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.
The Patient Safety Incident Response Framework
The introductory NHS England and NHS Improvement Patient Safety Incident Response Framework describes a new approach to incident management, one which facilitates inquisitive examination of a wider range of patient safety incidents “in the spirit of reflection and learning” rather than as part of a “framework of accountability”. Informed by feedback and drawing on good practice from healthcare and other sectors, it supports a systematic, compassionate and proficient response to patient safety incidents; anchored in the principles of openness, fair accountability, learning and continuous improvement.
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).
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
NHS England and NHS Improvement Patient Safety Incident Response Framework