p><p>of micro-assessment most of us make numerous times a day. Most</p><p>likely she was not even aware that she had weighed the risk of being</p><p>belittled or berated against the risk that the babies might in fact</p><p>need the medication to thrive. She told herself the doctor knew</p><p>better than she did, and she was not confident he would welcome</p><p>her input. Inadvertently, she had done something psychologists call</p><p>discounting the future – underweighting the more important issue</p><p>of the patients’ health, which would take some time to play out,</p><p>and overweighting the importance of the doctor’s possible response,</p><p>which would happen immediately. Our spontaneous tendency to</p><p>discount the future explains the prevalence of many unhelpful or</p><p>unhealthy behaviors – whether eating that extra piece of chocolate</p><p>cake or procrastinating on a challenging assignment – and the failure</p><p>to speak up at work is an important and often overlooked example</p><p>of this problematic tendency.</p><p>Like most people, Christina was spontaneously managing her</p><p>image at work. As noted sociologist Erving Goffman argued in</p><p>his seminal 1957 book, The Presentation of the Self in Everyday</p><p>Life, as humans, we are constantly attempting to influence others’</p><p>The Underpinning 5</p><p>perceptions of us by regulating and controlling information in social</p><p>interactions.2 We do this both consciously and subconsciously.</p><p>Put another way, no one wakes up in the morning excited to</p><p>go to work and look ignorant, incompetent, or disruptive. These are</p><p>called interpersonal risks, and they are what nearly everyone seeks to</p><p>avoid, not always consciously.3 In fact, most of us want to look smart,</p><p>capable, or helpful in the eyes of others. No matter what our line of</p><p>work, status, or gender, all of us learn how to manage interpersonal</p><p>risk relatively early in life. At some point during elementary school,</p><p>children start to recognize that what others think of them matters,</p><p>and they learn how to lower the risk of rejection or scorn. By the</p><p>time we’re adults, we’re usually really good at it! So good, we do it</p><p>without conscious thought. Don’t want to look ignorant? Don’t ask</p><p>questions. Don’t want to look incompetent? Don’t admit to mistakes</p><p>or weaknesses. Don’t want to be called disruptive? Don’t make sug-</p><p>gestions. While it might be acceptable at a social event to privilege</p><p>looking good over making a difference, at work this tendency can lead</p><p>to significant problems – ranging from thwarted innovation to poor</p><p>service to, at the extreme, loss of human life. Yet avoiding behaviors</p><p>that might lead others to think less of us is pretty much second nature</p><p>in most workplaces.</p><p>As influential management thinker Nilofer Merchant said about</p><p>her early days as an administrator at Apple, “I used to go to meetings</p><p>and see the problem so clearly, when others could not.” But worrying</p><p>about being “wrong,” she “kept quiet and learned to sit on my hands</p><p>lest they rise up and betray me. I would rather keep my job by staying</p><p>within the lines than say something and risk looking stupid.”4 In one</p><p>study investigating employee experiences with speaking up, 85% of</p><p>respondents reported at least one occasion when they felt unable to</p><p>raise a concern with their bosses, even though they believed the issue</p><p>was important.5</p><p>If you think this behavior is limited to those lower in the organi-</p><p>zation, consider the chief financial officer recruited to join the senior</p><p>team of a large electronics company. Despite grave reservations about</p><p>6 The Power of Psychological Safety</p><p>a planned acquisition of another company, the new executive said</p><p>nothing. His colleagues seemed uniformly enthusiastic, and he went</p><p>to discuss compliance with the</p><p>new rules and to emphasize that employees now had the right to</p><p>stop work if safety standards were not being met. New policies</p><p>were instituted to insure regular review of safety procedures and</p><p>to schedule times when management and executives continued to</p><p>solicit input from workers regarding safety operations. Guiding values</p><p>were established. Executive meetings were now required to begin</p><p>with lengthy updates and discussions on safety. Although fatalities</p><p>fell considerably – from 44 in 2006 to 17 in 2011, a reduction of</p><p>62%26 – they did not reach zero. The company honored any worker</p><p>who died with memorial services and by posting their photographs</p><p>in all buildings. The supervisor of the deceased visited the worker’s</p><p>family and village to convey respect and sympathy. All these measures</p><p>helped to institutionalize not only the safety protocols but also a</p><p>psychologically safe culture built by care and respect.</p><p>A year after the shutdown, Carroll chose to speak up yet again,</p><p>this time to people outside the organization – the National Union</p><p>of Mineworkers and the Minister of Mines – to ask for their help</p><p>in working together to achieve zero harm. Again, she was rebuffed.</p><p>However, in April 2008, a Safety Summit was held in Johannesburg</p><p>between Anglo American, the South African Department of Min-</p><p>erals and Energy, and the National Union of Mineworkers. It was</p><p>the first time the three major stakeholders had come together. As</p><p>with the mineworkers, it took time for representatives from the three</p><p>governing entities to build trust and respect. The catalyst for work-</p><p>ing together was the shared goal of dramatically improving physical</p><p>safety in the mines. And process was instrumental. By visiting dif-</p><p>ferent mines together and continuing to convene, the three groups</p><p>developed a growing sense of respect and trust for one another. The</p><p>stakeholder partnerships that eventually developed helped spread of</p><p>the passion for safety ignited at Anglo American into the rest of South</p><p>Africa’s mining industry.</p><p>142 Psychological Safety at Work</p><p>Although production and revenues fell in the year following the</p><p>mine shutdown, in both 2008 and 2011, during Carroll’s tenure, the</p><p>company achieved the highest operating profits in its history. Share</p><p>price rose commensurably. Carroll realized that increasing physical</p><p>safety in the mines was as much about transforming old attitudes about</p><p>worker safety and changing the culture to make it safe to speak up as</p><p>it was about technical or process improvements.</p><p>In previous chapters we saw how people up and down and across</p><p>an organization can contribute to creating a climate of silence and</p><p>fear. Similarly, people up and down and across the organization can</p><p>contribute to creating a climate of voice and safety. A leader can be</p><p>the driving force and catalyst for others to speak up; but ultimately,</p><p>the practice must be co-created – and continuously nurtured – by</p><p>multiple stakeholders. As we have seen, commitment to doing this is</p><p>particularly vital for preventing or managing a crisis.</p><p>Transparency by Whiteboard</p><p>When people think of leadership in a crisis, all too often they think</p><p>of someone like General George Patton, issuing decisive orders to his</p><p>soldiers and commandeering them to victory with toughness. But</p><p>that isn’t always the case, especially when the enemy is technology or</p><p>natural forces, or both.</p><p>Let’s look at a less obvious example of heroic leadership in a crisis:</p><p>Naohiro Masuda, the plant superintendent of the second Fukushima</p><p>nuclear plant when the giant earthquake struck in March 2011. Like</p><p>Patton, he inspired life-saving teamwork from his followers. However,</p><p>Masuda did so by adhering to key principles that build psycholog-</p><p>ical safety: honesty, vulnerability, communication, and information</p><p>sharing. And his key weapon was a whiteboard.</p><p>Fukushima Daini, less than five miles down the coast from its</p><p>sister plant, Daiichi, also suffered severe damage from the earthquake</p><p>and tsunami waves.27 In stark contrast to Daiichi, however, Masuda</p><p>and his 400 employees managed to safely shut down all 4 of the</p><p>Safe and Sound 143</p><p>plant’s reactors, thereby averting the ultimate disaster of releasing</p><p>nuclear material into the air and sea. They managed to lay 5.5 miles</p><p>of extremely heavy cable in 24 hours – a job that under normal</p><p>circumstances would take a team of 20, with machinery, at least a</p><p>month. And they worked for over 48 hours without sleep, in a state</p><p>of tremendous uncertainty, with fear for their lives and those of their</p><p>families.</p><p>How did Masuda motivate his men to stay under such tough</p><p>conditions? From the beginning, Masuda chose to issue information</p><p>rather than orders. After evacuating his workers to the Emergency</p><p>Response Center (ERC), and having heard from operators in the</p><p>control rooms that three of the plant’s four reactors had lost all opera-</p><p>tive cooling systems (the operators had bravely weathered the tsunami</p><p>from their posts), Masuda knew the situation was “extremely seri-</p><p>ous.”28 If the reactors could not be cooled, they would overheat,</p><p>resulting in a nuclear breach.</p><p>Masuda and his team unfortunately lacked information about the</p><p>physical condition of the plant. They didn’t know what was broken</p><p>or what resources they might have. To find that out, workers would</p><p>need to venture outside to assess the damage and figure out what</p><p>could be done to restore power to the reactors and stabilize the plant.</p><p>And, for Masuda, that meant helping the workers – already shaken</p><p>by earthquake and flood – feel psychologically safe enough to act.</p><p>Instead of grabbing a megaphone or commanding his men into</p><p>action, Masuda began writing things down on a whiteboard: the mag-</p><p>nitude and frequency of the earthquake’s aftershocks, calculations, and</p><p>a rough chart that demonstrated the decreasing danger of the quakes</p><p>over time. In other words, he armed his men with data. “I was not</p><p>sure if my team would go to the field if I asked, and if it was even</p><p>safe to dispatch people there,” Masuda later reflected.29 Indeed, he</p><p>allowed the men to make their own decisions about whether they</p><p>wanted to assist in what might be a dangerous mission. At 10 p.m.,</p><p>when Masuda finally asked the men to pick 4 groups of 10 workers</p><p>to go out and survey the damage at each of the 4 reactors, not a single</p><p>one refused.</p><p>144 Psychological Safety at Work</p><p>Having begun his career at Daini in 1982, when it was still under</p><p>construction, Masuda was intimately acquainted with the plant. That</p><p>knowledge allowed him to give each group detailed instructions about</p><p>where to go and what to do. Concerned that fear might interfere with</p><p>workers’ ability to remember his instructions, he made the groups</p><p>repeat the instructions back to him before they left. The point was</p><p>not to command action but to assist them in acting quickly should</p><p>the situation change, and their safety be compromised.</p><p>By 2 a.m. on March 12, all 40 workers had safely returned to the</p><p>ERC with information. One of the reconnaissance teams reported a</p><p>crucial break of good luck: there was still power inside the radiation</p><p>waste building behind Reactor 1. That meant the men could poten-</p><p>tially get power to the cooling systems. But they would need to lay</p><p>heavy-duty cables – and a lot of them.</p><p>By dawn, Masuda and his team had drawn up a route to run cables</p><p>from the building down to the reactor units by the water. However,</p><p>team leaders calculated that they lacked sufficient supplies to do the</p><p>job. Masuda, in turn, quickly contacted TEPCO headquarters and the</p><p>Japanese government to request additional supplies and the calculated</p><p>50 spools of cables.</p><p>While the men waited for the cables to arrive – which would not</p><p>be until the morning of March 13 – they learned about the explosion</p><p>at Daiichi. Some were in disbelief. Many were afraid. Could the same</p><p>thing happen at Daini? Might they be endangering themselves by</p><p>sticking around? Masuda addressed the 500–600 people in the room:</p><p>“Please, trust me,” he said. “I definitely won’t do anything to harm</p><p>you, but Fukushima Daini</p><p>is still in trouble, and I need you to do</p><p>your best.”30</p><p>When the cables finally arrived, the men immediately got to work</p><p>laying them from the waste building to the reactor units down by the</p><p>water. They began with Reactor 2, because it was at greatest risk of</p><p>overheating. To power the three disabled reactors, the men would</p><p>need to lay almost 9 kilometers (5.5 miles) of cable. Each piece of</p><p>cable was 200 meters long and weighed about a ton. The opera-</p><p>tors calculated they had only about 24 hours to perform a job that</p><p>Safe and Sound 145</p><p>under normal circumstances would take a month or more. And so,</p><p>200 workers began frantically laying cables. Working in shifts, they</p><p>made agonizingly slow progress. It took about 100 workers to move</p><p>each piece.</p><p>As the men raced against the clock, Masuda slowly came to an</p><p>unwelcome realization: his plan was untenable. Even at the super-</p><p>human pace the men were working, they would not have enough</p><p>time to hook up all three reactors. The waste building was just too</p><p>far away.</p><p>Masuda’s strength as a leader was demonstrated by the immedi-</p><p>ate admission of his mistake. In keeping with Ray Dalio’s Principles,</p><p>Masuda succeeded by virtue of extreme candor – by telling people</p><p>the worst news, which he believed would increase the chances they</p><p>could figure out how to handle the situation. Despite its unwelcome</p><p>nature, the admission increased the psychological safety in the team</p><p>and bonded the group more tightly. Consulting with his team leaders,</p><p>Masuda concluded that they had no choice but to gamble by utilizing</p><p>some of the power from the generator of the lone functioning reac-</p><p>tor unit. On the whiteboard, Masuda added in adjustments to the</p><p>original plan.</p><p>The men continued to work tirelessly throughout the day. Yet, as</p><p>night approached, some engineers noticed that the pressure in Unit 1</p><p>was now climbing faster than that of Unit 2. Fortunately, they spoke</p><p>up to inform Masuda that they now believed Unit 1 to be most vul-</p><p>nerable and suggested to him that the workers refocus their energy.</p><p>Equally important, Masuda listened closely to his engineers and took</p><p>their suggestions seriously.</p><p>Having seen his team push onward, without having slept in almost</p><p>two days, Masuda was understandably reluctant to tell them, “redo</p><p>it! Shift from Unit 2 to Unit 1!” Still, he broke the news. Though</p><p>some were upset, a climate of psychological safety and a recogni-</p><p>tion of what was at stake helped them to commit to the new course</p><p>of action.</p><p>Just before midnight, ecstatic applause broke out when the</p><p>workers finished laying the last of the cable. At 1:24 a.m., they were</p><p>146 Psychological Safety at Work</p><p>notified that the cooling function had been restored to Unit 1 – with</p><p>about two hours to spare. On the morning of March 15, Masuda and</p><p>his team were notified that all reactors were finally in cold shutdown.</p><p>Finally, they could rest.</p><p>Masuda influenced the workers to act, even as the ground shook</p><p>beneath their feet. Through his calmness, openness, and willingness to</p><p>admit his own fallibility as a leader, Masuda created the conditions for</p><p>the team to make sense of their surroundings, overcome fear, and solve</p><p>problems on the fly. Although their physical safety was in constant</p><p>danger, they felt psychologically safe, and this allowed them to come</p><p>together, try things, fail, and regroup. In the many moments of fear</p><p>for their lives over the course of those days, interpersonal fear within</p><p>the group was nearly nil. Masuda’s words and actions set the tone and</p><p>reassured workers that they could – and must – save the plant.</p><p>Unleashing Talent</p><p>Reflecting on the more than 20 cases included in Part II of this book</p><p>helps us understand both how challenging and how important it is to</p><p>build psychological safety to ensure that the talent in an organization</p><p>is able to be put to good use to learn, innovate, and grow. Speaking</p><p>up is not a natural act in hierarchies. It must be nurtured. When it’s</p><p>not, the results can be catastrophic – for people and for the bottom</p><p>line. But when it is nurtured, you can be certain that it is the product</p><p>of deliberate, thoughtful effort.</p><p>Creating a psychologically safe workplace takes leadership. Lead-</p><p>ership can be seen as a force that helps people and organizations</p><p>engage in unnatural acts like speaking up, taking smart risks, embrac-</p><p>ing diverse views, and solving remarkably challenging problems. And</p><p>so the chapters that lie ahead in Part III are focused on what lead-</p><p>ers can and must do to create psychological safety. They invite you to</p><p>consider, and perhaps try out, a variety of practices that can contribute</p><p>to creating a fearless organization.</p><p>Safe and Sound 147</p><p>Chapter 6 Takeaways</p><p>◾ Clear, direct, candid communication is an important aspect of</p><p>reducing accidents.</p><p>◾ A compelling company purpose combined with caring leader-</p><p>ship motivates people to go the extra mile to do what’s needed</p><p>to ensure safe work practices and employee dignity.</p><p>◾ Worker safety starts with encouraging and reinforcing employ-</p><p>ees’ speaking up about hazards and other concerns.</p><p>Endnotes</p><p>1. This quote is the popular version of a line written by the Stoic philoso-</p><p>pher Marcus Aurelius in Book XII of his The Meditations: “ . . . if thou</p><p>shalt be afraid not because thou must some time cease to live, but if thou shalt fear</p><p>never to have begun to live according to nature- then thou wilt be a man worthy</p><p>of the universe which has produced thee.” You can find Book XII of The</p><p>Meditations, translated by George Long, for free here: http://classics.mit</p><p>.edu/Antoninus/meditations.12.twelve.html. Accessed July 27, 2018.</p><p>2. Key details in the story of US Airways Flight 1549 described in this</p><p>chapter come from the National Transportation Safety Board’s accident</p><p>report, and from a series of published case studies:</p><p>◾ National Transportation Safety Board. “Loss of Thrust in Both</p><p>Engines After Encountering a Flock of Birds and Subsequent</p><p>Ditching on the Hudson River, US Airways Flight 1549, Airbus</p><p>A320-214, N106US, Weehawken, New Jersey, January 15, 2009.”</p><p>◾ Aircraft Accident Report NTSB/AAR-10/03. Washington, D.C.,</p><p>2010;</p><p>◾ Howitt, A.M., Leonard, H.B., & Weeks, J. Miracle on the Hudson</p><p>(A): Landing U.S. Airways Flight 1549. Case Study. HKS No. 1966.</p><p>Cambridge, MA: HKS Case Program, 2012;</p><p>◾ Howitt, A.M., Leonard, H.B., & Weeks, J. Miracle on the Hudson</p><p>(B): Rescuing Passengers and Raising the Plane. Case Study. HKS</p><p>No. 1967. Cambridge, MA: HKS Case Program, 2012;</p><p>http://classics.mit.edu/Antoninus/meditations.12.twelve.html</p><p>http://classics.mit.edu/Antoninus/meditations.12.twelve.html</p><p>148 Psychological Safety at Work</p><p>◾ Howitt, A.M., Leonard, H.B., & Weeks, J. Miracle on the Hudson</p><p>(C): Epilogue. Case Study. HKS No. 1967.1. Cambridge, MA: HKS</p><p>Case Program, 2012.</p><p>3. “Statement of Captain Marc Parisis, Vice President, Flight Operations</p><p>and Services, Airbus.” National Transportation Safety hearing. June 9,</p><p>2009. Washington, DC. 80–82.</p><p>4. U.S. Airways FOM 1.3.4, Captains Authority, online at National Trans-</p><p>portation Safety Board, Operations/Human Performance Group Chair-</p><p>men, Exhibit No. 2-Q.</p><p>5. Sullenberger III, C. & Zaslow, Z. Highest Duty: My Search for What Really</p><p>Matters. New York, NY: William Morrow, 2009.</p><p>6. Edmondson, A.C. “The Local and Variegated Nature of Learning in</p><p>Organizations: A Group-Level Perspective.” Organization Science, 13.2</p><p>(2002): 128–46.</p><p>7. Sullenberger III, C. & Zaslow, Z. 2009: 229.</p><p>8. Wheeler, M. “Asiana Airlines: ‘Sorry Captain, You’re Wrong.’” LinkedIn</p><p>Pulse. 2014. https://www.linkedin.com/pulse/20140217220032-</p><p>266437464-asiana-airlines-sorry-captain-you-re-wrong/ Accessed</p><p>June 12, 2018.</p><p>9. See, for instance, Oriol, M.D. “Crew resource management: applica-</p><p>tions in healthcare organizations.” Nursing Administration 36.9 (2006):</p><p>402–6; McConaughey E. “Crew resource management in healthcare:</p><p>the evolution of teamwork training and MedTeams.” Journal of Perinatal</p><p>Neonatal Nursing, 22.2 (2008): 96–104.</p><p>10. Shea-Lewis, A. “Teamwork: crew resource management in a commu-</p><p>nity hospital.” Journal</p><p>of Healthcare Quality. 31.5 (2009): 14–18.</p><p>11. The Three Musketeers, written in 1844 by French author Alexandre</p><p>Dumas and set in 1625 France, has achieved popularity via its many</p><p>adaptations into film, video, and television.</p><p>12. Key details about DaVita and its CEO/lead musketeer Kent Thiry come</p><p>from a series of case studies:</p><p>◾ Pfeffer, J. Kent Thiry and DaVita: Leadership Challenges in</p><p>Building and Growing a Great Company. Case Study. Stanford GSB</p><p>No. 0B-54. Palo Alto, CA: Stanford Graduate School of Business,</p><p>2006.</p><p>◾ O’Reilly, C. Pfeffer, J., Hoyt, D., & Drabkin, D. DaVita: A</p><p>Community First, A Company Second. Case Study. Stanford GSB</p><p>No. OB-89. Palo Alto, CA: Stanford Graduate School of Business,</p><p>2014.</p><p>https://www.linkedin.com/pulse/20140217220032-266437464-asiana-airlines-sorry-captain-you-re-wrong</p><p>https://www.linkedin.com/pulse/20140217220032-266437464-asiana-airlines-sorry-captain-you-re-wrong</p><p>Safe and Sound 149</p><p>◾ George, B., & Kindred, N. Kent Thiry: “Mayor” of DaVita. Case</p><p>Study. HBS Case No. 410-065. Boston, MA: Harvard Business</p><p>School Publishing, 2010.</p><p>13. Pfeffer, J. Kent Thiry and DaVita: Leadership Challenges in Building</p><p>and Growing a Great Company. 2006: 19.</p><p>14. Pfeffer, J. Kent Thiry and DaVita: Leadership Challenges in Building</p><p>and Growing a Great Company. 2006: 2.</p><p>15. Kent Thiry, presentation at the Stanford Graduate School of Business.</p><p>November 17, 2011.</p><p>16. O’Reilly, C. et al. DaVita: A Community First, A Company Second.</p><p>2014: 7.</p><p>17. “Integrated Care Enhances Clinical Outcomes for Dialysis Patients.”</p><p>News-Medical.net. October 31, 2017. https://www.news-medical</p><p>.net/news/20171031/Integrated-care-enhances-clinical-outcomes-</p><p>for-dialysis-patients.aspx Accessed June 8, 2018.</p><p>18. Berwick, D.M., Nolan, T.W., & Whittington, J. “The Triple Aim: Care,</p><p>Health, and Cost.” Health Affairs. 27.3 (2008): 759–69.</p><p>19. Key details describing the safety initiative at Anglo American under</p><p>Cynthia Carroll in this chapter come from a series of case studies by</p><p>HBS Professor Gautam Mukunda and colleagues:</p><p>◾ Mukunda, G., Mazzanti, L., & Sesia, A. Cynthia Carroll at Anglo</p><p>American (A). Case Study. HBS No. 414-019. Boston, MA: Har-</p><p>vard Business School Publishing, 2013.</p><p>◾ Mukunda, G., Mazzanti, L., & Sesia, A. Cynthia Carroll at Anglo</p><p>American (B). Case Study. HBS No. 414-020. Boston, MA: Harvard</p><p>Business School Publishing, 2013.</p><p>◾ Mukunda, G., Mazzanti, L., & Sesia, A. Cynthia Carroll at Anglo</p><p>American (C). Case Study. HBS No. 414-021. Boston, MA: Har-</p><p>vard Business School Publishing, 2013.</p><p>20. Carroll, C. “The CEO of Anglo American on Getting Serious about</p><p>Safety” Harvard Business Review. 2012. https://hbr.org/2012/06/the-</p><p>ceo-of-anglo-american-on-getting-serious-about-safety Accessed</p><p>June 14, 2018.</p><p>21. Mukunda, G. et al. Cynthia Carroll at Anglo American (A). 2013: 7.</p><p>22. Ibid.</p><p>23. Carroll, C. 2012, op cit.</p><p>24. De Liefde, W. Lekgotla: The Art of Leadership Through Dialogue.</p><p>Houghton, South Africa: Jacana Media, 2005.</p><p>25. Mukunda, G. et al. Cynthia Carroll at Anglo American (B). 2013: 2.</p><p>http://news-medical.net</p><p>https://www.news-medical.net/news/20171031/Integrated-care-enhances-clinical-outcomes-for-dialysis-patients.aspx</p><p>https://www.news-medical.net/news/20171031/Integrated-care-enhances-clinical-outcomes-for-dialysis-patients.aspx</p><p>https://www.news-medical.net/news/20171031/Integrated-care-enhances-clinical-outcomes-for-dialysis-patients.aspx</p><p>https://hbr.org/2012/06/the-ceo-of-anglo-american-on-getting-serious-about-safety</p><p>https://hbr.org/2012/06/the-ceo-of-anglo-american-on-getting-serious-about-safety</p><p>150 Psychological Safety at Work</p><p>26. Carroll, C. 2012, op cit.</p><p>27. Key details on the close call at Fukushima Daini in this chapter come</p><p>from a spectacular episode of PBS’s NOVA from 2015, as well as a</p><p>Harvard Business Review piece by my colleague Ranjay Gulati, which</p><p>documented Masuda’s leadership style:</p><p>◾ O’Brien, M. (producer). “NOVA: Nuclear Meltdown Disaster.”</p><p>PBS, aired July 29, 2015. http://www.pbs.org/wgbh/nova/tech/</p><p>nuclear-disaster.html Accessed June 15, 2018.</p><p>◾ Gulati, R., Casto, C., & Krontiris, C. “How the Other Fukushima</p><p>Plant Survived.” Harvard Business Review, 2015. https://hbr.org/</p><p>2014/07/how-the-other-fukushima-plant-survived Accessed June</p><p>13, 2018.</p><p>28. O’Brien, M. (producer). July 29, 2015, op cit.</p><p>29. Gulati, R. et al. 2015, op cit.</p><p>30. Ibid.</p><p>http://www.pbs.org/wgbh/nova/tech/nuclear-disaster.html</p><p>http://www.pbs.org/wgbh/nova/tech/nuclear-disaster.html</p><p>https://hbr.org/2014/07/how-the-other-fukushima-plant-survived</p><p>https://hbr.org/2014/07/how-the-other-fukushima-plant-survived</p><p>PART</p><p>III Creating a Fearless</p><p>Organization</p><p>7</p><p>Making it Happen</p><p>You can tell whether a man is clever by his answers. You can tell whether a man is</p><p>wise by his questions.</p><p>—Naguib Mahfouz1</p><p>When Julie Morath came on board as chief operating officer at</p><p>Children’s Hospital and Clinics in Minneapolis, Minnesota, her goal</p><p>was simple: 100% patient safety for the hospitalized children under</p><p>her care.2 The goal may have been simple. How to accomplish it was</p><p>not. This was late 1999, and few people were talking about patient</p><p>safety. It’s not that most clinicians thought patients were completely</p><p>safe from mistakes and harm; it’s just that they tended to think that</p><p>when things went wrong, someone was to blame. This made it hard</p><p>to talk about the problem. Nurses and doctors, Morath knew, first</p><p>had to become willing to speak up to report errors if was going to be</p><p>possible to reduce the incidence of harm. In short, she needed the</p><p>153</p><p>154 Creating a Fearless Organization</p><p>data on what was happening, when, and where. Only then could the</p><p>hospital find new ways to enhance the safety of all of the vulnerable</p><p>young patients at their six medical facilities in the Twin Cities.</p><p>The Leader’s Tool Kit</p><p>In previous chapters, we saw how a lack of psychological safety</p><p>stopped a NICU nurse from speaking up about a possible medi-</p><p>cation error for fear of annoying the physician. We saw how well-</p><p>trained clinicians at a cutting-edge medical facility failed to question</p><p>a fatal chemotherapy dosing regimen over a period of several</p><p>days. These situations both took place in settings where a lot was</p><p>going on.</p><p>Tertiary care hospitals, like Children’s, are complex. It’s challeng-</p><p>ing to get every single task done perfectly every single time. To begin</p><p>with, every patient is different. No two care episodes are identical.</p><p>Upping the ante, the highly-interdependent work of patient care must</p><p>be seamlessly coordinated among narrow specialists with complemen-</p><p>tary knowledge and skills – who may not even know each other’s</p><p>names. Multiple, interdependent departments – pharmacy, labora-</p><p>tory, physicians, and nursing – who have conflicting priorities about</p><p>what service to provide at what time must coordinate their actions</p><p>for safe care to be consistently delivered. And so the organization had</p><p>long accepted that things would occasionally go wrong. A certain</p><p>number of slip-ups and crossed wires was just the way things were.</p><p>It wasn’t discussed much, and there was an unfortunate tendency</p><p>to blame individuals (rather than system complexity) for errors that</p><p>slipped through the cracks and led to patient harm.</p><p>Morath felt that this attitude had to change if progress was to be</p><p>made. She needed a leadership tool kit to get this done. In retrospect,</p><p>what happened to profoundly shift attitudes and behaviors at Chil-</p><p>dren’s can be divided into three categories: setting the stage, inviting</p><p>participation, and responding productively.</p><p>Making it Happen 155</p><p>Setting the Stage</p><p>As soon as she took the job, Morath began speaking to large and</p><p>small groups in the hospital to explain that healthcare delivery, by</p><p>its nature, was a complex system prone to breakdowns. She presented</p><p>new research and statistics on medical adverse events to educate every-</p><p>one about their prevalence. She introduced new terminology (“words</p><p>to work by”) that altered the meaning of events and actions in impor-</p><p>tant ways; for instance, instead of an “investigation”</p><p>into an adverse</p><p>event, the hospital would use the term “study;” instead of “error” she</p><p>suggested people use “accident” or “failure.” In subtle but important</p><p>ways, Morath was trying to help people think differently about the</p><p>work – and especially about what it means when things go wrong.</p><p>These leadership actions comprise what I refer to as framing the work.</p><p>Frames consist of assumptions or beliefs that we layer onto reality.3</p><p>All of us frame objects and situations automatically. Our focus is on the</p><p>situation itself, and we are typically blind to the effects of our frames.</p><p>Our prior experiences affect how we think and feel about what’s</p><p>presently around us in subtle ways. We believe we’re seeing reality –</p><p>seeing what is there. For instance, if we frame medical accidents as</p><p>indications that someone screwed up, we will ignore or suppress them</p><p>for fear of being blamed or of pointing the finger at a colleague.</p><p>However, we can shift our automatic frames and create a shared frame</p><p>that more accurately represents reality. More information about fram-</p><p>ing the work is provided later in this chapter. But when Morath</p><p>began to give presentations that called attention to hospital care as</p><p>a complex, error-prone system, what she was doing was framing the</p><p>work – or, more accurately, reframing it. Her goal was to help people</p><p>shift from a belief that incompetence (rather than system complexity)</p><p>was to blame. This shift in perspective would prove essential to help-</p><p>ing people feel safe speaking up about the problems, mistakes, and</p><p>risks they saw.4</p><p>In setting the stage for open discussion of error, Morath also</p><p>communicated urgency about the goal of 100% patient safety.</p><p>156 Creating a Fearless Organization</p><p>I consider this an important stage-setting act because it helped</p><p>people reconnect with the reasons they went into healthcare in the</p><p>first place: to save lives. This reminder helped motivate people to do</p><p>the hard work of reporting, analyzing, and finding ways to prevent</p><p>harm. In short, with an emphasis on the complex and error-prone</p><p>nature of the work, and a reminder of what was at stake (children’s</p><p>lives), Morath had set the stage for candor. But that was not enough</p><p>to make it happen.</p><p>Inviting Participation</p><p>As you may imagine, hardworking neonatal nurses and experienced</p><p>pediatric surgeons did not immediately flock to Morath’s office to</p><p>confess to having made or seen mistakes. People found it easier to</p><p>believe that medical errors happened elsewhere rather than in their</p><p>own esteemed institution. Even if they understood, deep down, that</p><p>things can and do go wrong, it was not front of mind, and they gen-</p><p>uinely believed they were providing great care.</p><p>Morath, hearing silence from the staff, stopped to consider. I’m</p><p>sure it crossed her mind to try again – to re-explain the complex,</p><p>error-prone nature of tertiary care hospital operations so as to correct</p><p>the staff’s implicit response that nothing was going wrong. If so, she</p><p>resisted the temptation to lecture. Instead, she did something that was</p><p>as simple as it was powerful. She asked a question. “Was everything as</p><p>safe as you would like it to have been this week with your patients?”5</p><p>The question – genuine, curious, direct – was respectful and con-</p><p>crete: “this week,” “your patients.” Its very wording conveys genuine</p><p>interest. Curiosity. It makes you think. Interestingly, she did not ask,</p><p>“did you see lots of mistakes or harm?” Rather, she invited people</p><p>to think in aspirational terms: “Was everything as safe as you would</p><p>like it to be?” Sure enough, psychological safety started to take hold.</p><p>People began to bring up incidents that they had seen and even con-</p><p>tributed to.</p><p>Making it Happen 157</p><p>Morath enhanced her invitation to participate with several struc-</p><p>tural interventions. First, she set up a core team called the Patient</p><p>Safety Steering Committee (PSSC) to lead the change initiative. The</p><p>PSSC was designed as a cross-functional, multilevel group to ensure</p><p>that voices from all over the hospital would be heard. Each member</p><p>was invited with a personal explanation for why his or her perspective</p><p>was sought. Second, Morath and the PSSC introduced a new policy</p><p>called “blameless reporting” – a system inviting confidential reports</p><p>about risks and failures people observed. Third, as people began to</p><p>feel safe enough to speak up, Morath led as many as 18 focus groups to</p><p>make it easy for people throughout the organization to share concerns</p><p>and experiences.</p><p>These simple structures made speaking up easier. When you join</p><p>a focus group, your input is explicitly requested. It feels more awk-</p><p>ward to remain silent than to offer your thoughts. In this way, the</p><p>voice asymmetry described in Chapter 2, in which silence dominates</p><p>because of the inherent risks of voice, is mitigated.</p><p>Responding Productively</p><p>Speaking up is only the first step. The true test is how leaders respond</p><p>when people actually do speak up. Stage setting and inviting partici-</p><p>pation indeed build psychological safety. But if a boss responds with</p><p>anger or disdain as soon as someone steps forward to speak up about</p><p>a problem, the safety will quickly evaporate. A productive response</p><p>must be appreciative, respectful, and offer a path forward.</p><p>Consider the “focused event analysis” (FEA), a cross-disciplinary</p><p>meeting that Morath instituted at Children’s to bring people together</p><p>after a failure. The FEA represents a disciplined exploration of what</p><p>happened from multiple perspectives – like the proverbial blind men</p><p>around the elephant. In this setting, however, the goal is not to fight</p><p>about who was right, as the blind men did, but rather to identify</p><p>contributing factors with the goal of improving the system to prevent</p><p>158 Creating a Fearless Organization</p><p>similar failures in the future.6 The FEA is thus a prime example of</p><p>responding productively.</p><p>Equally important, the blameless reporting policy enabled</p><p>productive responses to messengers who brought bad news about</p><p>an error or mishap. Instead of expecting blame or punishment, the</p><p>healthcare personnel at Children’s began to expect – and experi-</p><p>ence – appreciation for their effort in bringing valuable information</p><p>forward.</p><p>This goal of this chapter is to provide further examples of spe-</p><p>cific ways leaders build psychological safety in their organizations by</p><p>setting the stage, inviting participation, and responding productively.</p><p>With some practice and reflection, this tool kit is available to any</p><p>leader wishing to create psychological safety. Table 7.1 summarizes</p><p>the framework. To develop these behavioral tools, I drew from both</p><p>research and my years of experience studying and consulting with</p><p>organizations around the world.</p><p>How to Set the Stage for Psychological Safety</p><p>Whenever you are trying to get people on the same page, with com-</p><p>mon goals and a shared appreciation for what they’re up against, you’re</p><p>setting the stage for psychological safety. The most important skill to</p><p>master is that of framing the work. If near-perfection is what is needed</p><p>to satisfy demanding car customers, leaders must know to frame the</p><p>work by alerting workers to catch and correct tiny deviations before</p><p>the car proceeds down the assembly line. If zero worker fatalities in a</p><p>dangerous platinum mine is the goal, then leaders must frame physical</p><p>safety as a worthy and challenging but attainable goal. If discovering</p><p>new cures is the goal, leaders know to motivate researchers to generate</p><p>smart hypotheses for experiments and to feel okay about being wrong</p><p>far more often than right. In this section, I’ll first explaining how and</p><p>why framing the work includes reframing failure and clarifying the</p><p>need for voice. From there I’ll move on to another stage-setting tool</p><p>in the leader’s tool kit: motivating effort.</p><p>Trim Size: 6in x 9in Edmondson c07.tex V1 - 10/03/2018 7:55pm Page 159�</p><p>� �</p><p>�</p><p>159</p><p>Table 7.1 The Leader’s Tool Kit for Building Psychological Safety.</p><p>Category Setting the Stage Inviting Participation Responding Productively</p><p>Leadership</p><p>tasks</p><p>Frame the Work</p><p>◾ Set expectations about</p><p>failure, uncertainty, and</p><p>interdependence to clarify</p><p>the need for voice</p><p>Emphasize Purpose</p><p>◾ Identify what’s at stake,</p><p>why it matters, and for</p><p>whom</p><p>Demonstrate Situational</p><p>Humility</p><p>◾ Acknowledge gaps</p><p>Practice Inquiry</p><p>◾ Ask good questions</p><p>◾ Model intense listening</p><p>Set up Structures and</p><p>Processes</p><p>◾ Create forums for input</p><p>◾ Provide guidelines for</p><p>discussion</p><p>Express Appreciation</p><p>◾ Listen</p><p>◾ Acknowledge and thank</p><p>Destigmatize Failure</p><p>◾ Look forward</p><p>◾ Offer help</p><p>◾ Discuss, consider, and</p><p>brainstorm next steps</p><p>Sanction Clear Violations</p><p>Accomplishes Shared expectations and</p><p>meaning</p><p>Confidence that voice is</p><p>welcome</p><p>Orientation toward continuous</p><p>learning</p><p>160 Creating a Fearless Organization</p><p>Framing the Work</p><p>Reframing Failure</p><p>Because fear of (reporting) failure is such a key indicator of an envi-</p><p>ronment with low levels of psychological safety, how leaders present</p><p>the role of failure is essential. Recall Astro Teller’s observation at</p><p>Google X that “the only way to get people to work on big, risky</p><p>things . . . is if you make that the path of least resistance for them</p><p>[and] make it safe to fail.”7 In other words, unless a leader expressly</p><p>and actively makes it psychologically safe to do so, people will auto-</p><p>matically seek to avoid failure. So how did Teller reframe failure to</p><p>make it okay? By saying, believing, and convincing others that “I’m</p><p>not pro failure, I’m pro learning.”8</p><p>Failure is a source of valuable data, but leaders must understand</p><p>and communicate that learning only happens when there’s enough</p><p>psychological safety to dig into failure’s lessons carefully. In his book</p><p>The Game-Changer, published while he was still CEO of Proctor</p><p>and Gamble, A.G. Lafley celebrates his 11 most expensive product</p><p>failures, describing why each was valuable and what the company</p><p>learned from each.9 Recall, also, Ed Catmull’s assurance to Pixar</p><p>animators, that movies always start out bad, to help them “uncouple</p><p>fear and failure.”10 Here, Catmull is making a leadership framing</p><p>statement. He is making sure that people know this is the kind of</p><p>work for which stunning success occurs only if you’re willing to con-</p><p>front the “bad” along the way to the “good.” Similarly, OpenTable</p><p>CEO Christa Quarles tells employees, “early, often, ugly. It’s O.K.</p><p>It doesn’t have to be perfect because then I can course-correct much,</p><p>much faster.”11 This too is a framing statement. It says that success</p><p>in the online restaurant-reservation business occurs through course</p><p>correction – not through magically getting it right the first time.</p><p>Quarles is framing early, ugly versions as vital information to make</p><p>good decisions that lead to later, beautiful versions.</p><p>Learning to learn from failure has become so important that</p><p>Smith College (along with other schools around the country) is</p><p>Making it Happen 161</p><p>creating courses and initiatives to help students better deal with</p><p>failures, challenges, and setbacks. “What we’re trying to teach is that</p><p>failure is not a bug of learning, it’s a feature,”12 said Rachel Simmons,</p><p>a leadership development specialist in Smith’s Wurtele Center for</p><p>Work and Life and the unofficial “failure czar” on campus. “It’s not</p><p>something that should be locked out of the learning experience. For</p><p>many of our students – those who have had to be almost perfect to</p><p>get accepted into a school like Smith – failure can be an unfamiliar</p><p>experience. So when it happens, it can be crippling.”13 With</p><p>workshops on impostor syndrome, discussions on perfectionism and</p><p>a campaign to remind students that 64% of their peers will get (gasp)</p><p>a B-minus or lower, the program is part of a campus-wide effort to</p><p>foster student resilience.</p><p>Note that failure plays a varying role in different kinds of work.14</p><p>At one end of the spectrum is high-volume repetitive work, such as</p><p>in an assembly plant, a fast-food restaurant, or even a kidney dialysis</p><p>center. Failing to correctly plug a patient into a dialysis machine or</p><p>install an automobile airbag in precisely the right manner can have</p><p>disastrous consequences. So in this kind of work it’s vital that people</p><p>eagerly catch and correct deviations from best practice. Here, cele-</p><p>brating failure is a matter of viewing such deviations as “good catch”</p><p>events and appreciating those who noticed tiny mistakes as observant</p><p>contributors to the mission.</p><p>At the other end of the spectrum lies innovation and research,</p><p>where little is known about how to obtain a desired result. Creating</p><p>a movie, a line of original clothing, or a technology that can convert</p><p>seawater to fuel are all examples. In this context, dramatic failures</p><p>must be courted and celebrated because they are and integral part of</p><p>the journey to success. In the middle of the spectrum, where much</p><p>of the work done today falls, are complex operations, such as hospitals</p><p>or financial institutions. Here, vigilance and teamwork are both vital</p><p>to preventing avoidable failures and celebrating intelligent ones.</p><p>Reframing failure starts with understanding a basic typology</p><p>of failure types. As I have written in more detail elsewhere, failure</p><p>archetypes include preventable failures (never good news), complex</p><p>162 Creating a Fearless Organization</p><p>failures (still not good news), and intelligent failures (not fun, but</p><p>must be considered good news because of the value they bring).15</p><p>Preventable failures are deviations from recommended procedures</p><p>that produce bad outcomes. If someone fails to don safety glasses</p><p>in a factory and suffers an eye injury, this is a preventable failure.</p><p>Complex failures occur in familiar contexts when a confluence of</p><p>factors come together in a way that may never have occurred before;</p><p>consider the severe flooding of the Wall Street subway station in</p><p>New York City during Superstorm Sandy in 2012. With vigilance,</p><p>complex failures can sometimes, but not always, be avoided. Neither</p><p>preventable nor complex failures are worthy of celebration.</p><p>In contrast, intelligent failures, as the term implies, must be cele-</p><p>brated so as to encourage more of them. Intelligent failures, like the</p><p>preventable and complex, are still results no one wanted. But, unlike</p><p>the other two categories, they are the result of a thoughtful foray into</p><p>new territory. Table 7.2 presents definitions and contexts to clarify</p><p>these distinctions. An important part of framing is making sure peo-</p><p>ple understand that failures will happen. Some failures are genuinely</p><p>good news; some are not, but no matter what type they are, our</p><p>primary goal is to learn from them.</p><p>Clarifying the Need for Voice</p><p>Framing the work also involves calling attention to other ways,</p><p>beyond failure’s prevalence, in which tasks and environments differ.</p><p>Three especially important dimensions are uncertainty, interde-</p><p>pendence, and what’s at stake – all of which also have implications</p><p>for failure (e.g. expectations about its frequency, its value, and its</p><p>consequences). Emphasizing uncertainty reminds people that they</p><p>need to be curious and alert to pick up early indicators of change in,</p><p>say, customer preferences in a new market, a patient’s reaction to a</p><p>drug, or new technologies on the horizon.</p><p>Emphasizing interdependence lets people know that they’re</p><p>responsible for understanding how their tasks interact with other</p><p>Trim Size: 6in x 9in Edmondson c07.tex V1 - 10/03/2018 7:55pm Page 163�</p><p>� �</p><p>�</p><p>163</p><p>Table 7.2 Failure Archetypes – Definitions and Implications.16</p><p>Preventable Complex Intelligent</p><p>Definition Deviations from known</p><p>processes that produce</p><p>unwanted outcomes</p><p>Unique and novel</p><p>combinations of events</p><p>and actions that give rise</p><p>to unwanted outcomes</p><p>Novel forays into new</p><p>territory that lead to</p><p>unwanted outcomes</p><p>Common Causes Behavior, skill, and attention</p><p>deficiencies</p><p>Complexity, variability, and</p><p>novel factors imposed on</p><p>familiar situations</p><p>Uncertainty,</p><p>experimentation, and</p><p>risk taking</p><p>Descriptive Term Process deviation System breakdown Unsuccessful trial</p><p>Contexts Where Each</p><p>Is Most Salient</p><p>Production line manufacturing</p><p>Fast-food services</p><p>Basic utilities and services</p><p>Hospital care</p><p>NASA shuttle</p><p>program</p><p>Aircraft carrier</p><p>Nuclear power plant</p><p>Drug development</p><p>New product design</p><p>164 Creating a Fearless Organization</p><p>people’s tasks. Interdependence encourages frequent conversations to</p><p>figure out the impact their work is having on others and to convey</p><p>in turn the impact others’ work has on them. Interdependent work</p><p>requires communication. In other words, when leaders frame the</p><p>work they are emphasizing the need for taking interpersonal risks</p><p>like sharing ideas and concerns.</p><p>Finally, clarifying the stakes is important whether the stakes are</p><p>high or low. Reminding people that human life is on the line – say,</p><p>in a hospital, a mine, or at NASA – helps put interpersonal risk in</p><p>perspective. People are more likely to speak up – thereby overcoming</p><p>the inherent asymmetry of voice and silence – if leaders frame its</p><p>importance. Similarly, reminding people that the only thing that is at</p><p>stake is a bruised ego when a lab experiment doesn’t go as hoped is a</p><p>good way to get them to be willing to go for it – offer possibly crazy</p><p>ideas and figure out which ones to test first!</p><p>Finally, how most people see bosses presents a crucial area for</p><p>reframing. Table 7.3 compares a set of default frames to a deliberate</p><p>reframe for how we might think about bosses and others at work.</p><p>As a default, bosses are viewed as having answers, being able to give</p><p>orders, and being positioned to assess whether the orders are well</p><p>executed. With this frame, others are merely subordinates expected</p><p>to do as they are told. CEO Martin Winterkorn at VW is a prime</p><p>example of an executive governed by the default frame. Notice</p><p>that the default set of frames makes interpersonal fear sensible.</p><p>Table 7.3 Framing the Role of the Boss.</p><p>Default Frames Reframe</p><p>The Boss Has answers</p><p>Gives orders</p><p>Assesses others’</p><p>performance</p><p>Sets direction</p><p>Invites input to clarify and</p><p>improve</p><p>Creates conditions for continued</p><p>learning to achieve excellence</p><p>Others Subordinates who must</p><p>do what they’re told</p><p>Contributors with crucial</p><p>knowledge and insight</p><p>Making it Happen 165</p><p>In a world in which bosses have the answers and absolute authority</p><p>over how your work is judged, it makes sense to fear the boss and to</p><p>think very carefully about what you reveal. The reframe, in contrast,</p><p>spells out logic that clarifies the necessity for a psychologically safe</p><p>environment. This logic applies to the successful execution of work</p><p>in most organizations today.</p><p>The reframe shows that leaders must establish and cultivate psy-</p><p>chological safety to succeed in most work environments today.</p><p>The leader is obliged to set direction for the work, to invite rele-</p><p>vant input to clarify and improve on the general direction that has</p><p>been set, and to create conditions for continued learning to achieve</p><p>excellence. Cynthia Carroll reframed the work at Anglo American</p><p>by actively inviting the miners’ input to draw up new physical safety</p><p>practices. Naohiro Masuda, the plant superintendent for Fukushima</p><p>Daini, reframed the work when he set up a whiteboard to lead his</p><p>team successfully through a tsunami’s onslaught. He gave the team as</p><p>much ongoing information as he had available in a quickly chang-</p><p>ing environment. The more creativity and innovation are required to</p><p>achieve a particular goal, the more this stance is needed. The problem</p><p>with Winterkorn’s stance at VW wasn’t that it was wrong in a moral</p><p>sense; rather, it was wrong in a practical sense; it was wrong for achiev-</p><p>ing a goal that called for innovation. Making the company the largest</p><p>automaker in the world by leveraging diesel engine technology was</p><p>somewhat of a “moonshot” goal such as those pursued at Google X.</p><p>The diesel engine technology was not yet able to perform in ways</p><p>consistent with regulatory requirements; no amount of giving orders</p><p>could overcome that basic truth about the situation. A psychologically</p><p>safe environment, such as we saw at Google X, could have produc-</p><p>tively absorbed this innovation failure, allowing the senior executives</p><p>to rethink their strategy.</p><p>In the reframe, those who are not the boss are seen as valued</p><p>contributors – that is, as people with crucial knowledge and insight.</p><p>When Julie Morath asks people to speak up about patient error or</p><p>when Eileen Fisher orchestrates staff meetings to give everyone a</p><p>chance to speak, they do so because it will improve decision-making</p><p>and execution – not because they want to be nice. Leaders in a</p><p>166 Creating a Fearless Organization</p><p>volatile, uncertain, complex, and ambiguous (VUCA) world, who</p><p>understand that today’s work requires continuous learning to figure</p><p>out when and how to change course, must consciously reframe</p><p>how they think, from the default frames that we all bring to work</p><p>unconsciously to a more productive reframe.</p><p>Framing the work is not something that leaders do once, and then</p><p>it’s done. Framing is ongoing. Frequently calling attention to levels</p><p>of uncertainty or interdependence helps people remember that they</p><p>must be alert and candid to perform well. Had NASA leaders empha-</p><p>sized these essential features of the work, the invitation to engineers</p><p>to share tentative concerns would have been far more visible to them.</p><p>Motivating Effort</p><p>Emphasizing a sense of purpose is another key element of setting the</p><p>stage for psychological safety. Motivating people by articulating a</p><p>compelling purpose is a well-established leadership task. Leaders who</p><p>remind people of why what they do matters – for customers, for the</p><p>world – help create the energy that carries them through challenging</p><p>moments. Kent Thiry’s “one for all and all for one” motto motivates</p><p>staff at DaVita to care for patients with kidney disease. In this motto,</p><p>he at once reminds people of patients’ vulnerability and reminds</p><p>them that the team is all in it together. Note that even when it seems</p><p>obvious (for instance, taking care of vulnerable patients) that the</p><p>work is meaningful, leaders still must take the time to emphasize the</p><p>purpose the organization serves. This is because anyone can get tired,</p><p>distracted, and frustrated and lose sight of the larger picture – of</p><p>what’s at stake. Carroll brought her passion for zero harm to the</p><p>South African government and larger mining institutional bodies.</p><p>Once stakeholders from previously disconnected groups began</p><p>working together for the shared goal of safety in the mines they were</p><p>able to develop trust for one another. It’s the leader’s job to bring</p><p>people back to a psychological place where they are in touch with</p><p>how much their work matters. This also helps the overcome the</p><p>interpersonal risks they face at work.</p><p>Making it Happen 167</p><p>Meaning can be defined and framed in other ways, too. Ray Dalio</p><p>at Bridgewater Associates emphasizes to his hedge fund employees</p><p>that personal growth is as important as profit. That each employee</p><p>is becoming a better person matters to Dalio, and he hopes to them</p><p>as well. Bob Chapman’s belief that the company measures success by</p><p>how well it touches the lives of employees motivates all to bring their</p><p>best selves to the job.</p><p>Most leaders would be well served by stopping to reflect on</p><p>the purpose that motivates them and makes the organization’s work</p><p>meaningful to the broader community. Having done so, they should</p><p>ask themselves how often and how vigorously they are conveying</p><p>this compelling rationale for the work to others. Our primal need to</p><p>feel purpose and meaning in our lives, including at work, has been</p><p>demonstrated by numerous studies in psychology.17</p><p>How to Invite Participation So People Respond</p><p>The second essential activity in the leaders’ tool kit is inviting par-</p><p>ticipation in a way that people find compelling and genuine. The</p><p>goal is to lower what is usually a too-high bar for what’s considered</p><p>appropriate participation. Realizing that self-protection is natural, the</p><p>invitation to participate must be crystal clear if people are going to</p><p>choose to engage rather than to play it safe. Two essential behaviors</p><p>that signal an invitation is genuine are adopting a mindset of situa-</p><p>tional humility and engaging in proactive</p><p>inquiry. Designing struc-</p><p>tures for input, another powerful tool I discuss in this section, also</p><p>serves as an invitation for voice.</p><p>Situational Humility</p><p>The bottom line is that no one wants to take the interpersonal risk</p><p>of imposing ideas when the boss appears to think he or she knows</p><p>everything. A learning mindset, which blends humility and curiosity,</p><p>168 Creating a Fearless Organization</p><p>mitigates this risk. A learning mindset recognizes that there is always</p><p>more to learn.</p><p>Frankly, adopting a humble mindset when faced with the</p><p>complex, dynamic, uncertain world in which we all work today is</p><p>simply realism. The term situational humility captures this concept</p><p>well (the need for humility lies in the situation) and may make it</p><p>easier for leaders, especially those with abundant self-confidence, to</p><p>recognize the validity, and the power, of a humble mindset. MIT</p><p>Professor Ed Schein calls this “Here-and-Now Humility.”18 Keep in</p><p>mind that confidence and humility are not opposites. Confidence</p><p>in one’s abilities and knowledge, when warranted, is far preferable</p><p>to false modesty. But humility is not modesty, false or otherwise.</p><p>Humility is the simple recognition that you don’t have all the</p><p>answers, and you certainly don’t have a crystal ball. Research shows</p><p>that when leaders express humility, teams engage in more learning</p><p>behavior.19</p><p>Demonstrating situational humility includes acknowledging your</p><p>errors and shortcomings. Anne Mulcahy, Chairperson and CEO of</p><p>Xerox, who led the company through a successful transformation</p><p>out of bankruptcy in the 2000s, said that she was known to many</p><p>in the company as the “Master of I Don’t Know” because rather</p><p>than offer an uninformed opinion she would so often reply, “I don’t</p><p>know,” to questions.20 Although reminiscent of Eileen Fisher’s “Be a</p><p>Don’t Knower,” Mulcahy adopts this stance as the newly promoted</p><p>chief executive of a global corporation rather than as a founder of her</p><p>own company. Speaking to executives in the Advanced Management</p><p>Program at Harvard Business School, Mulcahy commented that</p><p>her willingness to be vulnerable with others and admit her own</p><p>shortcomings turned out to be a huge asset. “Instead of people losing</p><p>confidence, they actually gain confidence [in you] when you admit</p><p>you don’t know something,” she said.21 This created the space for</p><p>others at Xerox to step up, offer their expertise, and engage in the</p><p>process of turning the company around. Although this may seem</p><p>downright obvious, such humility can be strangely rare in many</p><p>organizations.</p><p>Making it Happen 169</p><p>London Business School Professor Dan Cable sheds light on why.</p><p>In a recent article in Harvard Business Review, he writes, “Power . . .</p><p>can cause leaders to become overly obsessed with outcomes and</p><p>control,” inadvertently ramping up “people’s fear – fear of not</p><p>hitting targets, fear of losing bonuses, fear of failing – and as a</p><p>consequence . . . their drive to experiment and learn is stifled.”22</p><p>Being overly certain or just plain arrogant can have similar effects –</p><p>increasing fear, reducing motivation, and inhibiting interpersonal</p><p>risk taking.</p><p>Recall that in our study of neonatal intensive care units men-</p><p>tioned in Chapter 2, Ingrid Nembhard, Anita Tucker, and I found</p><p>that NICUs with high psychological safety had substantially better</p><p>results from their quality improvement work than those with low psy-</p><p>chological safety.23 A factor we called leadership inclusiveness made</p><p>the difference. To illustrate, inclusive Medical Directors (physicians</p><p>in charge of the intensive care organization) said things like, “I may</p><p>miss something; I need to hear from you.” Others perhaps took it</p><p>for granted that people knew to speak up. Our survey measure rated</p><p>three behavioral attributes of leadership inclusiveness: one, leaders</p><p>were approachable and accessible; two, leaders acknowledged their</p><p>fallibility; and three, leaders proactively invited input from other</p><p>staff, physicians, and nurses. The concept of leadership inclusiveness</p><p>thus captures situational humility coupled with proactive inquiry</p><p>(discussed in the next section).</p><p>Building on this work, Israeli researchers Reuven Hirak and</p><p>Abraham Carmeli and two of their colleagues surveyed employees</p><p>from clinical units in a large hospital in Israel on leader inclusiveness,</p><p>psychological safety, units’ ability to learn from failures, and unit</p><p>performance. They found that units in which leaders were perceived</p><p>as more inclusive had higher psychological safety, which led to</p><p>increased learning from failure and better unit performance.24 In</p><p>sum, leaders who are approachable and accessible, acknowledge their</p><p>fallibility, and proactively invite input from others can do much to</p><p>establish and enhance psychological safety in their organizations.</p><p>Powerful tools, indeed.</p><p>170 Creating a Fearless Organization</p><p>Proactive Inquiry</p><p>The second tool for inviting participation is inquiry. Inquiry is</p><p>purposeful probing to learn more about an issue, situation, or person.</p><p>The foundational skill lies in cultivating genuine interest in others’</p><p>responses. Why is this hard? Because all adults, especially high-</p><p>achieving ones, are subject to a cognitive bias called naive realism that</p><p>gives us the experience of “knowing” what’s going on.25 As noted in</p><p>the previous section, we believe we are seeing “reality” – rather than</p><p>a subjective view of reality. As a result, we often fail to wonder what</p><p>others are seeing. We fail to be curious. Worse, many leaders, even</p><p>when they are motivated to ask a question, worry that it will make</p><p>them look uninformed or weak. Further exacerbating the challenge,</p><p>some companies sport “a culture of telling,” as a senior executive in</p><p>a global pharmaceutical company put it in a recent conversation we</p><p>had about his company. In a culture of telling, asking gets short shrift.</p><p>Yet when leaders overcome these biases to ask genuine questions,</p><p>it fosters psychological safety. Recall Morath at Children’s Hospital:</p><p>Was everything as safe as you would like it to have been this week</p><p>with your patients? Or Carroll’s question to the mineworkers: What</p><p>do we need to create a work environment of care and respect? Gen-</p><p>uine questions convey respect for the other person – a vital aspect</p><p>of psychological safety. Contrary to what many may believe, asking</p><p>questions tends to make the leader seem not weak but thoughtful</p><p>and wise.</p><p>The leaders’ tool kit contains a few rules of thumb for asking a</p><p>good question: one, you don’t know the answer; two, you ask ques-</p><p>tions that do not limit response options to Yes or No, and three, you</p><p>phrase the question in a way that helps others share their thinking</p><p>in a focused way. Consistent with these basic principles, the World</p><p>Café organization, which is dedicated to fostering conversations that</p><p>focus on finding new ways to accomplish important organizational or</p><p>social goals, identifies attributes of “powerful questions” – those that</p><p>provoke, inspire, and shift people’s thinking – as shown in the sidebar.</p><p>Making it Happen 171</p><p>Attributes of a Powerful Question26</p><p>◾ Generates curiosity in the listener</p><p>◾ Stimulates reflective conversation</p><p>◾ Is thought-provoking</p><p>◾ Surfaces underlying assumptions</p><p>◾ Invites creativity and new possibilities</p><p>◾ Generates energy and forward movement</p><p>◾ Channels attention and focuses inquiry</p><p>◾ Stays with participants</p><p>◾ Touches a deep meaning</p><p>◾ Evokes more questions</p><p>All of us can benefit from introducing more inquiry into our</p><p>work. The essential skill of inquiry involves picking the right type</p><p>of question for a situation. For instance, questions can go broad</p><p>or deep. To broaden understanding of a situation or expand an</p><p>option set, ask, “what might we be missing?”, “what other ideas</p><p>could we generate?”, or “who has a different perspective?”27 Such</p><p>questions ensure that more comprehensive information is considered</p><p>and that a larger set of options is generated related to a problem</p><p>or decision. Other questions are designed to deepen understand-</p><p>ing. Ask, “what leads you to think so?” or “can you give me an</p><p>example?” Such questions</p><p>are crucial to helping people learn about</p><p>each other’s expertise and goals. Moreover, when asked thoughtfully,</p><p>a good question indicates to others that their voices are desired –</p><p>instantly making that moment psychologically safe for offering</p><p>a response.</p><p>Bob Pittman, founder of MTV, offers an example of inquiry to</p><p>push for depth of analysis and diversity of perspective at the same</p><p>time. In an interview with former New York Times “Corner Office”</p><p>writer Adam Bryant, Pittman recounts,</p><p>172 Creating a Fearless Organization</p><p>Often in meetings, I will ask people when we’re discussing an idea, “What</p><p>did the dissenter say?” The first time you do that, somebody might say,</p><p>“Well, everybody’s on board.” Then I’ll say, “Well, you guys aren’t listen-</p><p>ing very well, because there’s always another point of view somewhere and</p><p>you need to go back and find out what the dissenting point of view is.”28</p><p>Here we can see that Pittman is practicing proactive inquiry and</p><p>also modeling to his employees how to do it. Further, the idea that</p><p>there’s always another point of view is a subtle move to frame the</p><p>work. In this small point, he is framing the work, implicitly remind-</p><p>ing the team that creative programming work, such as practiced at</p><p>MTV, benefits from a diversity of views. For more cases and detail on</p><p>the power of inquiry as a fundamental leadership skill, I recommend</p><p>Ed Schein’s thoughtful book, Humble Inquiry.29</p><p>Designing Structures for Input</p><p>A third way to invite participation and reinforce psychological safety</p><p>is to implement structures designed to elicit employee input. The</p><p>focus groups and FEA meetings at Children’s are examples of such</p><p>structures. These were so successful in getting conversations on safety</p><p>underway that hospital staff members began to design structures of</p><p>their own to elicit their own colleagues’ ideas and concerns. Notably,</p><p>Casey Hooke, a clinical nurse specialist, came up with the idea for a</p><p>safety action team in her unit. The cross-functional unit-based team</p><p>met monthly to identify safety hazards in the oncology unit. Soon,</p><p>two other units, inspired by Hooke’s efforts, launched their own safety</p><p>action teams. Eventually, the patient safety steering committee sug-</p><p>gested that all hospital units implement such teams.</p><p>Another way to chip away at interpersonal fear is through</p><p>employee-to-employee learning structures, as Google has done with</p><p>its creation of the “g2g” (Googler-to-Googler) network, consisting</p><p>of more than 6000 Google employees who volunteer time to helping</p><p>their peers learn.30 Participants in g2g do one-on-one mentoring,</p><p>coach teams on psychological safety, and teach courses in professional</p><p>Making it Happen 173</p><p>skills ranging from leadership to Python coding. Google claims that</p><p>g2g has helped develop the skills of countless employees. It is also</p><p>helping to build a psychologically safe culture where everyone is</p><p>both a learner and a teacher.</p><p>The global food company Groupe Danone created structured</p><p>conference events called “knowledge marketplaces” to foster inquiry</p><p>and knowledge sharing across country business units.31 Although</p><p>many good ideas and practices that improved operational perfor-</p><p>mance came out of these workshops, which brought employees from</p><p>different countries together, the executives who sponsored them saw</p><p>the most important outcome as a shift in the organizational culture</p><p>toward speaking up, asking for help, and sharing good ideas.</p><p>How to Respond Productively to Voice – No</p><p>Matter Its Quality</p><p>To reinforce a climate of psychological safety, it’s imperative that</p><p>leaders – at all levels – respond productively to the risks people</p><p>take. Productive responses are characterized by three elements:</p><p>expressions of appreciation, destigmatizing failure, and sanctioning</p><p>clear violations.</p><p>Express Appreciation</p><p>Imagine if Christina, the NICU nurse in Chapter 1, had spoken up</p><p>to Dr. Drake. Her quiet fear was that he would have berated or belit-</p><p>tled her. But what if he had said, “thank you so much for bringing</p><p>that up”? Her feeling of psychological safety would have gone up a</p><p>notch. This is an example of an appreciative response. It does not</p><p>matter whether the doctor believes the nurse’s suggestion or question</p><p>is good or bad. Either way, his initial response must be one of appreci-</p><p>ation. Then he can educate – that is, give feedback or explain clinical</p><p>subtleties. But to ensure that staff keeps speaking up so as to keep</p><p>174 Creating a Fearless Organization</p><p>patients safe from unexpected lapses in attention or judgment, the</p><p>courage it takes to speak up must receive the mini-reward of thanks.</p><p>Stanford Professor Carol Dweck, whose celebrated research on</p><p>mindset shows the power of a learning orientation for individual</p><p>achievement and resilience in the face of challenge, notes the impor-</p><p>tance of praising people for efforts, regardless of the outcome.32 When</p><p>people believe their performance is an indication of their ability or</p><p>intelligence, they are less likely to take risks – for fear of a result that</p><p>would disconfirm their ability. But when people believe that perfor-</p><p>mance reflects effort and good strategy, they are eager to try new</p><p>things and willing to persevere despite adversity and failure.</p><p>Praising effort is especially important in uncertain environments,</p><p>where good outcomes are not always the result of good process,</p><p>and vice versa. Although many of the examples in this book present</p><p>responses from CEOs, an equally important leadership responsibility</p><p>for C-level executives is making sure that people throughout the</p><p>organization respond productively to their colleagues. It helps if</p><p>everyone understands the logic conveyed in Figure 7.1, which</p><p>depicts the imperfect relationship between process and outcome.</p><p>Clearly, good process can lead to good outcomes, and bad process</p><p>can lead to bad outcomes (Figure 7.1a). But, as shown in Figure 7.1b,</p><p>good process also can produce bad outcomes (especially facing high</p><p>uncertainty or complexity, as in VUCA conditions), and bad process</p><p>can produce a good outcome (when you get lucky), or the illusion</p><p>of a good outcome (for a while, anyway, as in the cases of VW</p><p>and Wells Fargo). The lack of simple cause-effect relationships in</p><p>uncertain, ambiguous environments reinforces the importance of</p><p>productive responses to outcomes of all kinds, but especially to bad</p><p>news outcomes.</p><p>Productive responses often include expressions of appreciation,</p><p>ranging from the small (“thank you so much for speaking up”) to</p><p>the elaborate – celebrations or bonuses in response to intelligent</p><p>failure.</p><p>Making it Happen 175</p><p>Good Process</p><p>Bad Process</p><p>Good Outcome</p><p>often leads to...</p><p>often leads to...</p><p>(a)</p><p>(b)</p><p>Bad Outcome</p><p>Good Process</p><p>Bad Process</p><p>Good Outcome</p><p>VUCA</p><p>Luck</p><p>Bad Outcome</p><p>Figure 7.1 The Imperfect Relationship between Process and</p><p>Outcome.</p><p>Destigmatize Failure</p><p>Failure is a necessary part of uncertainty and innovation, but this must</p><p>be made explicit to reinforce the invitation for voice. Consider the</p><p>implications of the failure typology in Table 7.2 for designing a pro-</p><p>ductive response to news of a failure. Leaders who respond to all</p><p>failures in the same way will not create a healthy environment for</p><p>learning. When a failure occurs because someone violated a rule or</p><p>value that matters in the organization, this is very different than when</p><p>a thoughtful hypothesis in the lab turns out to be wrong. Although</p><p>obvious in concept, in practice people routinely get this wrong.</p><p>176 Creating a Fearless Organization</p><p>Table 7.4 Destigmatizing Failure for Psychological Safety.</p><p>Traditional</p><p>Frame</p><p>Destigmatizing</p><p>Reframe</p><p>Concept of</p><p>Failure</p><p>Failure is not</p><p>acceptable.</p><p>Failure is a natural by-product of</p><p>experimentation.</p><p>Beliefs About</p><p>Effective</p><p>Performance</p><p>Effective</p><p>performers</p><p>don’t fail.</p><p>Effective performers produce,</p><p>learn from and share the lessons</p><p>from intelligent failures.</p><p>The Goal Prevent failure. Promote fast learning.</p><p>The Frame’s</p><p>Impact</p><p>People hide</p><p>failures to</p><p>protect</p><p>themselves.</p><p>Open discussion, fast learning,</p><p>and innovation.</p><p>I frequently ask managers,</p><p>scientists, salespeople, and technologists</p><p>around the world the following question: What percent of the fail-</p><p>ures in your organizations should be considered blameworthy? Their</p><p>answers are usually in single digits – perhaps 1% to 4%. I then ask</p><p>what percent are treated as blameworthy. Now, they say (after a pause</p><p>or a laugh) 70% to 90%! The unfortunate consequence of this gap</p><p>between simple logic and organizational response is that many fail-</p><p>ures go unreported and their lessons are lost. As shown in Table 7.4,</p><p>the primary result of responding to failures in a negative way is that</p><p>you don’t hear about them. And that, as Mark Costa noted in Chapter</p><p>2, should be your biggest fear.</p><p>A productive response to a complex failure at Children’s Hospital</p><p>is embodied in the FEA process, described in the Leader’s Tool Kit</p><p>section. All of the people whose work or role touched the failure in</p><p>question are invited to sit around the same table to share their obser-</p><p>vations, their questions, and their concerns related to the events that</p><p>unfolded. Everyone listens intently to what others saw, felt, and did.</p><p>More often than not, individuals were doing their tasks in prescribed</p><p>Making it Happen 177</p><p>ways, but a host of factors came together in a new way to produce</p><p>a mishap. The FEA is not a fun activity, but it is deeply meaningful</p><p>and gratifying. People gain understanding of how various systems and</p><p>roles in the hospital intersect, and they leave with a deeper appreci-</p><p>ation of system complexity and interdependence. They do not feel</p><p>blamed but instead empowered to go back out and make the system</p><p>better so as to prevent a similar failure in the future. Most impor-</p><p>tantly, they feel psychologically safe enough to keep reporting what</p><p>they see, to keep asking for help or clarification, and to offer ideas</p><p>for improvement.</p><p>In fact, a productive response to intelligent failure can mean</p><p>actually celebrating the news. Some years ago, the chief scientific</p><p>officer at Eli Lilly introduced “failure parties” to honor intelligent,</p><p>high-quality scientific experiments that failed to achieve the desired</p><p>results.33 Might this be a bridge too far? I don’t think so. First,</p><p>and most obvious, it helps build a psychologically safe climate for</p><p>thoughtful risks, which is mission critical in science. Second, it helps</p><p>people acknowledge failures in a timely way, which allows redeploy-</p><p>ment of valuable resources – scientists and materials – to new projects</p><p>earlier rather than later, potentially saving thousands of dollars.</p><p>Third, when you hold a party, people tend to show up – which</p><p>means they learn about the failure. This in turn lowers the risk that</p><p>the company will repeat the same failure. An intelligent failure the</p><p>first time around no longer qualifies as intelligent the second time.</p><p>In brief, a productive response to preventable failures is to double</p><p>down on prevention, usually a combination of training and improved</p><p>system design to make it easier for people to do the right thing. How-</p><p>ever, there are instances in which a preventable failure is the result of</p><p>a blameworthy action or a repeated instance of deviation from pre-</p><p>scribed process, impervious to prior attempts at redirection. In such</p><p>cases, usually rare, there is an obligation to act in ways that prevent</p><p>future occurrence. This may mean fines or other sanctions, and in</p><p>some cases even firing someone.</p><p>178 Creating a Fearless Organization</p><p>Sanction Clear Violations</p><p>Yes, firing can sometimes be an appropriate and productive response –</p><p>to a blameworthy act. But won’t this kill the psychological safety?</p><p>No. Most people are thoughtful enough to recognize (and appreci-</p><p>ate) that when people violate rules or repeatedly take risky shortcuts,</p><p>they are putting themselves, their colleagues, and their organization at</p><p>risk. In short, psychological safety is reinforced rather than harmed by</p><p>fair, thoughtful responses to potentially dangerous, harmful, or sloppy</p><p>behavior.</p><p>In July 2017, Google engineer James Damore wrote a 10-page</p><p>memo railing against the company’s diversity stance, arguing that bio-</p><p>logical differences explained why Google had fewer women engineers</p><p>and paid them less well than men, and circulated it widely within</p><p>the company.34 Someone then leaked the memo, creating a public</p><p>firestorm.35</p><p>How did Google respond? Damore was promptly and publicly</p><p>fired a month later, earning the company both praise and criticism.</p><p>Thoughtful arguments have been made on both sides of the firing</p><p>debate. Rather than coming out on one side or the other, let’s step</p><p>back to consider when firing constitutes a “productive response,” and</p><p>when it doesn’t.</p><p>Take this specific case. To begin, it is a shame that Damore chose</p><p>to share his personal concerns electronically and widely within the</p><p>company, all but ensuring that someone who disliked the memo</p><p>would share it publicly. Ideally, an employee with an opinion to</p><p>express related to an important work issue or policy would first solicit</p><p>feedback from colleagues, especially with those who might be likely</p><p>to have a different view. The person might want to first learn more</p><p>about the potential impact of those ideas and the forms in which they</p><p>could be expressed. Very few of us are able to see complex issues from</p><p>multiple perspectives and consider the potential consequences well</p><p>enough to make good decisions about them alone. This doesn’t matter</p><p>when stakes are low. But stakes are high when a document that affects</p><p>your colleagues, customers, or company may be read by millions.</p><p>Making it Happen 179</p><p>But, once the inflammatory memo has been made public, how</p><p>should a company respond? My intention is not to illuminate the</p><p>specifics of Damore’s memo at Google but rather to suggest a general</p><p>strategy for productive responses to actions or events in your organi-</p><p>zation that you wish had not occurred.</p><p>If there are clear policies against the use of company email</p><p>addresses or social media platforms for the expression of personal</p><p>opinions, then an employee who violates these policies commits what</p><p>we can call a blameworthy act. In this case, a productive response</p><p>indeed involves tough sanctions, which may include terminating</p><p>the employee. A tough response is productive because it lets people</p><p>know that the company is serious about its policies and values, which</p><p>shapes future behavior, and because it constitutes a fair response to a</p><p>stated violation.</p><p>If policies are unclear, however, a productive response is one</p><p>that turns the unfortunate event into a different kind of learning</p><p>opportunity – for the company and sometimes for the interested</p><p>public. In the Damore case, executives might express dismay at the</p><p>employee’s opinion (and perhaps dismay at his ignorance of a larger</p><p>set of societal forces that have systematically diminished advancement</p><p>opportunities for certain demographic groups over decades). They</p><p>might then go on to explain their plans for educating employees on</p><p>what they believe to be the value of a diverse workforce. As part of</p><p>this organizational learning process, company managers at all levels</p><p>would elicit and listen to ideas, questions, concerns, and frustra-</p><p>tions. They might create opportunities for engaging in perspective</p><p>taking, building empathy, developing inquiry skills, and more. The</p><p>organization might also seek ways to come up with new, improved</p><p>ways to leverage employee diversity to build better products and</p><p>services.</p><p>In short, a productive response is concerned with future impact.</p><p>Punishment sends a powerful message, and an appropriate one if</p><p>boundaries were clear in advance. Indeed, it is vital to send messages</p><p>that reinforce values the company holds dear. However, it is equally</p><p>vital not to inadvertently send a message that says, “diverse opinions</p><p>180 Creating a Fearless Organization</p><p>simply won’t be tolerated here,” or “one strike and you’re out.”</p><p>Such messages reduce psychological safety and ultimately erode</p><p>the quality of the work. In contrast, a message that reinforces the</p><p>values and practices of a learning organization is, “it’s okay</p><p>to make</p><p>a mistake, and it’s okay to hold an opinion that others don’t like,</p><p>so long as you are willing to learn from the consequences.” The</p><p>most important goal is figuring out a way to help the organization</p><p>learn from what happened. And so, if there is ambiguity about</p><p>public self-expression related to company policies, then a productive</p><p>response is one that engages people in a learning dialogue to better</p><p>understand and improve how the company functions. Table 7.5</p><p>shows how a productive response to failure in an organization should</p><p>vary for different failure types.</p><p>Table 7.5 Productive Responses to Different Types</p><p>of Failure.</p><p>Preventable</p><p>Failure</p><p>Complex</p><p>Failure</p><p>Intelligent</p><p>Failure</p><p>Productive</p><p>Response</p><p>– Training</p><p>– Retraining</p><p>– Process</p><p>improvement</p><p>– System redesign</p><p>– Sanctions, if</p><p>repeated or</p><p>otherwise</p><p>blameworthy</p><p>actions are</p><p>found</p><p>– Failure analysis</p><p>from diverse</p><p>perspectives</p><p>– Identification</p><p>of risk factors</p><p>to address</p><p>– System</p><p>improvement</p><p>– Failure parties</p><p>– Failure awards</p><p>– Thoughtful</p><p>analysis of</p><p>results to figure</p><p>out implications</p><p>– Brainstorming</p><p>of new</p><p>hypotheses</p><p>– Design of next</p><p>steps or</p><p>additional</p><p>experiments</p><p>Making it Happen 181</p><p>Leadership Self-Assessment</p><p>The practices described in this chapter are dominated by complex</p><p>interpersonal skills and thus not easy to master. They take time, effort,</p><p>and practice.36 Perhaps the most important aspect of learning them is</p><p>to practice self-reflection. A set of self-assessment questions, provided</p><p>in a sidebar, can be used to do just that. The questions map to and</p><p>operationalize the framework introduced in this chapter.</p><p>Leadership Self-Assessment</p><p>I. Setting the Stage</p><p>Framing the work</p><p>◾ Have I clarified the nature of the work? To what extent is the</p><p>work complex and interdependent? How much uncertainty</p><p>do we face? How often do I refer to these aspects of the</p><p>work? How well do I assess shared understanding of these</p><p>features?</p><p>◾ Have I spoken of failures in the right way, given the nature of</p><p>the work? Do I point out that small failures are the currency</p><p>of subsequent improvement? Do I emphasize that it is not</p><p>possible to get something brand new “right the first time?”</p><p>Emphasizing Purpose</p><p>◾ Have I articulated clearly why our work matters, why it</p><p>makes a difference, and for whom?</p><p>◾ Even if it seems obvious given the type of work or industry</p><p>I’m in, how often do I talk about what’s at stake?</p><p>II. Inviting Participation</p><p>Situational Humility</p><p>◾ Have I made sure that people know that I don’t think I have</p><p>all the answers?</p><p>◾ Have I emphasized that we can always learn more? Have I</p><p>been clear that the situation we’re in requires everyone to be</p><p>humble and curious about what’s going to happen next?</p><p>182 Creating a Fearless Organization</p><p>Proactive Inquiry</p><p>◾ How often do I ask good questions rather than rhetorical</p><p>ones? How often do I ask questions of others, rather than</p><p>just expressing my perspective?</p><p>◾ Do I demonstrate an appropriate mix of questions that go</p><p>broad and go deep?</p><p>Systems and Structures</p><p>◾ Have I created structures to systematically elicit ideas and</p><p>concerns?</p><p>◾ Are these structures well designed to ensure a safe environ-</p><p>ment for open dialogue?</p><p>III. Responding Productively</p><p>Express Appreciation</p><p>◾ Have I listened thoughtfully, signaling that what I am hear-</p><p>ing matters?</p><p>◾ Do I acknowledge or thank the speaker for bringing the idea</p><p>or question to me? Listen thoughtfully</p><p>Destigmatize Failure</p><p>◾ Have I done what I can to destigmatize failure? What more</p><p>can I do to celebrate intelligent failures?</p><p>◾ When someone comes to me with bad news, how do I make</p><p>sure it’s a positive experience?</p><p>◾ Do I offer help or support to guide the next steps?</p><p>Sanction Clear Violations</p><p>◾ Have I clarified the boundaries? Do people know what con-</p><p>stitute blameworthy acts in our organization?</p><p>◾ Do I respond to clear violations in an appropriately tough</p><p>manner so as to influence future behavior?</p><p>Making it Happen 183</p><p>Chapter 7 Takeaways</p><p>◾ Three interrelated practices help create psychological safety –</p><p>setting the stage, inviting participation, and responding</p><p>productively.</p><p>◾ These practices must be repeatedly used, in interactive,</p><p>learning-oriented ways, to create and restore a climate of</p><p>candor in an ongoing way.</p><p>◾ Building and reinforcing psychological safety is the responsi-</p><p>bility of leaders at all levels of the organization.</p><p>Endnotes</p><p>1. This quote is from Gelb, M.J. Thinking for a Change: Discovering the Power</p><p>to Create, Communicate, and Lead. Harmony, 1996. Print, pp. 96.</p><p>2. The details on Julie Morath at Children’s Hospital draw from a case</p><p>study that I conducted with my colleagues Mike Roberto and Anita</p><p>Tucker: Edmondson, A.C., Roberto, M., & Tucker, A.L. Children’s</p><p>Hospital and Clinics (A). Case Study. HBS Case No. 302-050. Boston:</p><p>Harvard Business School Publishing, 2001.</p><p>3. For additional details on framing, see Chapter 3 of Edmondson, A.C.</p><p>Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge</p><p>Economy. San Francisco: Jossey-Bass, 2011. Print, pp. 83–113.</p><p>4. Edmondson, A.C., Nembhard, I.M., & Roloff, K.S. Children’s Hospital</p><p>and Clinics (B). Case Study. HBS Case No. 608-073. Boston: Harvard</p><p>Business School Publishing, 2007.</p><p>5. Edmondson, A.C. et al. Children’s Hospital and Clinics (A). 2001, op</p><p>cit.</p><p>6. One version of the famous fable is found in an 1872 poem by John</p><p>Godfrey Saxe, which includes these lines: “And so these men of</p><p>Indostan disputed loud and long, each in his own opinion exceeding</p><p>stiff and strong. Though each was partly in the right, and all were in</p><p>184 Creating a Fearless Organization</p><p>the wrong.” The full poem can be found here: https://en.wikisource</p><p>.org/wiki/The_poems_of_John_Godfrey_Saxe/The_Blind_Men_</p><p>and_the_Elephant Accessed June 12, 2018.</p><p>7. Teller, A. “The Unexpected Benefit of Celebrating Failure.” TED.</p><p>2016. https://www.ted.com/talks/astro_teller_the_unexpected_benefit_</p><p>of_celebrating_failure Accessed June 8, 2018.</p><p>8. This quote comes from a talk Teller gave at Stanford University on</p><p>April 20, 2016 as part of Stanford’s Entrepreneurial Thought Leaders</p><p>series. You can watch the full talk at Stanford’s eCorner: https://ecorner</p><p>.stanford.edu/video/celebrating-failure-fuels-moonshots-entire-talk/.</p><p>9. Lafley, A.G., & Charan, R. The Game-Changer: How You Can Drive</p><p>Revenue and Profit Growth with Innovation. 1st ed. Crown Business, 2008.</p><p>Print.</p><p>10. Catmull, E. & Wallace, A. Creativity, Inc.: Overcoming the Unseen Forces</p><p>That Stand in the Way of True Inspiration. New York: Random House,</p><p>2013. Print, pp. 123.</p><p>11. Bryant, A. “Christa Quarles of OpenTable: The Advantage of ‘Early,</p><p>Often, Ugly.” The New York Times. April 12, 2016. https://www</p><p>.nytimes.com/2016/08/14/business/christa-quarles-of-opentable-</p><p>the-advantage-of-early-often-ugly.html Accessed June 14, 2018.</p><p>12. Bennett, J. “On Campus, Failure Is on the Syllabus.” The New</p><p>York Times. June 24, 2017. https://www.nytimes.com/2017/06/24/</p><p>fashion/fear-of-failure.html Accessed June 14, 2018.</p><p>13. Ibid.</p><p>14. For more on different types of work, see Chapter 1 of Teaming: How</p><p>Organizations Learn, Innovate, and Compete in the Knowledge Economy. San</p><p>Francisco: Jossey-Bass, 2012. Print, pp. 11–43.</p><p>15. Edmondson, A.C. “Strategies for Learning from Failure.” Harvard</p><p>Business Review. April 2011. https://hbr.org/2011/04/strategies-for-</p><p>learning-from-failure Accessed June 14, 2018.</p><p>16. This table presents a modified version of a table that appeared in Chapter</p><p>5 of Edmondson, A.C. Teaming: How Organizations Learn, Innovate, and</p><p>Compete in the Knowledge Economy. San Francisco: Jossey-Bass, 2012.</p><p>Print, pp. 166.</p><p>17. To cite just one example, Wharton professor Adam Grant and a team</p><p>of researchers conducted a study in which they arranged for a group</p><p>of university call center workers, tasked with the tedious and frustrat-</p><p>ing work of trying to raise money for the university’s scholarship fund,</p><p>to meet the actual scholarship recipients funded by the donations they</p><p>solicited. By seeing how their work contributed to the lives of others,</p><p>https://en.wikisource.org/wiki/The_poems_of_John_Godfrey_Saxe/The_Blind_Men_and_the_Elephant</p><p>along with the decision. Later, when the takeover had clearly failed,</p><p>the executives gathered with a consultant for a post-mortem. Each</p><p>was asked to reflect on what he or she might have done to contribute</p><p>to or avert the failure. The CFO, now less of an outsider, shared his</p><p>earlier concerns, acknowledging that he had let the team down by</p><p>not speaking up. Openly apologetic and emotional, he lamented that</p><p>the others’ enthusiasm had left him afraid to be “the skunk at the</p><p>picnic.”</p><p>The problem with sitting on our hands and staying within the</p><p>lines rather than speaking up is that although these behaviors keep</p><p>us personally safe, they can make us underperform and become</p><p>dissatisfied. They can also put the organization at risk. In the case</p><p>of Christina and the newborns, fortunately, no immediate damage</p><p>was done, but as we will see in later chapters, the fear of speaking</p><p>up can lead to accidents that were in fact avoidable. Remaining</p><p>silent due to fear of interpersonal risk can make the difference</p><p>between life and death. Airplanes have crashed, financial institutions</p><p>have fallen, and hospital patients have died unnecessarily because</p><p>individuals were, for reasons having to do with the climate in</p><p>which they worked, afraid to speak up. Fortunately, it doesn’t have</p><p>to happen.</p><p>Envisioning the Psychologically Safe Workplace</p><p>Had Christina worked in a hospital unit where she felt psycholog-</p><p>ically safe, she would not have hesitated to ask the neonatologist</p><p>whether or not he thought treating the newborns with prophylactic</p><p>lung medicine was warranted. Here too, she might not even be aware</p><p>of making a conscious decision to speak up; it would simply seem</p><p>natural to check. She would take for granted that her voice was appre-</p><p>ciated, even if what she said didn’t lead to a change in the patient’s care.</p><p>In a climate characterized by psychological safety – which blends trust</p><p>The Underpinning 7</p><p>and respect – the neonatologist might quickly agree with Christina</p><p>and call the pharmacy to put in a request, or he might have explained</p><p>why he thought it wasn’t warranted in this case. Either way, the unit</p><p>would be better off as a result. The patients would have received</p><p>life-saving medication, or the team would have learned more about</p><p>the subtleties of neonatal medicine. Before leaving the room, the doc-</p><p>tor might thank Christina for her intervention. He’d be glad he could</p><p>rely on her to speak up in case he slipped up, missed a detail, or was</p><p>simply distracted.</p><p>Finally, as she gave the medicine to the babies, Christina might</p><p>come up with the idea that the NICU could institute a protocol to</p><p>make sure that that all babies who need a surfactant would get it.</p><p>She might seek out her manager to make this suggestion during a</p><p>break in the action. And because psychological safety exists in work</p><p>groups, rather than between specific individuals (such as Christina</p><p>and Dr. Drake), it’s likely her nurse manager would be receptive to</p><p>her suggestion.</p><p>Speaking up describes back-and-forth exchanges people have at</p><p>work – from volunteering a concern in a meeting to giving feed-</p><p>back to a colleague. It also includes electronic communication (for</p><p>example, sending an extra email to ask a coworker to clarify a partic-</p><p>ular point or seek help with a project). Valuable forms of speaking up</p><p>include raising a different point of view in a conference call, asking</p><p>a colleague for feedback on a report, admitting that a project is over</p><p>budget or behind schedule, and so on – the myriad verbal interactions</p><p>that make up the world of twenty-first century work.</p><p>There is, of course, a range of interpersonal riskiness involved</p><p>in speaking up. Some cases of speaking up occur after significant</p><p>trepidation; others feel reasonably straightforward and feasible.</p><p>Still others simply don’t occur – as in the case of Christina in the</p><p>NICU – because one has weighed the risk (consciously or not)</p><p>and come out on the side of silence. The free exchange of ideas,</p><p>concerns or questions is routinely hindered by interpersonal fear far</p><p>more often than most managers realize. This kind of fear cannot be</p><p>directly seen. Silence – when voice was possible – rarely announces</p><p>8 The Power of Psychological Safety</p><p>itself! The moment passes, and no one is the wiser except the person</p><p>who held back.</p><p>I have defined psychological safety as the belief that the work</p><p>environment is safe for interpersonal risk taking.6 The concept refers</p><p>to the experience of feeling able to speak up with relevant ideas, ques-</p><p>tions, or concerns. Psychological safety is present when colleagues</p><p>trust and respect each other and feel able – even obligated – to be</p><p>candid.</p><p>In workplaces with psychological safety, the kinds of small</p><p>and potentially consequential moments of silence experienced by</p><p>Christina are far less likely. Speaking up occurs instead, facilitating</p><p>the open and authentic communication that shines the light on</p><p>problems, mistakes, and opportunities for improvement and increases</p><p>the sharing of knowledge and ideas.</p><p>As you will see, our understanding of interpersonal risk manage-</p><p>ment at work has advanced since Goffman studied the fascinating</p><p>micro-dynamics of face-saving. We now know that psychological</p><p>safety emerges as a property of a group, and that groups in organi-</p><p>zations tend to have very interpersonal climates. Even in a company</p><p>with a strong corporate culture, you will find pockets of both high</p><p>and low psychological safety. Take, for instance, the hospital where</p><p>Christina works. One patient care unit might be a place where nurses</p><p>readily speak up to challenge or inquire about care decisions, while in</p><p>another it feels downright impossible. These differences in workplace</p><p>climate shape behavior in subtle but powerful ways.</p><p>An Accidental Discovery</p><p>As much as I’m passionate about the ideas in this book, I didn’t set out</p><p>to study psychological safety on purpose. As a first-year doctoral stu-</p><p>dent in the process of clarifying my research interests for my eventual</p><p>dissertation, I had been fortunate to join a large team studying medical</p><p>error in several hospitals. This was a great way to gain research expe-</p><p>rience and to sharpen my general interest in how organizations can</p><p>The Underpinning 9</p><p>learn and succeed in an increasingly challenging, fast-paced world.</p><p>I had long been interested in the idea of learning from mistakes for</p><p>achieving excellence.</p><p>My role in the research team was to examine the effects of team-</p><p>work on medical error rates. The team had numerous experts, includ-</p><p>ing physicians who could judge whether human error had occurred</p><p>and trained nurse investigators who would review medical charts and</p><p>interview frontline caregivers in patient care units in two hospitals</p><p>to obtain error rates for each of these teams. These experts were, in</p><p>effect, getting the data for what would be the dependent variable in</p><p>my study – the team-level error rates. This was a great arrangement</p><p>for me, for at least two reasons. First, I lacked the medical expertise to</p><p>identify medical errors on my own. Second, from a research methods</p><p>perspective, it meant that my survey measures of team effectiveness</p><p>would not be subject to experimenter bias – the cognitive tendency</p><p>for a researcher to see what she wants to see rather than what is actu-</p><p>ally there. So the independence of our data collection activities was</p><p>an important strength of the study.7</p><p>The nurse investigators collected error data over a six-month</p><p>period. During the first month, I distributed a validated instrument</p><p>called the team diagnostic survey to everyone working in the study</p><p>units – doctors, nurses, and clerks – slightly altering the language</p><p>of the survey items to make sure they would make sense to people</p><p>working in a hospital, and adding a few new items to assess people’s</p><p>views about making mistakes. I also spent time on the floor (in the</p><p>patient care units) observing how each of the teams worked.</p><p>Going into the study, I hypothesized, not surprisingly, that the</p><p>most effective teams would make the fewest errors. Of course, I had</p><p>to wait six months</p><p>https://en.wikisource.org/wiki/The_poems_of_John_Godfrey_Saxe/The_Blind_Men_and_the_Elephant</p><p>https://en.wikisource.org/wiki/The_poems_of_John_Godfrey_Saxe/The_Blind_Men_and_the_Elephant</p><p>https://www.ted.com/talks/astro_teller_the_unexpected_benefit_of_celebrating_failure</p><p>https://ecorner.stanford.edu/video/celebrating-failure-fuels-moonshots-entire-talk</p><p>https://ecorner.stanford.edu/video/celebrating-failure-fuels-moonshots-entire-talk</p><p>https://www.nytimes.com/2016/08/14/business/christa-quarles-of-opentable-the-advantage-of-early-often-ugly.html</p><p>https://www.nytimes.com/2016/08/14/business/christa-quarles-of-opentable-the-advantage-of-early-often-ugly.html</p><p>https://www.nytimes.com/2016/08/14/business/christa-quarles-of-opentable-the-advantage-of-early-often-ugly.html</p><p>https://www.nytimes.com/2017/06/24/fashion/fear-of-failure.html</p><p>https://www.nytimes.com/2017/06/24/fashion/fear-of-failure.html</p><p>https://hbr.org/2011/04/strategies-for-learning-from-failure</p><p>https://hbr.org/2011/04/strategies-for-learning-from-failure</p><p>https://www.ted.com/talks/astro_teller_the_unexpected_benefit_</p><p>https://www.ted.com/talks/astro_teller_the_unexpected_benefit_of_celebrating_failure</p><p>Making it Happen 185</p><p>the callers subsequently increased both the time they spent on the phone</p><p>and how much money they brought in, compared to callers who did</p><p>not meet the scholarship recipients. See Grant, A.M., Campbell, E.M.,</p><p>Chen, G., Cottone, K., Lapedis, D., & Lee, K. “Impact and the Art</p><p>of Motivation Maintenance: The Effects of Contact with Beneficiaries</p><p>on Persistence Behavior.” Organizational Behavior and Human Decision</p><p>Processes 103.1 (2007): 53–67.</p><p>18. Schein, E.H. Humble Inquiry: the Gentle Art of Asking Instead of Telling.</p><p>1st ed. Berrett-Koehler Publishers, Inc., 2013. Print, pp. 11.</p><p>19. Owens, B.P., Johnson, M.D., & Mitchell, T.R. “Expressed Humility in</p><p>Organizations: Implications for Performance, Teams, and Leadership.”</p><p>Organization Science 24.5 (2013): 1517–38.</p><p>20. Anne Mulcahy, HBS class comments, October 11, 2017.</p><p>21. Ibid.</p><p>22. Cable, D. “How Humble Leadership Really Works.” Harvard Business</p><p>Review. April 23, 2018. https://hbr.org/2018/04/how-humble-</p><p>leadership-really-works Accessed June 14, 2018.</p><p>23. Tucker, A.L., Nembhard, I.M., and Edmondson, A.C. “Implementing</p><p>new practices: An empirical study of organizational learning in hospital</p><p>intensive care units.” Management Science 53.6 (2007): 894 –907.</p><p>24. Hirak, R., Peng, A.C., Carmeli, A., & Schaubroeck, J.M. “Linking</p><p>Leader Inclusiveness to Work Unit Performance: The Importance of</p><p>Psychological Safety and Learning from Failures.” The Leadership Quar-</p><p>terly 23.1 (2012): 107–17.</p><p>25. Ross, L. & Ward, A. “Naive Realism: Implications for Social Con-</p><p>flict and Misunderstanding.” In Values & Knowledge. Ed. T. Brown, E.S.</p><p>Reed, & E. Turiel. Lawrence Erlbaum Associates (1996): 103–35.</p><p>26. Adapted from “The Art of Powerful Questions.” World Café. http://</p><p>www.theworldcafe.com Accessed July 27, 2018.</p><p>27. For great work on advocacy and inquiry, the Actionsmith group posts</p><p>this paper: http://actionsmithnetwork.net/wp-content/uploads/2015/</p><p>09/Advocacy-and-Inquiry-Article_Final.pdf . Accessed June 21, 2018.</p><p>28. Bryant, A. “Bob Pittman of Clear Channel, on the Value of Dissent”</p><p>The New York Times. November 16, 2013. https://www.nytimes.com/</p><p>2013/11/17/business/bob-pittman-of-clear-channel-on-the-value-</p><p>of-dissent.html Accessed June 14, 2018.</p><p>29. Schein, E.H. Humble Inquiry: The Gentle Art of Asking Instead of Telling.</p><p>1st ed., Berrett-Koehler Publishers, Inc., 2013. Print.</p><p>30. “Guide: Create an Employee-to-Employee Learning Pro-</p><p>gram.” re:Work. https://rework.withgoogle.com/guides/learning-</p><p>https://hbr.org/2018/04/how-humble-leadership-really-works</p><p>https://hbr.org/2018/04/how-humble-leadership-really-works</p><p>http://www.theworldcafe.com</p><p>http://www.theworldcafe.com</p><p>http://actionsmithnetwork.net/wp-content/uploads/2015/09/Advocacy-and-Inquiry-Article_Final.pdf</p><p>http://actionsmithnetwork.net/wp-content/uploads/2015/09/Advocacy-and-Inquiry-Article_Final.pdf</p><p>https://www.nytimes.com/2013/11/17/business/bob-pittman-of-clear-channel-on-the-value-of-dissent.html</p><p>https://www.nytimes.com/2013/11/17/business/bob-pittman-of-clear-channel-on-the-value-of-dissent.html</p><p>https://www.nytimes.com/2013/11/17/business/bob-pittman-of-clear-channel-on-the-value-of-dissent.html</p><p>https://rework.withgoogle.com/guides/learning-development-employee-to-employee/steps/introduction</p><p>186 Creating a Fearless Organization</p><p>development-employee-to-employee/steps/introduction/ Accessed</p><p>June 14, 2018.</p><p>31. For more on Danone’s knowledge marketplaces, see the following case</p><p>study I conducted with David Lane: Edmondson, A.C. & Lane, D.</p><p>Global Knowledge Management at Danone (A) (Abridged). Case Study.</p><p>HBS No. 613-003. Boston, MA: Harvard Business School Publishing,</p><p>2012.</p><p>32. For more on Dweck’s fantastic work on fixed vs. growth mindsets, see</p><p>Dweck, C.S. Mindset: The New Psychology of Success. Updated ed. Ran-</p><p>dom House, 2016. Print.</p><p>33. Burton, T. “By Learning From Failures, Lilly Keeps Drug Pipeline</p><p>Full.” The Wall Street Journal. April 21, 2004. https://www.wsj.com/</p><p>articles/SB108249266648388235 Accessed June 14, 2018.</p><p>34. The memo was first leaked to the public here: https://gizmodo.com/</p><p>exclusive-heres-the-full-10-page-anti-diversity-screed-1797564320</p><p>Accessed June 15, 2018.</p><p>35. See, for example:</p><p>◾ Wakabayashi, D. “Contentious Memo Strikes Nerve Inside Google</p><p>and Out.” The New York Times. August 8, 2017. https://www</p><p>.nytimes.com/2017/08/08/technology/google-engineer-fired-</p><p>gender-memo.html Accessed June 14, 2018.</p><p>◾ Molteni, M. & Rogers, A. “The Actual Science of James Damore’s</p><p>Google Memo.” WIRED. August 15, 2017. https://www.wired</p><p>.com/story/the-pernicious-science-of-james-damores-google-</p><p>memo/ Accessed June 14, 2018.</p><p>36. The late HBS Professor David A. Garvin, a friend and colleague, was</p><p>fond of telling students that any word in the English language that</p><p>ends in the suffix “ing” is a process, which means first, that it’s not a</p><p>one-and-done, and second, that a leader can get better at it with prac-</p><p>tice. In that vein, creating psychological safety in an organization is</p><p>a messy process that requires leaders to set the stage, invite participa-</p><p>tion, and respond productively each and every day. It never ends! But</p><p>just like you can optimize a manufacturing process, you can definitely</p><p>improve at it.</p><p>https://rework.withgoogle.com/guides/learning-development-employee-to-employee/steps/introduction</p><p>https://www.wsj.com/articles/SB108249266648388235</p><p>https://www.wsj.com/articles/SB108249266648388235</p><p>https://gizmodo.com/exclusive-heres-the-full-10-page-anti-diversity-screed-1797564320</p><p>https://gizmodo.com/exclusive-heres-the-full-10-page-anti-diversity-screed-1797564320</p><p>https://www.nytimes.com/2017/08/08/technology/google-engineer-fired-gender-memo.html</p><p>https://www.nytimes.com/2017/08/08/technology/google-engineer-fired-gender-memo.html</p><p>https://www.nytimes.com/2017/08/08/technology/google-engineer-fired-gender-memo.html</p><p>https://www.wired.com/story/the-pernicious-science-of-james-damores-google-memo</p><p>https://www.wired.com/story/the-pernicious-science-of-james-damores-google-memo</p><p>https://www.wired.com/story/the-pernicious-science-of-james-damores-google-memo</p><p>8</p><p>What’s Next?</p><p>The greatest enemy of learning is knowing.</p><p>—John Maxwell1</p><p>By now it should be clear that psychological safety is foundational to</p><p>building a learning organization. Organizations that seek to stay rele-</p><p>vant through continuous learning and agile execution must cultivate</p><p>a fearless environment that encourages speaking up. In any company</p><p>that thrives in our complex and uncertain world, leaders must be lis-</p><p>tening intently, with a deep understanding that people are both the</p><p>sensors who pick up signals that change is necessary and the source</p><p>of creative new ideas to test and implement.</p><p>Continuous Renewal</p><p>We’ve seen that leaders have many tools at their disposal to create and</p><p>nurture a workplace conducive to learning, innovation, and growth.</p><p>187</p><p>188 Creating</p><p>for the data on the dependent variable (the error</p><p>rates) to be fully collected. And here is where the story took an unex-</p><p>pected turn.</p><p>First, the good news (from a research perspective anyway).</p><p>There was variance! Error rates across teams were strikingly different;</p><p>indeed, there was a 10-fold difference in the number of human errors</p><p>per thousand patient days (a standard measure) from the best to the</p><p>10 The Power of Psychological Safety</p><p>worst unit on what I sincerely believed was an important performance</p><p>measure. A wrong medicine dosage, for example, might be reported</p><p>every three weeks on one ward but every other day on another.</p><p>Likewise, the team survey data also showed significant variance.</p><p>Some teams were much stronger – their members reported more</p><p>mutual respect, more collaboration, more confidence in their ability</p><p>to deliver great results, more satisfaction, and so on – than others.</p><p>When all of the error and survey data were compiled, I was at first</p><p>thrilled. Running the statistical analysis, I immediately saw that there</p><p>was a significant correlation between the independently collected</p><p>error rates and the measures of team effectiveness from my survey. But</p><p>then I looked closely and noticed something wrong. The direction</p><p>of the correlation was exactly the opposite of what I had predicted.</p><p>Better teams were apparently making more – not fewer – mistakes than</p><p>less strong teams. Worse, the correlation was statistically significant. I</p><p>briefly wondered how I could tell my dissertation chair the bad news.</p><p>This was a problem.</p><p>No, it was a puzzle.</p><p>Did better teams really make more mistakes? I thought about the</p><p>need for communication between doctors and nurses to produce safe,</p><p>error-free care. The need to ask for help, to double-check each other’s</p><p>work to make sure, in this complex and customized work environ-</p><p>ment, that patients received the best care. I knew that great care meant</p><p>that clinicians had to team up effectively. It just didn’t make sense that</p><p>good teamwork would lead to more errors. I wondered for a moment</p><p>whether better teams got overconfident over time and then became</p><p>sloppy. That might explain my perplexing result. But why else might</p><p>better teams have higher error rates?</p><p>And then came the eureka moment. What if the better teams had</p><p>a climate of openness that made it easier to report and discuss error?</p><p>The good teams, I suddenly thought, don’t make more mistakes; they</p><p>report more. But having this insight was a far cry from proving it.</p><p>I decided to hire a research assistant to go out and study these</p><p>patient care teams carefully, with no preconceptions. He didn’t know</p><p>which units had made more mistakes, or which ones scored better on</p><p>The Underpinning 11</p><p>the team survey. He didn’t even know my new hypothesis. In research</p><p>terms, he was “blind” to both the hypothesis and the previously col-</p><p>lected data.8</p><p>Here is what he found. Through quiet observation and</p><p>open-ended interviews about all aspects of the work environment,</p><p>he discovered that the teams varied wildly in whether people felt</p><p>able to talk about mistakes. And these differences were almost</p><p>perfectly correlated with the detected error rates. In short, people</p><p>in the better teams (as measured by my survey, but unbeknownst</p><p>to the research assistant) talked openly about the risks of errors,</p><p>often trying to find new ways to catch and prevent them. It would</p><p>take another couple of years before I labeled this climate difference</p><p>psychological safety. But the accidental finding set me off on a new</p><p>and fruitful research direction: to find out how interpersonal climate</p><p>might vary across groups in other workplaces, and whether it might</p><p>matter for learning and speaking up in other industries – not just in</p><p>healthcare.</p><p>Over the years, in studies in companies, hospitals, and even gov-</p><p>ernment agencies, my doctoral students and I have found that psy-</p><p>chological safety does indeed vary, and that it matters very much for</p><p>predicting both learning behavior and objective measures of perfor-</p><p>mance. Today, researchers like me have conducted dozens of studies</p><p>showing greater learning, performance, and even lower mortality as a</p><p>result of psychological safety. In Chapter 2, I will tell you about some</p><p>of the studies.</p><p>In that initial study over two decades ago, I learned that psycho-</p><p>logical safety varies across groups within hospitals. Since that time, I</p><p>have replicated this finding in many industry settings. The data are</p><p>consistent in this simple but interesting finding: psychological safety</p><p>seems to “live” at the level of the group. In other words, in the organi-</p><p>zation where you work, it’s likely that different groups have different</p><p>interpersonal experiences; in some, it may be easy to speak up and</p><p>bring your full self to work. In others, speaking up might be expe-</p><p>rienced as a last resort – as it did in some of the patient-care teams</p><p>I studied. That’s because psychological safety is very much shaped by</p><p>12 The Power of Psychological Safety</p><p>local leaders. As I will elaborate later in this book, subsequent research</p><p>has borne out my initial, accidental discovery.</p><p>Standing on Giants’ Shoulders</p><p>I might have stumbled into psychological safety by accident, but</p><p>understanding of its importance traces back to organizational change</p><p>research in the early 1960s. Massachusetts Institute of Technology</p><p>professors Edgar Schein and Warren Bennis wrote about the need</p><p>for psychological safety to help people cope with the uncertainty</p><p>and anxiety of organizational change in a 1965 book.9 Schein</p><p>later noted that psychological safety was vital for helping people</p><p>overcome the defensiveness and “learning anxiety” they face at work,</p><p>especially when something doesn’t go as they’d hoped or expected.10</p><p>Psychological safety, he argued, allows people to focus on achieving</p><p>shared goals rather than on self-protection.</p><p>Later seminal work by Boston University professor William Kahn</p><p>in 1990 showed how psychological safety fosters employee engage-</p><p>ment.11 Drawing from rich case studies of a summer camp and an</p><p>architecture firm, Kahn explored the conditions in which people</p><p>at work can engage and express themselves rather than disengage</p><p>or defend themselves. Meaningfulness and psychological safety both</p><p>mattered. But Kahn further noted that people are more likely to</p><p>believe they’ll be given the benefit of the doubt – a wonderful way</p><p>to think about psychological safety – when they experience trust and</p><p>respect at work.</p><p>Next, my dissertation introduced and tested the idea that psy-</p><p>chological safety was a group-level phenomenon.12 Building on the</p><p>unexpected insights into interpersonal climate from the hospital error</p><p>study, I studied 51 teams in a manufacturing company in the Mid-</p><p>west, measuring psychological safety on purpose this time. Published</p><p>in 1999 in a leading academic journal, this research – which later</p><p>influenced Google’s celebrated Project Aristotle, discussed in Chapter</p><p>2 – showed that psychological safety differed substantially across teams</p><p>The Underpinning 13</p><p>in the company and that it enabled both team learning behaviors and</p><p>team performance.13</p><p>A key insight from this work was that psychological safety is not a</p><p>personality difference but rather a feature of the workplace that lead-</p><p>ers can and must help create. More specifically, in every company</p><p>or organization I’ve since studied, even some with famously strong</p><p>corporate cultures, psychological safety has been found to differ sub-</p><p>stantially across groups. Nor was psychological safety the result of a</p><p>random or elusive group chemistry. What was clear was that leaders</p><p>in some groups had been able to effectively create the conditions for</p><p>psychological safety while other leaders had not. This is true whether</p><p>you’re looking across floors in a hospital, teams in a factory, branches</p><p>in a retail bank, or restaurants in a chain.</p><p>The results of my dissertation research bolstered my confidence</p><p>that all of us are subject to subtle interpersonal risks at work that</p><p>can be mitigated. Whether explicitly or implicitly, when</p><p>you’re at</p><p>work, you’re being evaluated. In a formal sense, someone higher up in</p><p>the hierarchy is probably tasked with assessing your performance. But</p><p>informally, peers and subordinates are sizing you up all the time. Our</p><p>image is perpetually at risk. At any moment, we might come across as</p><p>ignorant, incompetent, or intrusive, if we do such things as ask ques-</p><p>tions, admit mistakes, offer ideas, or criticize a plan. Unwillingness to</p><p>take these small, insubstantial risks can destroy value (and often does,</p><p>as you will see in Chapters 3 and 4). But they can also be overcome.</p><p>People at work do not need to be crippled by interpersonal fear. It is</p><p>possible to build environments, such as those showcased in Chapters</p><p>5 and 6, where people are more afraid of failing the customer than of</p><p>looking bad in front of their colleagues.</p><p>Why Fear Is Not an Effective Motivator</p><p>Fear may have once acted to motivate assembly line workers on the</p><p>factory floor or farm workers in the field – jobs that reward individ-</p><p>ual speed and accuracy in completing repetitive tasks. Most of us have</p><p>14 The Power of Psychological Safety</p><p>been exposed to, and internalized, the figure of a villainous boss who</p><p>rules by fear. Indeed, popular culture has exaggerated the stereotype</p><p>to become comical, as in the animated Pixar film Ratatouille, where</p><p>Remy the rat, the story’s cartoon hero, must first overcome the tyran-</p><p>nical restaurant chef who rules the kitchen if he is to realize his dream</p><p>of becoming a chef.</p><p>Worse, many managers – both consciously and not – still believe</p><p>in the power of fear to motivate. They assume that people who are</p><p>afraid (of management or of the consequences of underperforming)</p><p>will work hard to avoid unpleasant consequences, and good things</p><p>will happen. This might make sense if the work is straightforward and</p><p>the worker is unlikely to run into any problems or have any ideas for</p><p>improvement. But for jobs where learning or collaboration is required</p><p>for success, fear is not an effective motivator.</p><p>Brain science has amply demonstrated that fear inhibits learning</p><p>and cooperation. Early twentieth century behavioral scientist Ivan</p><p>Pavlov, who housed dozens of dogs in his laboratory, found their abil-</p><p>ity to learn behavioral tasks was inhibited after they’d been frightened</p><p>in the Leningrad flood of 1924. The lab workers who swam in to</p><p>rescue the animals reported that water had filled the cage, with only</p><p>the dogs’ noses visible above water.14 Since then, neuroscientists have</p><p>discovered that fear activates the amygdala, the section of the brain</p><p>that is responsible for detecting threats. If you’ve ever felt your heart</p><p>pound your palms sweat before making an important presentation,</p><p>that’s due to the automatic responses of your amygdala.</p><p>Fear inhibits learning. Research in neuroscience shows that fear</p><p>consumes physiologic resources, diverting them from parts of the</p><p>brain that manage working memory and process new information.</p><p>This impairs analytic thinking, creative insight, and problem solv-</p><p>ing.15 This is why it’s hard for people to do their best work when</p><p>they are afraid. As a result, how psychologically safe a person feels</p><p>strongly shapes the propensity to engage in learning behaviors, such as</p><p>information sharing, asking for help, or experimenting. It also affects</p><p>employee satisfaction. Hierarchy (or, more specifically, the fear it cre-</p><p>ates when not handled well) reduces psychological safety. Research</p><p>The Underpinning 15</p><p>shows that lower-status team members generally feel less safe than</p><p>higher-status members. Research also shows that we are constantly</p><p>assessing our relative status, monitoring how we stack up against oth-</p><p>ers, again mostly subconsciously. Further, those lower in the status</p><p>hierarchy experience stress in the presence of those with higher sta-</p><p>tus.16</p><p>Psychological safety describes a belief that neither the formal nor</p><p>informal consequences of interpersonal risks, like asking for help or</p><p>admitting a failure, will be punitive. In psychologically safe environ-</p><p>ments, people believe that if they make a mistake or ask for help, oth-</p><p>ers will not react badly. Instead, candor is both allowed and expected.</p><p>Psychological safety exists when people feel their workplace is an</p><p>environment where they can speak up, offer ideas, and ask ques-</p><p>tions without fear of being punished or embarrassed. Is this a place</p><p>where new ideas are welcomed and built upon? Or picked apart and</p><p>ridiculed? Will your colleagues embarrass or punish you for offering</p><p>a different point of view? Will they think less of you for admitting</p><p>you don’t understand something?</p><p>What Psychological Safety Is Not</p><p>As more and more consultants, managers, and other observers of</p><p>organizational life are talking about psychological safety, the risk of</p><p>misunderstanding what the concept is all about has intensified. Here</p><p>are some common misconceptions, along with clarifications.</p><p>Psychological Safety Is Not About Being Nice</p><p>Working in a psychologically safe environment does not mean that</p><p>people always agree with one another for the sake of being nice. It</p><p>also does not mean that people offer unequivocal praise or uncondi-</p><p>tional support for everything you have to say. In fact, you could say</p><p>it’s the opposite. Psychological safety is about candor, about making</p><p>16 The Power of Psychological Safety</p><p>it possible for productive disagreement and free exchange of ideas.</p><p>It goes without saying that these are vital to learning and innova-</p><p>tion. Conflict inevitably arises in any workplace. Psychological safety</p><p>enables people on different sides of a conflict to speak candidly about</p><p>what’s bothering them.</p><p>In many companies in which I’ve consulted or conducted</p><p>research, I’ll hear a variation of the following: “We have a problem</p><p>with ‘[Company Name] Nice’.” They go on to describe the</p><p>common experience of being “polite” to one another in meetings,</p><p>only to disagree later when people talk privately in the hallway,</p><p>along with a tendency to not actually implement that which was</p><p>discussed in the meeting. Nice, in short, is not synonymous with</p><p>psychologically safe. In a related vein, psychological safety does not</p><p>imply ease or comfort. In contrast, psychological safety is about</p><p>candor and willingness to engage in productive conflict so as to learn</p><p>from different points of view.</p><p>Psychological Safety Is Not a Personality Factor</p><p>Some have interpreted psychological safety as a synonym for extrover-</p><p>sion. They might have previously concluded that people don’t speak</p><p>up at work because they’re shy or lack confidence, or simply prefer to</p><p>keep to themselves. However, research shows that the experience of</p><p>psychological safety at work is not correlated with introversion and</p><p>extroversion.17 This is because psychological safety refers to the work</p><p>climate, and climate affects people with different personality traits in</p><p>roughly similar ways. In a psychologically safe climate, people will</p><p>offer ideas and voice their concerns regardless of whether they tend</p><p>toward introversion or extroversion.</p><p>Psychological Safety Is Not Just Another Word for Trust</p><p>Although trust and psychological safety have much in common,</p><p>they are not interchangeable concepts. A key difference is that</p><p>The Underpinning 17</p><p>psychological safety is experienced at a group level. People working</p><p>together tend to have similar perceptions of whether or not the</p><p>climate is psychologically safe. Trust, on the other hand, refers to</p><p>interactions between two individuals or parties; trust exists in the</p><p>mind of an individual and pertains to a specific target individual or</p><p>organization. For instance, you might trust one colleague but not</p><p>another. Or, to illustrate trust in an organization, you might trust a</p><p>particular company to uphold high standards.</p><p>Further, psychological safety describes a temporally immediate</p><p>experience. Whereas trust describes an expectation about whether</p><p>another person or organization can be counted on to do what it</p><p>promises to do in some future moment, the psychological experience</p><p>of safety pertains to expectations</p><p>about immediate interpersonal con-</p><p>sequences. For example, when Christina fails to ask a physician about</p><p>a medication she believes might be warranted, she is worried about</p><p>the immediate consequence of asking her question – the risk of being</p><p>berated or humiliated. Trust pertains instead to whether Christina</p><p>believes the doctor can and will do the right thing for patients. One</p><p>way to put this is that trust is about giving others the benefit of the</p><p>doubt, and psychological safety relates to whether others will give</p><p>you the benefit of the doubt when, for instance, you have asked for</p><p>help or admitted a mistake.</p><p>Psychological Safety Is Not About Lowering Performance Standards</p><p>Psychological safety is not an “anything goes” environment where</p><p>people are not expected to adhere to high standards or meet</p><p>deadlines. It is not about becoming “comfortable” at work. This is</p><p>particularly important to understand because many managers appre-</p><p>ciate the appeal of error-reporting, help-seeking, and other proactive</p><p>behavior to help their organizations learn. At the same time, they</p><p>implicitly equate psychological safety with relaxing performance</p><p>standards – that is, with an inability to, in their words, “hold people</p><p>accountable.” This conveys a misunderstanding of the nature of the</p><p>18 The Power of Psychological Safety</p><p>Low Standards High Standards</p><p>High Psychological Safety Comfort Zone Learning & High</p><p>Performance Zone</p><p>Low Psychological Safety Apathy Zone Anxiety Zone</p><p>Figure 1.1 How Psychological Safety Relates to</p><p>Performance Standards.18</p><p>phenomenon. Psychological safety enables candor and openness and,</p><p>as such, thrives in an environment of mutual respect. It means that</p><p>people believe they can – and must – be forthcoming at work. In</p><p>fact, psychological safety is conducive to setting ambitious goals and</p><p>working toward them together. Psychological safety sets the stage</p><p>for a more honest, more challenging, more collaborative, and thus</p><p>also more effective work environment. As Chapter 2 will explain,</p><p>researchers around the world have found that psychological safety</p><p>promotes high performance in a wide range of work environments</p><p>and industries. In short, as depicted in Figure 1.1, psychological</p><p>safety and performance standards are two separate, equally impor-</p><p>tant dimensions – both of which affect team and organizational</p><p>performance in a complex interdependent environment.</p><p>When both psychological safety and performance standards are</p><p>low (lower left), the workplace becomes a kind of “apathy zone.”</p><p>People show up at work, but their hearts and minds are elsewhere.</p><p>They choose self-protection over exertion every time. Discretionary</p><p>effort might be spent perusing social media or on making each other’s</p><p>lives miserable.</p><p>Next, in workplaces with high psychological safety but low per-</p><p>formance standards (upper left), people generally enjoy working with</p><p>one another; they are open and collegial but not challenged by the</p><p>work. Let’s call this the “comfort zone.” Today, fewer workplaces</p><p>around the world than ever fall into this quadrant, and it’s just as</p><p>well. When employees are comfortable being themselves but don’t</p><p>see a compelling reason to seek additional challenge, there won’t be</p><p>The Underpinning 19</p><p>much learning or innovation – nor will there be much engagement</p><p>or fulfillment.</p><p>But it’s not the comfort or apathy zones that worry me most.</p><p>What keeps me up at night is the lower right-hand quadrant. When</p><p>performance standards are high but psychological safety is low – a sit-</p><p>uation far too common in today’s workplace – employees are anxious</p><p>about speaking up, and both work quality and workplace safety suffer.</p><p>In Chapters 3 and 4, you will see many such workplaces. Managers in</p><p>these organizations have unfortunately confused setting high standards</p><p>with good management. High standards in a context where there is</p><p>uncertainty or interdependence (or both) combined with a lack of</p><p>psychological safety comprise a recipe for suboptimal performance.</p><p>And sometimes, as you will see in the chapters ahead, it’s a recipe for</p><p>disaster. I call this the “anxiety zone.” Here I’m not referring to anx-</p><p>iety about being able to accomplish a demanding goal or about the</p><p>competitive business environment but rather to interpersonal anxiety.</p><p>The experience of having a question or an idea but not feeling able</p><p>to share it can be deeply unsatisfying at work. And it is a serious risk</p><p>factor in any company facing volatility, uncertainty, complexity, and</p><p>ambiguity, or VUCA – the acronym introduced by the U.S. Army</p><p>War College and widely used in the business world today.19</p><p>Finally, when standards and psychological safety are both high</p><p>(upper right in Figure 1.1), I call this the learning zone. If the work is</p><p>uncertain, interdependent, or both, this is also the high-performance</p><p>zone. Here, people can collaborate, learn from each other, and get</p><p>complex, innovative work done. In a VUCA world, high perfor-</p><p>mance occurs when people are actively learning as they go.</p><p>Measuring Psychological Safety</p><p>Researchers and managers have useful tools at their disposal to mea-</p><p>sure psychological safety, and these are in the public domain. Sur-</p><p>veys are certainly the most popular of these, and Figure 1.2 presents</p><p>seven survey items, introduced in my dissertation and widely used in</p><p>20 The Power of Psychological Safety</p><p>1. If you make a mistake on this team, it is often held against you. (R)</p><p>2. Members of this team are able to bring up problems and tough issues.</p><p>3. People on this team sometimes reject others for being different. (R)</p><p>4. It is safe to take a risk on this team.</p><p>5. It is difficult to ask other members of this team for help. (R)</p><p>6. No one on this team would deliberately act in a way that undermines my efforts.</p><p>7. Working with members of this team, my unique skills and talents are valued and</p><p>utilized.</p><p>Figure 1.2 A Survey Measure of Psychological Safety.20</p><p>the research community ever since. I use a seven-point Likert scale</p><p>(from strongly agree to strongly disagree) to obtain responses, but a</p><p>five-point scale works as well. Note that three of the seven items</p><p>are expressed positively, such that agreement indicates greater psy-</p><p>chological safety, and three are expressed negatively (represented in</p><p>Figure 1.2 with an “R” for reverse), such that disagreement is consis-</p><p>tent with higher psychological safety. In analyzing the data, therefore,</p><p>it is important to “reverse score” data from the negatively worded</p><p>items, where a 1 in the data set is converted to a 7, a 7 to a 1, a 2 to</p><p>a 6, and so on.</p><p>Fortunately, the psychological safety measure has proven to be</p><p>robust despite variations in both the number and the wording of the</p><p>items used. By robust, I mean that the collected data demonstrate the</p><p>necessary statistical properties, such as inter-item reliability as mea-</p><p>sured by Chronbach’s alpha and predictive validity, as measured by</p><p>correlations with other variables of interest. The appendix at the back</p><p>of the book shows some of the survey item variations of which I am</p><p>aware. The measure has also been translated into numerous other lan-</p><p>guages, including German, Spanish, Russian, Japanese, Chinese, and</p><p>Korean, all of which have yielded robust research findings.</p><p>In purely qualitative case-study research, interview data can be</p><p>coded to detect the presence or absence of psychological safety.</p><p>The Underpinning 21</p><p>Several examples of research where this approach has been taken</p><p>are found in Chapter 2. Another fruitful approach is to provide</p><p>interviewees with hypothetical scenarios that fall into gray areas</p><p>at work and ask them what they or their colleagues might do in</p><p>that situation. When people trust that their answers will be kept</p><p>confidential, they will be quite open in reporting that they would</p><p>hold back unless they were extremely confident that what they want</p><p>to say will be well received. Well-designed vignettes, with questions</p><p>asking about how people would respond, can also be used to collect</p><p>data from a larger number of employees than individual</p><p>interviews</p><p>will allow. I will mention examples of both approaches in Chapter 2.</p><p>Psychological Safety Is Not Enough</p><p>I do not mean to imply that psychological safety is all you need for</p><p>high performance. Not even close. I like to say that psychological</p><p>safety takes off the brakes that keep people from achieving what’s</p><p>possible. But it’s not the fuel that powers the car. In any challenging</p><p>industry setting, leaders have two vital tasks. One, they must build</p><p>psychological safety to spur learning and avoid preventable failures;</p><p>two, they must set high standards and inspire and enable people to</p><p>reach them. Setting high standards remains a crucial management task.</p><p>So does sharing, sharpening, and continually emphasizing a worthy</p><p>purpose.</p><p>The key insight to take away from this chapter is that in most</p><p>workplaces today it’s simply not possible to ensure excellence by</p><p>inspecting proverbial widgets. In knowledge work, excellence cannot</p><p>be measured easily and simply along the way. More to the point,</p><p>it’s almost impossible to determine whether people have failed to</p><p>hit the highest possible standards. It takes time for the results of</p><p>uncertain programs to become clear, and reliably measuring good</p><p>process is difficult. In other words, today’s leaders must motivate</p><p>people to do their very best work by inspiring them, coaching them,</p><p>22 The Power of Psychological Safety</p><p>providing feedback, and making excellence a rewarding experience.</p><p>Motivating and coaching both receive substantial attention already.</p><p>What I hope you will take away from this chapter is that making</p><p>the environment safe for open communication about challenges,</p><p>concerns, and opportunities is one of the most important leadership</p><p>responsibilities in the twenty-first century.</p><p>Chapter 1 Takeaways</p><p>◾ People constantly manage interpersonal risk at work, con-</p><p>sciously and not, inhibiting the open sharing of ideas,</p><p>questions, and concerns.</p><p>◾ When people don’t speak up, the organization’s ability to inno-</p><p>vate and grow is threatened.</p><p>◾ Psychological safety describes a climate where people feel safe</p><p>enough to take interpersonal risks by speaking up and sharing</p><p>concerns, questions, or ideas.</p><p>◾ Leaders of teams, departments, branches, or other groups</p><p>within companies play an important role in shaping psycho-</p><p>logical safety.</p><p>Endnotes</p><p>1. Rozovsky, J. “The five keys to a successful Google team.” re:Work Blog.</p><p>November 17, 2015. https://rework.withgoogle.com/blog/five-keys-</p><p>to-a-successful-google-team/ Accessed June 13, 2018.</p><p>2. Goffman, E. The Presentation of Self in Everyday Life. Overlook Press,</p><p>1973. Print.</p><p>3. Edmondson, A.C. “Managing the risk of learning: Psychological safety</p><p>in work teams.” International Handbook of Organizational Teamwork and</p><p>Cooperative Working. Ed. M. West. London: Blackwell, 2003, 255–276.</p><p>4. Merchant, N. “Your Silence is Hurting Your Company.” Harvard</p><p>Business Review. September 7, 2011. https://hbr.org/2011/09/your-</p><p>silence-is-hurting-your-company Accessed June 13, 2018.</p><p>https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team</p><p>https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team</p><p>https://hbr.org/2011/09/your-silence-is-hurting-your-company</p><p>https://hbr.org/2011/09/your-silence-is-hurting-your-company</p><p>The Underpinning 23</p><p>5. Milliken, F.J., Morrison, E.W., & Hewlin, P.F. “An Exploratory Study of</p><p>Employee Silence: Issues that Employees Don’t Communicate Upward</p><p>and Why.” Journal of Management Studies 40.6 (2003): 1453–1476.</p><p>6. Edmondson, A.C. “Psychological Safety and Learning Behavior in</p><p>Work Teams.” Administrative Science Quarterly 44.2 (1999): 350–83.</p><p>7. Edmondson, A.C. “Learning from Mistakes Is Easier Said Than Done:</p><p>Group and Organizational Influences on the Detection and Correction</p><p>of Human Error.” The Journal of Applied Behavioral Science 32.1 (1996):</p><p>5–28.</p><p>8. The research assistant, Andy Molinsky, is now an accomplished scholar</p><p>and Professor of International Management and Organizational Behav-</p><p>ior at Brandeis University.</p><p>9. Schein, E.H. & Bennis, W.G. Personal and Organizational Change through</p><p>Group Methods: The Laboratory Approach. Wiley, 1965. Print.</p><p>10. Schein, E.H. “How Can Organizations Learn Faster? The Challenge</p><p>of Entering the Green Room.” Sloan Management Review 34.2 (1993):</p><p>85–92. Print.</p><p>11. Kahn, W.A. “Psychological Conditions of Personal Engagement and</p><p>Disengagement at Work.” Academy of Management Journal 33.4 (1990):</p><p>692–724.</p><p>12. Edmondson, A.C. “Learning from Mistakes Is Easier Said Than Done:</p><p>Group and Organizational Influences on the Detection and Correction</p><p>of Human Error.” The Journal of Applied Behavioral Science 32.1 (1996):</p><p>5–28.</p><p>13. Edmondson, A.C. (1999), op cit.</p><p>14. Todes, D.P. Ivan Pavlov: A Russian Life in Science. Oxford University</p><p>Press, 2014. Print.</p><p>15. Rock, D. “Managing with the Brain in Mind.” strategy+business.</p><p>August 27, 2009. https://www.strategy-business.com/article/09306?</p><p>gko=5df7f Accessed June 13, 2018.</p><p>16. Zink, C.F., Tong, Y., Chen, Q., Bassett, D.S., Stein, J.L., &</p><p>Meyer-Lindenberg, A. “Know Your Place: Neural Processing of Social</p><p>Hierarchy in Humans.” Neuron 58.2 (2008): 273–83.</p><p>17. Edmondson, A.C. & Mogelof, J.P. “Explaining Psychological Safety in</p><p>Innovation Teams: Organizational Culture, Team Dynamics, or Person-</p><p>ality?” Creativity and Innovation in Organizational Teams. Ed. L. Thomp-</p><p>son & H. Choi. Mahwah, NJ: Lawrence Erlbaum Associates Press, 2005:</p><p>109–36.</p><p>18. This is a modified version of the framework first published by Edmond-</p><p>son, A.C. “The Competitive Imperative of Learning.” Harvard Business</p><p>https://www.strategy-business.com/article/09306?gko=5df7f</p><p>https://www.strategy-business.com/article/09306?gko=5df7f</p><p>24 The Power of Psychological Safety</p><p>Review. July–August, 2008. Print. It was later published in Edmond-</p><p>son, A.C. Teaming: How Organizations Learn, Innovate, and Compete in</p><p>the Knowledge Economy. San Francisco: Jossey-Bass, 2012. Print.</p><p>19. Stiehm, J.H. & Townsend, N.W. The U.S. Army War College: Military</p><p>Education in a Democracy. Temple University Press, 2002. Print.</p><p>20. See Edmondson, A.C. “Psychological Safety and Learning Behavior in</p><p>Work Teams.” Administrative Science Quarterly 44.2 (1999): 350–83.</p><p>2</p><p>The Paper Trail</p><p>“Your greatest fear as a CEO is that people aren’t telling you the truth.”</p><p>—Mark Costa1</p><p>Mark Costa, CEO of Eastman Chemical Company, was speaking to a</p><p>classroom full of second-year MBA students at the Harvard Business</p><p>School in the late spring of 2018. The students were paying unusu-</p><p>ally close attention; there was something about his confidence, his</p><p>energy – and indeed his taking the time to share his insights with</p><p>them – that exuded “role model.” An alumnus of the school, Costa</p><p>had spent many years in strategy consulting before taking an exec-</p><p>utive role at Eastman – from which he was later promoted to run</p><p>the company. Now four years into his tenure as CEO, he clearly rel-</p><p>ished both the opportunity and the responsibility of leading the $10</p><p>billion-dollar global specialty chemical manufacturer headquartered</p><p>in Kingsport, Tennessee. Under Costa’s leadership, the portion of</p><p>sales accounted for by innovative specialty products rather than com-</p><p>modity products had steadily risen, consistent with a crucial strategic</p><p>25</p><p>26 The Power of Psychological Safety</p><p>goal he’d articulated for the company. Financial performance was</p><p>correspondingly strong. To accomplish this, engaging the expertise,</p><p>ideas, and market knowledge of Eastman’s 15 000 employees around</p><p>the world had been mission critical.</p><p>For the benefit of the students for whom diplomas and new jobs</p><p>were imminent, Costa reflected on what he had learned in the quarter</p><p>century since he’d graduated from business school. As the quote at the</p><p>opening of the chapter conveys, he stated – likely surprising many of</p><p>them – that his greatest fear as CEO was of not knowing what’s really</p><p>going on. He worked hard to make it clear to his employees that he</p><p>wanted the truth—good, bad, ugly, or disappointing. He explained to</p><p>the class that, as a leader,</p>