Date published: 1 August 2022
Of all the decisions we’ve made as a Trust over the last few years, the introduction of Restorative Just and Learning Culture (RJ&LC) perhaps stands as one of our most radical, but one that gains greater momentum as each year passes. I’m going to use this blog to take stock and remind you of what it’s all about and why we did it.
I don’t think any of us appreciated at the time the simple power of the “Be Kind” message we started to use three or four years ago. As we changed work practices to deal with the challenges of the pandemic, those two simple words really gained resonance.
For Mersey Care, the kindness message was just a part of our work on RJ&LC, albeit important with its own workstream and practical outputs. Our progress with it has had impacts in other unexpected places in the last few years.
It’s highlighted the challenges of running a large complex organisation which supports people who have complex needs and employs a widely distributed workforce with many of their own traditions and microcultures. We’ve learned so much during our journey that we've recently published a book about it, ‘Restorative Just and Learning Culture in Practice.’
For those new to the terminology, let me give you the basics. What the academic Professor Sidney Dekker called “Just Culture” is now a hot topic in many organisations. Simply put, when something happens in an organisation that’s unexpected, difficult or, as we used to say ‘goes wrong’, we now ask in new ways about who was affected. We ask what their needs are and determine whose obligation it is to meet them.
Compare this with disciplining someone when something ‘went wrong’. Clearly, even a suspension is not seen or regarded by all as the neutral act it’s intended to be.
The aim is to create a sustainable just, restorative culture. Interest in this area is often quoted as originating in the aviation industry, especially following exceptionally serious incidents like plane crashes, but safety critical practice is much wider.
Older models of practice, with those demands for a more retributive approach, are a blunt instrument, an expression of power over justice and hinder the acceleration of any learning or improvement.
When I looked at some of the issues affecting us back in 2014 to 2015, I saw our own Trust systems stifling honesty, reporting and learning. I saw people being damaged by the system as our processes at the time just didn’t deliver either answers or, importantly, compassion.
For those who haven't seen it, I'd recommend the difficult but essential film below which Professor Dekker made about us at the time.
It hurts but we were really galvanised to act. What evolved from this took us into areas we were aware of but not embracing, like true psychological safety, but also informed how we act and behave.
This needed support from the Executive Board, from staff side, managers and everyone within the Trust and while we can point to real change and data to support that, the experience for some is still not as we’d want it. We all have a part to play.
Leading this, often with challenge from outside, has been something new for me and for all our Trust leaders. The lessons I’ve learned are fuelled by conversations with patients, service users, relatives and staff about their experiences with Mersey Care when something went wrong in the delivery of healthcare. These were hard conversations in themselves, with raw emotion and damaged people to answer to, but they were essential.
Like many, I’ve also been on the receiving end of healthcare - as a son, husband, father and friend. More than once, I’ve experienced sitting on my sofa at home talking about the loss of a loved one, knowing and experiencing the first hand devastation of that loss. Once, during my time as Chief Executive there was a moment when I found myself sitting on another sofa, this time with a distraught mother, talking to her and apologising for the family devastation caused by the death by suicide of one of her children while they were in our care.
That parent made the most reasonable of requests - ‘surely there must be something to learn from all of this?’ That question triggered a desire within me to understand how to answer it as the accountable officer for Mersey Care. This, in turn, resulted in a leadership tipping point for all the Trust’s Board of Directors.
The way our systems responded to incidents was clearly biased. It meant that full reflection and transparency inhibited true learning. They didn’t help in preventing similar future occurrences. They didn’t take any account of individual team nor organisational reflections.
We now know these lead to really valuable learning incidents and help us reduce the chances of it happening again. The safety culture we had was based on what the wider regulatory system expected – not the people in it, but the system itself and its outdated processes. Central to our thinking was the need to find mechanisms that not only altered our policies and behaviours but also shifted our mindset to a place of better care.
We asked staff, we engaged with our union partners, and we’ve had brilliant support from ambassadors – people of all bands, backgrounds, disciplines and geography – to keep ourselves grounded.
For us though, kindness is much more than a ‘good to have’ or even recognition of our work in tough times. The advantages, to patients and service users, of a system freed of negativity and operating in psychological safety, are profound, and each step we all take towards this marks the reshaping of a system towards being truly holistic. We treat the whole person, caring for anyone affected by distress, a complex need or presentation, and we therefore change the whole system.
When I’m asked about the impact of our restorative just culture, I sometimes leap too quickly to quote the statistics, the savings for reinvestment in learning or the improvements in reporting serious incidents because that’s such a feature of the CEO and NHS world.
But really, I know the personal value is the need to live this stuff, to role model it and to not be afraid of the awkward and hard to hear news. After all, if you don’t know about issues, how can you improve them?
Prof Joe Rafferty CBE
(He, his, him)