Fostering a “Just Culture”
By Amy Shaw, Clinical Leader, Specialist Learning Disability Division
As many of you are probably aware, Mersey Care held their Centre for Perfect Care Conference at Aintree Racecourse on 21 December 2016, which was well attended by many of you. Service user clinical issues prevented me from experiencing the day, including the valued discussions that would have enabled me to go away thinking further about how I adopt a ‘Just Culture’ as a clinical leader within the Specialist Learning Disability Division. Thankfully, colleagues of mine attended and fed back the information, which I believe is vitally important to share if we are to work towards a shared vision of fostering a ‘Just Culture.’
Two weeks later I was fortunate to spend a morning with Mersey Care’s Chief Executive, Joe Rafferty, who was engaging in the ‘Jobs for Joe’ initiative. During his time with us, Joe and the multi-disciplinary team engaged in wider discussion about what a just culture might look like and recognise how we were promoting the cultural shift encouraged by the government to ensure the NHS is the safest and most transparent health care system in the world. In other words, we are talking about a cultural shift, a change from a culture that’s been highlighted in many NHS reports as using an approach to deal with system errors punitively. It is one that has prevented learning, listening, openness, honesty, excellence in care and ultimate patient safety.
Many of you reading this have probably worked within the NHS, or maybe other organisations that have dealt with risk for some time and would probably relate to a culture where punitive influences have prevented them doing the right thing. For most people their biggest fears are the consequences of making a departure from standards or professional codes of conduct, so not doing the right thing may be the only option.
This echoes the need for NHS organisations to continuously develop systems that recognise and deal with people in a Just way, acknowledging through learning to support the changes required when people make errors. Sometimes those errors can be human, others through behavioural choices and some through system error. Ultimately, we all have a joint responsibility to learn from errors that lead to accidents and morbidity, even possibly mortality and this should not happen in a world class health service.
That said, it should not be ignored that some errors can be made through recklessness, and where a departure is made in practice from high standards causing harm to those we are “accountable to and responsible for,” the response should be fair. It should consider an equal balance of support, but also weighty depending on the circumstance, which is a fundamental dimension of adopting the just culture.
This doesn’t mean people will only face consequences for serious incidents and everything else will be blamed on systems, but by learning from these processes as they happen, we improve our understanding as an organisation on how systems impact on the care we deliver and how we deliver it. This culture does not rely on the theory of find the people responsible and punish them by blaming them, this culture is derived on supporting people and systems to change, by asking the question: ‘what was responsible?’ rather than ‘who was responsible. This encourages people to become open and transparent in order to improve patient safety, and foster the Just Culture that puts an equal emphasis on accountability and learning.
The main thing I will take from the discussion is that if we are to improve patient safety and aim to achieve a world class health service, we all have a role to play in fostering this culture at every single level because, we are all held responsible for the quality of our own choices. Leadership, in particular, is key but we should remember that you can be in any role to be a leader, not someone who is merely in a management position. We should encourage each other to see errors as events and those events as opportunities to learn, which in turn will improve understanding while encouraging one another to be honest in disclosure without fear of retribution in an every changing learning and supportive organisation.