Organisations with a ‘just’ culture have a fair process to decide culpability
Although incidents are rarely down to one individual’s behaviour, there are still instances where staff have behaved recklessly, or deliberately deviated from protocols that the majority of others adhere to. In this case, they should, of course, be held to account for their behaviour, but such instances are rare. NHS Improvement have produced a ‘just culture guide’ to help managers decide on culpability in patient safety incidents. They advocate questions probing five key areas:
Deliberate harm – was there any intention to cause harm?
Health – are there indications of substance abuse, physical ill health or mental ill health?
Foresight – did the individual depart from a routinely used protocol?
Substitution – did the individual behave as a peer might have done?
Mitigating circumstances – were there any significant mitigating circumstances?
For further information, see the reference below.
Organisations with a ‘just’ culture learn from incidents
There is evidence that where an unjust culture operates, staff respond by choosing not to report safety incidents for fear of retribution. In contrast, organisations with a ‘just’ culture respond to incidents by understanding them and learning the lessons, and these are the organisations where staff are least likely to suffer if they make a mistake. Sadly, this response remains far too rarely seen. We conducted a survey of over one thousand UK doctors, and they told us that reporting an adverse event resulted in local improvements less than a quarter of the time, and in systems changes less than a fifth of the time.
Organisations with a ‘just’ culture promote the well-being of their staff
Having a ‘just’ culture is about more than response to incidents. For example, when teams receive feedback about actions taken as a result of leadership walk-rounds, this can impact positively on staff wellbeing and safety culture (Sexton et al., 2017).
More generally still, Michael West (2016) argues that NHS leaders ‘should be promoting the idea that humans can flourish in the workplace, by ensuring that staff have opportunities for growth and development, the experience of supportive relationships at work, work environments that promote their physical health, and leaders who provide the resources that enable them to cope effectively with the demands of their work’.
Harrison, R., Lawton, R., & Stewart, K. (2014). Doctors’ experiences of adverse events in secondary care: the professional and personal impact. Clinical Medicine, 14(6), 585-590.
Sexton, J. B., Adair, K. C., Leonard, M. W., Frankel, T. C., Proulx, J., Watson, S. R., … & Frankel, A. S. (2017). Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf, bmjqs-2016.
Creating a workplace where NHS staff can flourish – The King’s fund
A just culture guide – NHS Improvement