Career & Success

Creating a Culture of Healthy Debate

Creating an environment of psychological safety yields benefits to organizations, teams, and leaders.

October 31, 2023

Does your company have a culture where people are truly free to speak their minds… without fear of retribution? At the start of the pandemic, Elikem Tamaklo, managing director for Nyaho Healthcare in Ghana, realized that the answer was no. Hear how he changed his company’s culture and his own behavior to lead his team through COVID-19 and beyond. Also, gain strategic insights from Sarah Soule, professor at Stanford Graduate School of Business, on the process and benefits of creating an environment of psychological safety in your organization.

Psychological safety wasn’t on Elikem Tamaklo’s mind when he joined his family’s private group medical practice. But in 2019 when the pandemic hit, uncertainty, fear, and challenging conversations were the norm. It didn’t take long to realize that if his team members weren’t willing to openly share what they were feeling and fearing, then decision-making would suffer.

Psychological safety, according to Sarah Soule, professor of organizational behavior, is a climate where people feel comfortable sharing their ideas and concerns and speaking up when needed. Most important, they must feel like they are not going to be judged or viewed negatively by the leaders when they do bring things up. Soule says the benefits to the organization are well-researched and impressive. “Morale is higher, burnout is lower, motivation is much, much higher. People are willing to participate in decision-making, and that leads to better decision-making. What we see is that team performance, creativity, and resilience increase, and we get higher levels of innovation,” Soule explains.

During COVID, everything was amplified, especially for those working in health care. The situation was made even worse when Tamaklo contracted the virus. He chose to publicize his diagnosis. “I said I would bear the risk personally. People acknowledged the bravery in sharing my COVID status and the narrative was more about people seeing that getting COVID is not your fault. So get tested,” he remembers. After much discussion, Nyaho became the first private organization to perform COVID testing.

Expressing vulnerability is one of the ways Soule says leaders can model the behavior they seek in others. She explains “The hardest thing that leaders have to do is to both model the kind of behavior that they want on the team and be sure when they invite the truth, it’s authentic and people believe it.” Soule also advises leaders and their frontline managers to speak less and last, engage in active listening, and construct norms for how teams interact.

Listen to Tamaklo’s personal and company journey toward psychological safety and the challenges and benefits they’ve experienced. And get practical advice from Soule on how leaders and teams can create an open culture where productivity and innovation thrive.

Grit & Growth is a podcast produced by Stanford Seed, an institute at Stanford Graduate School of Business which partners with entrepreneurs in emerging markets to build thriving enterprises that transform lives.

Hear these entrepreneurs’ stories of trial and triumph, and gain insights and guidance from Stanford University faculty and global business experts on how to transform today’s challenges into tomorrow’s opportunities.

Full Transcript

Elikem Tamaklo: There’s lots of uncertainty, and what was important was that we needed to create some space for people to slow down and get to a place where they could make decisions coherently.

Darius Teter: How do you build a team that tells you the truth and not just what they think you want to hear?

Elikem Tamaklo: Just creating that opportunity to talk, that was what psychological safety was. It was not in solving people’s problems, it was the understanding that all of us are going through this. So how do we create empathy and how do we slow down?

Darius Teter: Welcome to Grit & Growth from Stanford Seed, the podcast where Africa and South Asia’s intrepid entrepreneurs share their trials and triumphs with insights from Stanford faculty and global experts on how to tackle challenges and grow your business. I’m going to drop you into a difficult situation. So I joined Seed in late July, no, August 20, 2017, and two days after I joined, I flew to India for the opening of the India office, and I’m pretty sure that’s where I met you.

Elikem Tamaklo: Yes, that was where I met you.

Darius Teter: And we were standing outside. It was like 95 degrees Fahrenheit and we were sitting there in our suits going, good God, this is terrible.

Elikem Tamaklo: It was hotter than I expected.

Darius Teter: That’s not the difficult situation I was referring to, but it is today’s guest: Elikem Tamaklo.

Elikem Tamaklo: My name is Elikem Tamaklo. I’m the managing director for Nyaho Healthcare Limited, a health care provider in Ghana.

Darius Teter: Now, here’s a difficult situation. You might remember it.

Elikem Tamaklo: On March 12, there were two cases of COVID in the country. One of them was picked up by Nyaho, and the other was picked up in the public sector.

Darius Teter: Throughout the pandemic, Elikem and his team were faced with many hard decisions, often with life-or-death consequences.

Elikem Tamaklo: I mean, I had tough conversations with my executive team. There was a policy conversation about, should private sector be involved in COVID testing? There was a lot of fear. There was no guarantee that private sector will be recognized. The government did not ask us to do this, but clearly there was a big gap. The testing cycles were taking what should have been 48 hours, we’re taking two weeks, then four weeks, then six weeks just to test and confirm that someone was positive or not. We needed to make a decision: Were we going to engage or were we going to turn patients away and redirect them?

Darius Teter: Even small decisions carried huge importance.

Elikem Tamaklo: I had COVID quite early on, and so it was a tricky conversation that, how would I communicate this to the Ministry of Health? To different players? And in the end, we had a board meeting early in the morning. This conversation happened at a board meeting, and I said, I’ll do my personal communication on my personal social media channel, and then the company would have a different strategy. But then my executive team, we had a conversation where two members did not agree. They thought that it would impact the company. They thought that it would be detrimental. And we had a conversation.

Darius Teter: Oh, you mean because, well, look, the managing director can’t even keep himself safe. How is this company involved in COVID testing and screening?

Elikem Tamaklo: Or it would be used, it would be warped. The story would be warped and people would think I got it from the hospital, but I’d been working remotely in my home office the whole time. I had not stepped foot in the hospital. So there was a lot of dynamics around, how do we make that decision?

Darius Teter: Elikem’s decisions would have real impact. And I’ll let you know what he decided at the end of the episode. But before we get there, I want to focus on the underlying debate within his team. What was the conversation like for you as a leader with those frontline staff who are going to be wearing PPE [personal protective equipment] and putting themselves at risk every day? Did you have an environment established in your organization where people could say, Elikem, I disagree, or I’m scared and I don’t want to do this? Or explain to me why this is our problem? It’s a public health emergency. Did you have a culture in your organization where people could speak up and maybe disagree?

Elikem Tamaklo: Yeah, I mean, I think that I clearly remember actually one time going onto the lawn. We have a big lawn in our main airport site and a lot of staff were not happy. They weren’t sure, they were scared. And what we had to do was we had to engage. And that engagement was to acknowledge the emotions, acknowledge the fear, acknowledge that we did not have all the answers, but then also clarify what we stood for and try to connect people’s personal mission to the organization’s mission.

Darius Teter: The best decisions take into consideration many perspectives, and that’s one of the main benefits of even having a team. We talked about this with Professor Jesper Sorensen in our strategy masterclass. But think about your company. Would your employees have the courage to disagree with you? And would you even listen if they did? So how do you turn a room full of yes-men and yes-women into a team where people feel free to speak their minds?

Sarah Soule: I’m Sarah Soule, and I’m a professor of organizational behavior here at the Graduate School of Business.

Darius Teter: This is Professor Sarah Soule and she has an answer, one that’s proven.

Sarah Soule: So oftentimes we hear very, very bluntly a summary of a lot of research that says diversity of teams leads to better performance.

Darius Teter: I’m so sorry to cut you off before the punchline, but let’s define diversity in those studies.

Sarah Soule: Absolutely. Great. In those studies, they were trying to tap diversity of knowledge and experience. So in those studies, they were looking at different roles on teams.

Darius Teter: We need engineers in the room, we need the salespeople in the room, we need operations people in the room who are actually going to make the thing,

Sarah Soule: Right.

Darius Teter: We’re not talking about ethnicity, race, country of origin.

Sarah Soule: Correct. That particular study was about diversity of knowledge, but one of the things that we hear often again is just this idea: diversity leads to better team performance, better innovation, and so on. That may be true, but I think there’s a really important caveat, and that is that diversity of ideas, experiences, or even socio-demographic diversity can be linked to higher performance. But what these more recent studies are showing is that that’s only the case when there’s psychological safety.

Darius Teter: What is psychological safety?

Sarah Soule: Psychological safety is a climate on a team where people feel comfortable sharing their ideas, sharing their concerns, speaking up when needed, and, most importantly, I think, feel that they’re not going to be judged or viewed negatively by the leaders when they do bring up mistakes, for example, that they’re candid with one another and that this is done in a very respectful manner.

Darius Teter: What does the research tell us about employee morale, employee performance, and overall business outcomes that relate to the culture you’ve established within your workplace?

Sarah Soule: What psychological safety gets you in an organization is that morale is higher, burnout is lower, motivation is much, much higher. People are willing to participate in decision making, and that leads to better decision making. And one of my favorite popular studies on this — many people have read about it — was Google’s Project Aristotle. And what Google did some years ago was they decided they wanted to look across all of their teams and try to figure out what the secret sauce was for the higher performing teams. And they had a number of different metrics for what performance meant, and they studied all kinds of facets of these teams. And what they ended up finding out was the best predictor of high performing teams was psychological safety and, in particular, conversation turn-taking and candor of the teams.

Darius Teter: So when you explain it, it sounds obvious. Yeah, of course we would want that. But what are the barriers to people speaking their minds?

Sarah Soule: I think that’s also another great question, and I think, unfortunately, on so many teams, there is a feeling of fear, there’s a feeling of judgment, there’s a feeling of perhaps anxiety about being removed from the team if one makes mistakes. And so it really behooves the leader of the team to think about ways and be very intentional about ways to make sure people feel safe to speak up, to challenge, to be candid with one another, and to, most importantly, as part of this, to admit mistakes without fear of judgment.

Darius Teter: What is the hardest thing for a leader that they need to overcome in the pursuit of creating a team dynamic where truth telling can happen?

Sarah Soule: I think probably the hardest thing that leaders have to do is to both model the kind of behavior that they want on the team and be sure when they invite truth, it’s authentic and people believe it. And I think sometimes we say we want people to challenge us, but then our actions show that when they do challenge us, we have an outburst and tell them — we demean them in some way. So when we say that we want people to give us feedback to challenge us, we have to really mean it and demonstrate that.

Darius Teter: It sounds simple, but it’s not. A lot of leaders struggle with this, Elikem included.

Elikem Tamaklo: I would say that I didn’t handle it as well because, as you can imagine, I don’t have my full team. I haven’t taken leave working like that to deal with the operations while I was trying to clarify the strategy. And so I was also extremely stressed and my personal mental health was actually deteriorating. So I found that I was dealing with anxiety and that was really playing out in my conversation. So I would be very short, I would respond quickly, I would be defensive in my communication. And so those did not help as well in getting that approval. I reflect back and I wonder, could I have shortened the time? It’s not so much looking back to say, what would I have done differently, but more so how can I use those lessons and apply it?

Sarah Soule: So I think that’s very hard for leaders, and it’s partially hard for leaders because leaders got to be leaders because they’re really good at things and they’re often very good at decisions. And so I think sometimes it’s very hard to share the stage, if you will.

Darius Teter: So how do you create psychological safety, the kind that leads to healthy debate? Well, the first step is for leaders to shut up. So I’m a work in progress and one of my failings is that I tend to come into a meeting having done all the homework and with strong opinions, and I have a little note taped to my computer screen, because for two years we’re just doing everything on Zoom, and it says, “Don’t talk first.” What are some other attributes that leaders should be thinking about to encourage, particularly in uncertain times, complex, interdependent decisions to encourage the team to be willing to speak up?

Sarah Soule: These are great, and by the way, the first thing that you just said is one of the first things I always recommend: leaders speak last. I think that’s one of the most important things we can do, and I think part of the reason it’s so important is because of hierarchy on a team, natural hierarchy on a team, the leader, the highest ranking person. Of course, as soon as you say something, everybody’s going to fall in and nobody’s going to try to challenge that. But another, I think, is active listening. So oftentimes when we talk about communication and the importance of leaders to master communication, we spend a lot of time and maybe we over-index on the clear and compelling way that a leader needs to make their argument and provide information to people that they lead. But we miss that, just as important as clear communication of ideas, is listening, active listening, asking good questions to elicit conversation and listening to what people have to say. I think we don’t spend enough time doing that. We need to be training leaders on how to listen actively and empathetically, how to ask good, compelling questions, how to demonstrate curiosity so that they can get the kind of information that they need from the people on the team.

Darius Teter: Something that [GSB lecturer] Matt Abrahams said, and this was actually in reference to how to be good at small talk, but I think it’s actually really important for leaders who may be more extroverted — you talk the talk, you fake it till you make it. Leaders are used to telling stories, but sometimes the way Matt put it is: it’s more important to be interested than to be interesting.

Sarah Soule: I love that. I love that. And I think that does work in small talk and works in networking that we may do — business networking and so on. But I think it’s also really important for leaders to do that. If you want to encourage open communication, you’ve got to begin by asking questions and asking questions that people want to answer.

Darius Teter: Nyaho’ leaders weren’t always great at listening.

Elikem Tamaklo: We had a number of questionnaires getting feedback, and so the executive team, for example, scored low as a collective on kindness, and this is where the management, the middle managers, highlighted that, look, we don’t feel like you’re listening. We feel like you quickly are making decisions and you’re not hearing us.

Darius Teter: So during COVID, Elikem focused on making sure his staff were heard,

Elikem Tamaklo: There’s lots of uncertainty. And what was important was that we needed to create some space for people to slow down and get to a place where they could make decisions coherently. So psychological safety was just that process of helping people to take in the information to slow down and to be able to make a conscious decision. It was different in different scenarios. So for the person who was on the ward, we would have debrief sessions before and after a shift because processing what had happened, just creating that opportunity to talk, that was what psychological safety was. It was not in solving people’s problems, and it was also not about being paternalistic. It wasn’t about creating this “us versus them.” It was the understanding that all of us are going through this. So how do we create empathy and how do we slow down?

Darius Teter: It’s about giving people an opportunity to share what they’re feeling and what they’re fearing, giving people an opportunity to just talk and to be heard without judgment. But even if you create the space, speaking up still takes practice. So Sarah has some methods for promoting discussion.

Sarah Soule: One of the things that I have suggested to people, because I was once on a team that did this, was not only does the leader speak last, but there is a random start to the conversation. And what that does is make sure everybody comes to the conversation prepared because they may be picked first and you can kind of gamify it. The leader of the team that I was on bought a small little, handy Russian roulette wheel and would just spin it and then count the numbers around the table until somebody came up.

Darius Teter: Oh, my God, I love that. Because the other thing is that men tend to speak more than women.

Sarah Soule: Absolutely. The other that I often suggest to people is to have some kind of a template for people to submit their ideas, their questions, their concerns beforehand and possibly even anonymously, but to have them beforehand and to bring them into the room at the start of the meeting so that there’s something for people to react to. A third one, which is, I think, actually a lot of fun, is what’s known as the 1, 2, 4 brainstorm, and here’s how it works. You come in and say, “we’re going to brainstorm ideas,” and you pair people one and two and they brainstorm ideas and talk about their ideas, and then each pair is paired with another pair. So there’s the four, and then finally the groups of four share out for everybody or share out their ideas

Darius Teter: For everybody. Are they trying to funnel, or is this expansive or reductive?

Sarah Soule: It turns out being both, actually, because it starts out pretty expansive, and then people begin to combine ideas and maybe even build on some ideas, but they end up with more well-formed ideas, perhaps with more detail, because they are kind of combining. So it’s a pretty efficient way, and it also allows people who might be more introverted or less likely to speak up and start calling out ideas. It allows a safer space for them to do that.

Darius Teter: As your company gets bigger, you’ve got to think about consistency across the organization.

Elikem Tamaklo: So when we started to get more security, then the focus was that if you’re on a site, those smaller site meetings where you can be a bit more honest needed to start. So in 2021, we started to focus more on getting people to have site meetings and in 2022 town hall meetings, and in those town hall meetings, it wasn’t about me, it was about the site managers being the ones to share information and get feedback.

Darius Teter: This is so crucial. So you have your personal philosophy about creating psychological safety, being authentic, being honest. Presumably your executive team is modeling that behavior as well. But what you’re telling me is there’s the actual other, the next layer, which is the managers who are actually looking after the vast majority of your employees, and they were maybe not always on the same page.

Elikem Tamaklo: Definitely there was a competence gap with communication. So even though we were very clear that every team needed to meet on a weekly basis and on a site meet on a monthly basis, talk about what’s happening on the site that wasn’t happening. And sometimes it was because there was just a competence gap, and so we had to identify those. There was some really great examples of people who are going over and above what we even expected. So on one of our sites, they had focused on fun, creating an environment of fun, and they had had movie nights after work. They had, I mean, they’d done collaborative birthday celebrations. I mean, they’d done a number of things that had not been asked of. And so the question was, okay, we have some sites which are really exemplifying what we want to see, other sites which are not having meetings at all, and the question is then: How do people understand what’s going on? So then the focus was, how do we start to empower more peer-to-peer learning? That’s whereby the leadership team meetings started to shape up with having a group session and then breakout sessions and the breakout sessions using a bit more of that dialogue peer learning.

Darius Teter: Another way to promote that consistency and psychological safety across your organization is by establishing a strong, consistent culture. For what is culture but a set of expectations about how everyone in the organization should behave?

Sarah Soule: And one of the things that I think is key to understanding psychological safety is: psychological safety is not all happiness and people being nice to each other. I like to say it’s not all rainbows and unicorns. It’s really, really tough to foster psychological safety, because you as a leader, you need to make sure that there is a norm on the team of disagreeing and questioning and challenging ideas, but not the person. So making sure that it is clear that ideas are being questioned or suggestions are being questioned, but in a respectful manner and in a way that the individual is not being attacked.

Darius Teter: Which can happen through even body language, right?

Sarah Soule: Absolutely.

Darius Teter: Rolling your eyes means I think you’re an idiot, or crossing your arms,.Elikem learned the hard way what it’s like to debate without rules. You see, Nyaho was started by his father.

Elikem Tamaklo: So my father’s name is Colonel Dr. Kwami Tamaklo. Nyaho was his middle name. He changed it from Napoleon to Nyaho, which is an Ewe name, Ewe is a tribe, because he really believed in the fact that we as a people can find solutions for ourselves. So that’s where the name Nyaho Medical Center comes from.

Darius Teter: It’s a lot better than Napoleon Medical Center, that’s for sure. After Dr. Kwami’s death in 2001, Elikem’s mother, Janet Tamaklo, ran the business for 15 years. But when she wanted to retire, the family disagreed about the future of the business.

Elikem Tamaklo: It took a lot longer to align the stakeholders, and we had to then also take a step back and do our family governance work, and doing that for the first time, we as shareholders, because my father had been the first generation, he had the vision, he was the one who was the main sponsor. Now we were a family who had different opinions, and that is where the friction, even though the strategy to myself seemed clear, the adoption was difficult because we had not had the initial conversations as to what did we all want.

Darius Teter: ow did those debates … what did they look like?

Elikem Tamaklo: They looked like a stereotypical family having a heated discussion over lunch, because at that time we didn’t have that formalization of where the conversation is happening and what hats are we wearing at any given point. And so we had made some decisions like, all my family were on the board, my mother was still the chair. And that’s why the family governance conversations were important because it took time for us to then be emotionally ready to make the changes that we needed to make. Meaning that in the boardroom, is my mother talking to me as a mother — son or is it chairman — CEO, or is it brother and sister? And because we’re talking about quite emotive conversations, a deviation from what was previously known, and we’re talking about taking on more risk and what I’m coming in, I’m coming in with clarity that I’m coming in to transform. I’m coming in understanding that I want to impact beyond Ghana. It’s quite scary. And rightfully so. I underestimated the work I would need to do to help everyone see and go through this journey.

Darius Teter: Leaders need to show that it’s okay to make mistakes. They need to model vulnerability and fallibility. Elikem makes a point of being open and authentic.

Elikem Tamaklo: I also saw my role to model to people and to be extremely transparent. I first had to acknowledge I had my first panic attack. I talk a lot about mental health and wellness right now because I think that for any leader, self-awareness and self-management is key. But for me, I had to have a panic attack. And in terms of authenticity, where I had to model was my own personal story of what had happened in the past and what I was doing to manage myself in the midst of this pandemic because everyone was stressed. And so this stigma of talking about your mental health or talking about your emotions — Ghanaians don’t necessarily, as our culture, talk about what is going wrong. We tend to be very positive people. When someone says, how are you? Oh, I’m good, I’m fine.

Darius Teter: I’ve noticed that in Ghana,

Elikem Tamaklo: Yes, I think for me it was that sense that certain topics which are taboo, I can break it by talking about myself and we can create these conversations. So I spoke openly about my challenges dealing with anxiety, but I talked about how I had to prioritize exercise. Even though I was working long hours, I had to prioritize exercise. I had to prioritize sleeping even though I couldn’t sleep, I had to force myself to sleep at a decent hour. I had to focus on my diet. And when things got really bad and I had to see a clinical psychologist again to learn different tools, I had to talk openly. So we offered to our people a free clinical psychologist session or however many sessions they needed.

Darius Teter: This is during the pandemic?

Elikem Tamaklo: Yes, during the pandemic. And when we realized that actually people were not — I mean, only a few people took advantage of this offer. So it was then a question, okay, this is still a challenge. How do we make this more accessible? So de-stigmatize. Let’s just have a team conversation, but the clinical psychologist there being the facilitator. And so we started to look at some of these conversations.

Darius Teter: Of course, this type of leadership is complicated by a crisis like COVID. The example I keep thinking about is, and I believe it was Professor Brian Lowery in a previous interview that I did, sometimes in a crisis, a leader can’t necessarily be their authentic selves. They need to be the leader that the team needs in that moment. But there are other times when it’s really important as a leader to acknowledge that maybe you got it wrong or you’ve made the wrong bet. Help me understand how to navigate that.

Sarah Soule: In the early months of the global pandemic, we all needed to know that somebody was working on vaccines and working to understand the coronavirus and that we were going to be okay. That’s what we needed to hear because we were in a state of fear. And I think often in crisis kinds of situations, that’s what we need. We need a leader who is going to make us feel less afraid, and that’s very, very important. But I think in more day-to-day kinds of conversations with our team, sometimes admitting that we are vulnerable and that we have made mistakes can both model the behavior so others will feel comfortable doing that. But I think we often don’t do that, and we don’t do that because as leaders, we’ve often gotten to where we are because we haven’t made a lot of mistakes. And so it’s hard to admit mistakes and fallibility and to be a little vulnerable. But some research here at the Graduate School of Business by one of our colleagues, Zak Tormala, has shown that when we do demonstrate a little bit of vulnerability, people like us more. We become more relatable to people. He refers to this as relational humility. So any deficits that we might get in terms of people thinking of us as competent are more than made up for by the fact that they like us more and we’re more relatable to them.

Darius Teter: Healthy debate doesn’t preclude decisiveness. It just makes your decisions better.

Elikem Tamaklo: I signal to my team that I’m going to try and be facilitative as much as I can, but there are times I’m going to have the directive and I’m going to be the decision maker. In those topics, we definitely always try to look for consensus, and we most times got it, but at certain points when a decision needed to be made because time was running out, I did not hesitate to also make a decision.

Darius Teter: Speaking of decisions, that brings us back to the tough choices that Elikem was faced with, at the top of this episode.

Elikem Tamaklo: We found ourselves in the hot zone in the district that was closest to the airport that had a lot of travelers. We needed to make a decision: Were we going to engage? Or were we going to turn patients away and redirect them? And the decision was that we’ve always said we would meet people at the point in need. We are a health care organization, so if the health care issue is COVID, what we need to do is to get the competencies and prepare ourselves to deal with that. And so we became the first private organization to do COVID testing.

Darius Teter: Then there was the matter of whether Elikem should publicize his own COVID diagnosis in those highly charged fearful weeks of the early pandemic.

Elikem Tamaklo: We didn’t get consensus in that particular meeting, but I made that decision because it was my personal story, and I said, I will take the risk. I would bear the risk personally. So I did a video sharing my story, and that went viral. It got picked up by the different news channels, amplified, but it was a risk, and it just happened to be favorable. People acknowledged the bravery in sharing my COVID status. And the narrative was more about everyone not seeing it as a stigma, to getting COVID is not your fault, it’s happening, so get tested. So it became a public health message tool. The world has been going through a very difficult time with COVID-19, and in my capacity as the managing director of Nyaho Medical Center, we have been playing a part to ensure that Ghana’s response has always been strong and where private and public sector have had to work together. We are so proud that we’ve been doing our very best to work with all the different agencies and being able to actually test for COVID. A few days ago, I fell ill. As of yesterday when I got my results, it was found that I was positive from COVID-19, as well as my family.

Darius Teter: Psychological safety wasn’t just for leadership. It helped all of Nyaho get through the pandemic.

Elikem Tamaklo: We as a policy, especially during COVID, always said we would try and retain jobs, that that would be the last decision we would make. This was as a result of us being a COVID treatment center. A lot of people went to other facilities, but we also had to refer, it was easier to refer non-COVID cases out because you couldn’t refer COVID cases anywhere. And so in the middle of the COVID pandemic, we had a 70 percent drop in revenue. So we had to ask our people, and it goes to the fact that, did we have alignment? And we did have alignment when we asked our people that this is a situation for the next three months, we need to get to voluntary pay cuts. Would you be willing to reduce your pay? And we had more than 90 percent of our people doing some level of pay cut for three months. The executive team went down by 15 percent, managers by 10, staff by 5, but also because it was voluntary, people were able to say: As much as I want to, I can’t. And that’s really a testament of the fact that we did not pressure anyone to do that. But by doing that, it gave us a reprieve so that we could collect money, and we were able to exceed our expectations in that year. So we gave two bonuses, one bonus for actually exceeding our goals for the year, but then also a COVID-related bonus.

Darius Teter: And the culture that Elikem has developed will help Nyaho tackle the next challenges too. Five years from now, what’s your dream for Nyaho Medical Center?

Elikem Tamaklo: So we changed our vision to be Africa’s most trusted name in health care. That was one of the key changes. So I would say that in five years, I would want to have really transitioned out of the company and I’m able to influence in another African country. So I’m extremely passionate about this restructure because that will allow me to focus on our not-for-profit foundation. And that foundation is where the education of the next generation of doctors and nurses and clinical leaders is coming from. So the reversal of the brain drain is coming from there. And so it’s really about championing that and making sure that we can get people who are community focused, ethically minded, because it’s not me going to do the work. It’s really about other people who can really hold this and live their vision and their mission.

Darius Teter: Psychological safety is essential for teams facing adaptive challenges, ones for which there are no obvious answers. It allows them to have honest, productive discussions and innovate without fear. But to construct an environment of psychological safety, you have to be intentional. Leaders must create norms for how teams interact both structurally and interpersonally. They have to engage in active listening, which often means holding back or speaking last, and ensuring that quieter members have their chance to contribute. And leaders have to make an environment where it’s okay to fail by modeling vulnerability and acknowledging their own mistakes. Elikem employed all these tactics to create psychological safety at Nyaho. That culture allowed for healthy debate, which enabled Elikem to move more confidently. If you follow his lead, difficult conversations may not be so difficult anymore.

I’d like to thank Sarah Soule for her insights and Elikem Tamaklo for sharing his story. This has been Grit & Growth from the Stanford Graduate School of Business. I’m your host, Darius Teter. If you liked this episode, follow us and leave a review on your favorite podcast app. Erika Amoako-Agyei and VeAnne Virgin researched and developed content for this episode. Kendra Gladych is our production coordinator, and our executive producer is Tiffany Steeves, with writing and production from Andrew Ganem and sound design and mixing by Alex Bennett at Lower Street Media. Thanks for joining us. We’ll be back soon with another episode.

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