A Just Culture has an important role to play in the management of patient safety incidents.
Organisations with a Just Culture:
- know incidents are rarely down to one individual
- have a fair process to decide culpability
- learn from incidents
- promote the well-being of their staff
”"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 accountability1."
Organisations with a Just Culture know incidents are rarely down to one individual
Healthcare staff aim to provide the absolute best care within extraordinarily complex healthcare systems, often in the presence of competing pressures. Keeping patients safe is a huge priority; but sometimes things will go wrong. One common response to patient safety incidents within healthcare is to identify the staff involved and to blame them. Such responses following a patient safety incident often result in blanket recommendations to retrain staff – yet retraining staff is unlikely to help make care safer for patients. This is because patient safety events are rarely the result of one individual making a mistake, but instead are result from multiple ‘failures’ within complex systems.
A large survey of healthcare professionals in America – the Agency of Healthcare Research and Quality Hospital survey on patient safety culture2 – 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. A recent report by the British Medical Association3 described how NHS healthcare services had been running ‘hot’ for a prolonged period even before the COVID-19 pandemic. Healthcare staff continue to be overstretched and feel pushed to do more as they continue to deal with the COVID–19 pandemic backlog, endeavour to restore routine care, and transform the way healthcare is delivered in line with the NHS England operational mandates to enable realisation of the Long Term Plan. In combination, these challenges may make it challenging to ensure the provision provide safe care to patients who need it.
This pressure to get more done in less time can lead to mistakes or workarounds, and some of these may result in harm to a patient. In the aftermath of a patient safety incident or failure, penalties (financial, reputational, professional, and disciplinary) must be avoided in almost all circumstances. Measures must be taken to prevent those involved in a patient safety incident being stigmatised (e.g. indiviudals being stigmatised as incompetent). For organisations to move towards a more Just Culture they need to recognise the consequences of being involved in a patient safety incident for healthcare staff and be ready to provide support for all involved, including patients, their family and staff.
Organisations with a Just Culture have a fair process to decide culpability
This NHS Just Culture guide4 supports conversations between healthcare managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely. It should only be used when there is a sense a member of staff requires such support. The guide has been developed to help reduce the role of unconscious bias when making decisions about culpability and will help ensure all individuals are consistently treated equally and fairly no matter what their staff group, profession or background.
The guide advocates 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 “A just culture guide – NHS Improvement” in the references 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 regarding them as an opportunity for learning how to continuously improve as opposed to a failure or crisis. Just Culture organisations emphasise the purpose of incident reporting being to learn; not to monitor quality and safety. Organisations which understand why a patient safety incident has occurred and learn the lessons from this, are the organisations where staff are more likely to recover following involving in a patient safety incident. A Just Culture prevents enduring or lasting consequences for staff and their employer; enabling learning to gain wisdom and action to improve patient safety.
Unfortunately, there is much work to be done to realise a more just and learning culture in healthcare organisations. 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 time5.
Organisations with a Just Culture promote the well-being of their staff
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 culture6.
More generally still, Michael West7 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’.
Just Culture Assessment Framework
There are things that healthcare 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 mistakes8.
About the Just Culture Assessment Framework
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 Dekker9 , the NHS Patient Safety Incident Response Framework10 and other research evidence in this area, in particular the ‘Just Culture’ measure developed by Petschonek et al11.
The Just Culture Assessment Framework: Domains and Standards
The interactive illustration above shows the four key domains within the Just Culture Assessment Framework (JCAF): Organisational commitment to a just culture; High quality investigations (with learning for safety as the goal); Critically reviewing, sharing and acting on recommendations; Fair and supportive treatment of staff, patients and families/carers. Linked to each domain are several standards (hover over the numbers to see a description of each standard) which organisations can assess themselves against and use to identify areas for improvement which if actioned would lead to improvements in organisational Just Culture.
The prototype Framework has been developed in co-production with members of the Yorkshire and Humber Improvement Academy’s ‘A Just Culture Network’ and members of the network are piloting it in their organisation. A word version of the framework is available, which includes all descriptors of all 21 standards along with examples of how they can be evidenced.
If you are interested in using the Framework and its linked resources (including a word version of the Framework) to measure and improve organisational Just Culture within your organisation, please contact Academy@yhia.nhs.uk.
- ‘Being Fair’ – NHS Resolution, 2019
- Agency of Healthcare Research and Quality(2018) Hospital survey on patient safety culture: 2018 User Database Report
- British Medical Association. (2021). Rest, recover, restore: Getting UK health services back on track. Accessed online on 28th October 2021 at https://www.bma.org.uk/media/3932/bma-getting-nhs-back-on-track-covid-report-march-2021.pdf
- A just culture guide – NHS Improvement
- 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.
- The King’s fund[West,M] (2016) Creating a workplace where NHS staff can flourish
- Willis D, Yarker J, Lewis R. (2019). Lessons for leadership and culture when doctors become second victims: a systematic literature review. BMJ Leader, 3, 81-91.
- Dekker, S. (2012). Just culture: Balancing safety and accountability. Ashgate Publishing, Ltd
- NHS England, NHS Improvement. (2020). Patient Safety Incident Response Framework. An introductory framework for implementation by nationally appointed early adopters.
- Petschonek, S., Burlison, J., Cross, C., Martin, K., Laver, J., Landis, R.S. and Hoffman, J.M. (2013). Development of the Just Culture Assessment Tool (JCAT): Measuring the perceptions of healthcare professionals in hospitals. Journal of patient safety, 9(4), p.190.