A just culture has an important role to play in the management of patient safety incidents.
Organisations with a Just Culture:
”"A just and learning culture is the balance of fairness, justice and learning and taking responsibility for actions. It is not about blame but it is also not about an absence of responsibility and accountability."
'Being Fair', NHS Resolution, 2019
One common response to patient safety incidents within the NHS is to find the people who made the errors and to punish or re-train them. Although this might seem to solve the problem, this response does not actually help to make care safer for patients. This is because adverse events are rarely the fault of an individual, but instead the fault of groups of people working within a faulty system.
A large survey of healthcare professionals in America – the Agency of Healthcare Research and Quality Hospital survey on patient safety culture (2018) – found that over a quarter of respondents said that whenever pressure builds up, managers want staff to work faster, even if it means taking shortcuts. Half of the healthcare professionals surveyed said they work in crisis mode, trying to do too much, too quickly, and over a third reported that safety is sacrificed to get more done. This situation is all too familiar in the UK too.
This pressure to get more done in less time can lead to errors or workarounds, and some of these errors or workarounds may result in harm to a patient – an adverse event or even a death. If staff are being encouraged to work unsafely then we might ask whether it is unjust to punish them when things go wrong. Organisations with a Just Culture recognise this.
”"We need to recognise that when things go wrong, it’s not usually because people have made a deliberate mistake and therefore we actually need to support them … how can we make the right thing the easy thing to do?"
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.
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 (Harrison et al, 2014).
Having a just culture is about more than just responding 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’.
”"I think we need to be clearer about what we’re intending to do when we declare errors. That’s different from reporting a violation, where somebody’s deliberately done something wrong; but at the moment they’re almost treated in similar fashion."
There are things that organisations can do to demonstrate to their employees, patients and other stakeholders to show that they are committed to creating a Just Culture, but before setting this out it is important to say that creating a Just Culture is not a tick-box exercise. Fundamentally, the creation of a Just Culture is something that takes time, effort and is underpinned by important concepts – TRUST and FAIRNESS.
The behaviour of the board and managers at all levels throughout the organisation in responding to situations (not just those where things go wrong) needs to demonstrate that they can be trusted and that they will care for people and treat them fairly.
Leaders and managers have a vital role in creating caring and supportive cultures where dialogue can take place in an environment which is open and constructive. This approach does not avoid accountability but acknowledges that fallibility and imperfection are human conditions. We all make mistakes. Just cultures contribute towards positive learning climates for all staff to benefit and learn from these mistakes (Willis et al, 2019).
The Yorkshire Quality and Safety Research Group and the Yorkshire and Humber Improvement Academy are developing a Just Culture Assessment Framework to support organisations in measuring and improving their organisational culture.
The Just Culture Assessment Framework has been adapted from Dekker (2012), the NHS Patient Safety Incident Response Framework (2020) and other research evidence in this area, in particular the ‘Just Culture’ measure developed by Petschonek et al (2013). It includes the following dimensions of a Just Culture: feedback and communication; openness of communication; balance; quality of event reporting process; continuous learning and improvement and trust.
The prototype Framework is being piloted by members of the Yorkshire and Humber Improvement Academy’s ‘A Just Culture Network‘.
References
The King’s fund[West,M] (2016) Creating a workplace where NHS staff can flourish
A just culture guide – NHS Improvement
‘Being Fair’ – NHS Resolution, 2019
Dekker, S. (2012). Just culture: Balancing safety and accountability. Ashgate Publishing, Ltd
