The role of psychological safety and learning behavior in the development of effective quality improvement teams in Ghana: an observational study

BACKGROUND: As lower-income countries look to develop a mature healthcare workforce and to improve quality and reduce costs, they are increasingly turning to quality improvement (QI), a widely-used strategy in higher-income countries. Although QI is an effective strategy for promoting evidence-based practices, QI interventions often fail to deliver desired results. This failure may reflect a problem with implementation. As the key implementing unit of QI, teams are critical for the success or failure of QI efforts. Thus, we used the model of work-team learning to identify factors related to the effectiveness of newly-formed hospital-based QI teams in Ghana. METHODS: This was a cross-sectional, observational study. We used structural equation modeling to estimate relationships between coaching-oriented team leadership, perceived support for teamwork, team psychological safety, team learning behavior, and QI implementation. We used an observer-rated measure of QI implementation, our outcome of interest. Team-level factors were measured using aggregated survey data from 490 QI team members, resulting in a sample size of 122 teams. We assessed model fit and tested significance of standardized parameters, including direct and indirect effects. RESULTS: Learning behavior mediated a positive relationship between psychological safety and QI implementation (β = 0.171, p = 0.001). Psychological safety mediated a positive relationship between team leadership and learning behavior (β = 0.384, p = 0.068). Perceived support for teamwork did not have a significant effect on psychological safety or learning behavior. CONCLUSIONS: Psychological safety and learning behavior are key for the success of newly formed QI teams working in lower-income countries. Organizational leaders and implementation facilitators should consider these leverage points as they work to establish an environment where QI and other team-based activities are supported and encouraged.