Aon’s Mark Riley-Pitt – Head of Healthcare Risk Consulting, and Lorraine Roberts-Rance – Director Healthcare Risk Consulting explain how developing a ‘just culture’ can help organisations and individuals learn from their mistakes, and reduce avoidable deaths and injuries in the health and social care sector.
It’s estimated that one million patients die in hospitals worldwide as a result of avoidable clinical harm. Analysis by Hogan, Darzi and Black found that 3.6% of hospital deaths in England have a 50% or greater probability of being avoidable. Of course, mistakes will always happen but what is important is when things go wrong in a health or social care setting, organisations learn from that experience and embed that knowledge through a learning culture to prevent similar incidents reoccurring.
Dealing with the Blame Game
Unfortunately healthcare systems around the world are not great at learning from incidents due to a range of factors not least because healthcare has become highly complex with complicated service delivery, while simultaneously fixating on identifying individuals responsible for causing harm. These high pressure circumstances don’t necessarily create the environment required for people to openly report mistakes and share their insight as to why the mistake was made. In turn, this leads to more problems because no one is given the opportunity to learn from someone else’s mistakes. Fortunately, over the past 20 years patient safety leaders have been promoting the required cultural shift where employees are encouraged to raise potential issues rather than hide problems.
Adopting a ‘just culture’ can play an important role here. In June 2018, a review into Gross Negligence Manslaughter in Healthcare defined a just culture as one that “considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution. In a just culture investigators principally attempt to understand why failings occurred and how the system led to sub-optimal behaviours.”
Values of a Just Culture
What a just culture means in practice is that employees must feel fully supported when reporting an incident with their organisation closely following four values: no employee intends to cause harm or be in an accident; an employee involved in an incident is also affected and should be supported appropriately; an individual is part of a much larger, complex system which inevitably leads to greater risk; and finally, management teams must be open and responsive to bad news.
To make a just culture work, there are steps an organisation can take, principally through the creation of safe spaces, a process of learning from incidents, and making sure that frontline staff are fully engaged.
Provide Safe Spaces
Admitting fallibility at work should not be seen as a weakness and the more managers and team leaders can be open about mistakes they have made or areas where they feel they are not at their best, the safer the space for other colleagues to do the same. Ideally, this message should come from the very top. It takes a strong chief executive to admit they have a gap in their knowledge, but acknowledging their own fallibility helps to create trust within their organisation’s systems and teams.
In a safe space environment, managers and team leaders asking direct questions around how a shift had gone, or on issues like safety and procedures, can help show that open discussion on risk and safety is encouraged.
Learn from Incidents
Rather than suspending an employee during the investigation of an incident, there is a powerful opportunity for a more compassionate approach where an active fact finding and listening approach to work out the contributory factors that led to an incident can have a much more positive impact on individuals and teams. In addition, holding structured sessions to explore risk can help to bring people together and make them less afraid of looking at a particular issue.
Frontline Engagement
Engaging frontline teams is also critical in creating the right culture given they have the expertise in their work processes and are key to creating effective safety mitigations. It’s important here to promote mutual responsibility and accountability between employees and the organisation, where everyone understands they have professional and personal accountability around how they work and the tasks they perform.
Strong and Committed Leadership
These steps are all important but success in developing a just culture ultimately depends on having a strong, committed leadership. The board of an organisation must live the values and principles of their business and know that every day their staff turn up without any intent of being involved in an incident of harm to a patient, service user or colleague. They must value transparency and communicate to employees that ‘we are here to hear bad news’ and that escalating an issue, risk, or concern is actually a good thing to allow an organisation to quickly address a potential problem.
Change Takes Time
Cultural change takes time but the prize is not only a reduction in thousands of avoidable deaths and injuries, but also a reduction in the spiralling financial cost to individual organisations and society in dealing with mistakes in health and social care.
If you would like to find out more about developing a just and learning culture within your organisation, contact Mark Riley-Pitt ([email protected]) or Lorraine Roberts-Rance ([email protected])
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This article has been compiled using information available to us up to 24.07.2023
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