People make mistakes, we call it human error. In healthcare sometimes an error results in a patient being harmed.
When this happens what is the correct way to deal with it? Should the behaviour of staff be judged and blame apportioned? Which policies and procedures should be followed? Are policies clear and effective enough to help leaders and staff learn from such situations to prevent recurrence? Furthermore, are procedures in place to allow staff to speak up about safety issues without fear of retribution?
Ultimately, when a patient safety incident occurs, does it result in an improvement of the quality of healthcare?
What is just culture?
Just culture balances accountability between organisational systems and individuals, recognising the importance of looking at systems, not human behaviour. By doing so, processes can be redesigned to prevent the error from occurring in future. It is a culture which creates good habits in a safe and transparent environment where investigations seek to identify risk, not fault.
Just culture shifts the focus away from individual blame and instead looks at what went wrong to prevent it happening again. Sometimes people are at fault, but other times it is the system which results in an error.
Even in situations where care was not delivered as well as hoped, staff should feel supported in openly disclosing details of an issue in the knowledge they will be treated fairly. Healthcare professionals involved in a serious patient safety incident experience a profound psychological impact, even in cases where the cause is a system which has been badly designed. An investigation which then punishes behaviour instead of attempting to understand what went wrong and how it can be prevented in future, compounds this impact.
Our healthcare management consultancy work often requires us to investigate an incident involving patient safety where organisational culture issues have played a significant part. So the principles of a just culture should be an area of focus for healthcare organisations to significantly improve patient safety in future. Hospitals which demonstrate a culture of safety and which do not focus on blame and shame have been reported to be associated with enhanced patient safety.
The challenges of adopting a just culture
Changes in organisational culture require a shift from a blame culture to a learning culture. In order to improve and learn from errors, issues which affect patient safety need to be constantly reported. This requires staff to feel confident that they will be treated fairly when reporting a safety issue, instead of fearing blame.
When something goes wrong there is a tendency to judge behaviour harshly instead of looking at the organisational processes which may have been the cause. But learning depends on everyone telling the truth so it is essential that staff are encouraged to report concerns and are not reluctant to engage with investigations.
As well as organisational culture, the approach to the way investigations are conducted also needs attention. When carrying out a patient safety investigation, staff will feel more comfortable to report errors if the investigator asks the question “why did something go wrong?” rather than “Who is to blame?” After all, if a member of staff sees something which threatens patient safety but doesn’t feel comfortable reporting it, it becomes a missed opportunity to learn and improve.
How is gross negligence dealt with in a just culture?
In a just culture inadvertent human error does not normally result in punishment to encourage reporting of safety issues. However, a just culture doesn’t remove the need to deal with an individual who has committed gross negligence or knowingly caused an error leading to harm of a patient.
In June 2018, the Professor Sir Norman Williams’s Review into Gross Negligence Manslaughter in Healthcare report stated that;
A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution…however a just culture also holds people appropriately to account where there is evidence of gross negligence or deliberate acts.
Does a just culture change patient safety investigations?
In a just culture, patient safety investigations, blame, or the management of individual staff should be excluded so that the investigation enhances the opportunities for system learning and improvement. Investigations should be focussed on how the system led to flawed behaviour and what action should be taken to improve it.
It is also important for investigators and clinicians to carry out separate, specialised roles. This speeds up investigations as clinicians are not tied up with investigative duties. This also removes bias arising from the working relationships clinicians have with staff involved in an incident.
Just Culture in the NHS
The NHS staff survey 2017 highlighted action which helped promote a culture of safety, demonstrating the importance of just culture in supporting staff to be open about mistakes so that valuable lessons could be learnt. The survey noted instances where the NHS supported a culture of fairness, openness and learning so the same errors could be prevented from being repeated.
As the policies and procedures which govern how trusts respond to incidents is fairly similar, the personal behaviour of leaders in those situations is crucial. The basic culture they create is what makes the difference because a just culture affects all aspects of an organisation, from relatively minor everyday issues through to serious incidents.
Just culture creates continuity in how NHS staff are treated by managers when a patient safety incident occurs. This ensures staff do not feel as if they have been treated unfairly compared with someone else in a similar situation, and also provides clarity to managers when dealing with an incident.
Respondents were aware of the importance of patient safety investigation training, but that the personalities of those conducting the review plays a significant role in reducing staff anxiety. The type of language used, such as ‘getting views’ instead of ‘questioning’ and communicating in a non-threatening, non-personal way by asking “how?” instead of “who?” helps an investigation to be conducted fairly as well as provide practical actions. To bring about improvements in patient safety, it is necessary for investigators to look at how to design out the error, rather than simply stating an incident was as a result of human error.
How can a healthcare organisation implement a just culture?
As with many areas involving patient safety, implementing a just culture requires action at a number of levels. Perhaps most importantly, the barriers which stand in the way of just culture need to be removed. For examples, incident management processes and policies which focus on punishment for errors being made will not lead to a just culture and prevents learning from incidents.
It can take time to develop trust between managers and employees. The behaviour of leaders is crucial and a genuine commitment to fairness needs to be shown and sustained for the changes to become embedded in the organisational culture. Leadership must be fully engaged and show a commitment to implementing and sustaining a just culture by being visible and approachable. Leaders should be proactive in providing resources and offering support where needed. In order for staff to be on board with cultural change, leadership needs to walk the talk and take responsibility for mistakes to encourage staff to do the same.
Education and awareness
Education at all staff levels on the principles of a just culture is important in the initial stages of implementation but also ongoing to enhance competency and confidence. This could take the form of training on the concepts of a just culture and how to investigate, report and respond to errors in a supportive and constructive way.
Principles of a just culture should be included within policies and codes of conduct, outlining the organisation’s commitment to a just culture and how errors will be handled. It can also be beneficial to encourage staff to think critically about behaviour in terms of inadvertent human error, failing to recognise risk, or that which disregards safety policies.
Leaders are responsible to create a culture of accountability where organisations are responsible for systems and individuals responsible for behaviour. They should provide clear direction and expectation for how work should be accomplished and that staff will be treated fairly when mistakes are made unless they knowingly fail to follow safety procedures or policies. Just culture doesn’t prevent individuals from being supported where necessary to ensure they work safely.
Organisations should communicate regularly about just culture to keep healthcare professionals informed and engaged. Staff should have the opportunity to provide feedback on the organisation’s just culture initiatives, such as in employee forums where it is allowed to ask questions of leadership. Open communication can be encouraged through joint reflection and listening and approaching situations without preconceptions.
Communication includes avoiding blame when things go wrong, and instead focusing on identifying and resolving organisational issues which may have been the cause.
Implementing a just culture is to improve patient safety and support staff. A contributing factor to staff feeling well supported is a full-time patient safety incident investigation team which is present at some trusts, however, not all have this resource. If you need help in this area Verita provides patient safety investigation training course which provides an understanding of the investigative process and how to apply it in situations relevant to their care setting.
What are the benefits of a just culture?
In addition to the improvements in patient safety and staff experiences, just culture can also result in a decrease in the number of disciplinary investigations and suspensions. In line with this, it increases the reporting of patient safety incidents, providing more data for the organisation to learn and improve. Additionally, improving the standard of care presents economic benefits making a business case for its adoption.
How a just culture Supports staff and families
Supporting patients and staff affected by incidents makes the experience better for everyone. Staff should feel confident that they will be presumed innocent until proven guilty but at the same time need to acknowledge if they can’t perform safely even with all possible support having been given.
It is important to actively seek views from families, as well as considering giving families and staff the chance to talk to each other.
Families would benefit from understanding how the Just culture guide works. Often families call for accountability and think they are asking ‘who’ is responsible, but my experience is they really want to know ‘what happened and why’. This would help them on their journey after the avoidable death of a loved one.
– Joanne Hughes, NHS Improvement patient and public representative and founder of mothers instinct.
How Verita can help
EVA is an application which is easy to integrate with existing patient safety processes and allows a large number of reports to be viewed in one place so that themes can be detected and acted upon. The application consolidates data making it easier to see trends, where issues need to be address and where improvements need to be made.
Learning from mistakes is essential for an organisation to improve and Verita provides impartial and independent investigations advising on how systems can be improved and what learning can take place to prevent recurrence. This helps to identify areas for improvement within an organisation so that a just culture can be implemented.
If you would like to learn more about just culture and how it impacts patient safety within your healthcare organisation please book a free consultation or contact Ed Marsden on 020 7494 5670 or [email protected].