Leveraging the power of a just culture to promote accountability and inform system improvement
Steven Bellemare, MD
Leaders must ensure that staff align their behavioural choices with the values that underpin their organization’s vision and mission. When adverse events occur, the just culture model emphasizes accountability by acknowledging that adverse events are typically the result of both system design flaws and the behavioural choices of the health care providers in the system. Leaders are accountable for the design of the system and for managing health care providers’ behavioural choices. Individuals are accountable for their own behavioural choices as well as for reporting both their own errors and system flaws.
KEY WORDS: values, patient safety, health care, just culture model, accountability, discipline, at-risk behaviour, human error, reckless behaviour, adverse events
A physician is verbally abusive to a nurse on the telephone. A resident delays attending a deteriorating patient on the ward. A surgeon operates on the wrong limb. Whatever the situation, adverse events in health care typically involve human beings who, through their behavioural choices, played a role in the genesis of the event. The effective management of such individual choices can play a key role in improving patient safety. Top
The amount of insight providers have into the impact of their behaviour on the safety of care is a key factor in their ability to improve their practice and deliver safe medical care. Much has been written on the topic of health professional insight and the results are worrisome: we are poor judges of our own performance and unskilled at identifying our learning needs.1-3 However, through the establishment of a just culture and the use of effective coaching, health leaders can play a crucial role in filling this insight gap. Holding health care providers accountable for their actions and providing an opportunity to help individuals identify areas where they can alter their behaviours can promote safe care.
Your values, your culture
Leaders expend considerable effort working with staff, patients, and other stakeholders to create vision and mission statements that establish purpose and guide operations. To operationalize a vision, leaders must interpret and deconstruct it into a set a values that staff can use as a compass to guide their decisions. Whether it be to provide cost effective care, to act in the patient’s best interests, or to maximize patient turnover, clearly articulated values serve as the foundation on which a workplace culture is built. One might define a unit’s culture as the extent to which health care providers, through their behavioural choices, will be protective of their unit’s shared values. It’s about what people do when no one is looking.
Establishing our values clearly is foundational to achieving reliable and safe care, but it is not sufficient. To manage a system that strives for safe care, we must understand drift and manage it.
Our training teaches us to follow time-tested methods, such as conducting proper clinical assessments that include both a history and a physical examination, considering a broad array of differential diagnoses, and adhering to established processes. In reality, however, over years of practice, we become increasingly comfortable with our tasks and we start to drift.4 As we develop expertise, we employ heuristics5-7 — cognitive shortcuts — and begin to bypass steps in processes to maximize our efficiency and accomplish our “mission.” Our assessments become more cursory, we limit our histories and physical examinations a bit too much, we don’t consider other possibilities as formally, and we don’t wash our hands as we should. Top
As we stray from expected behaviour and manage to tame our unwieldy task lists, all without apparent harm to patients, we become increasingly comfortable with our “new normal,” which deviates from best practices, yet, nevertheless, gets things done — seemingly safely. In other words, we become comfortable with an increasing risk of harm that we do not readily perceive. We lose sight of the fact that this new normal is, in fact, unsafe. Often, it takes an adverse event and the ensuing quality-of-care review to remind us that we have unwittingly strayed from safe practice into a riskier one.
Health care providers drift away from rules, policies, and their training as they gain comfort with the tasks they are performing.
Moving from theory to practice
With values firmly established and communicated and drift theory firmly in mind, leaders must then turn to tame drift by ensuring that staff align their behavioural choices with the values that underpin the institution’s vision. Leaders can achieve this directly, through their managerial decisions, or indirectly, via their influence on policy and through distributed leadership and alignment. Top
Without the benefit of clearly articulated values to guide our actions and frequent reminders to that effect, our daily mission often overshadows our ultimate purpose: to provide care without doing harm. The typical physician’s daily mission often boils down to getting through their day’s to-do list, which may include seeing a large number of inpatients and an equally large number of outpatients, as well as returning telephone calls, managing dozens if not hundreds of laboratory results, and communicating with elusive consultants, to name but a few tasks. This daily cognitive overload, combined with drift, creates a perfect storm of circumstances that increase a health care provider’s risk of making behavioural choices that do not align with safe medical care principles.
Dealing with adverse events through accountability
In creating accountability, leaders have two roles: foster learning and influence culture. First, to foster truly effective and healthy learning systems, leaders should seek to ensure psychological safety. Psychological safety is foundational to safe care. It empowers everyone to speak up, identify safety risks, and make suggestions to manage recognized vulnerabilities without fear of reprisal or ridicule.8-10 Top
Edmondson11 has written extensively on creating psychological safety. Easily implemented leadership behaviours, such as being inclusive and open to learning and suggestions as well as encouraging questions and curiosity, can promote psychological safety. In addition, inquiring specifically about the psychological safety of one’s team can have dramatic impacts on fostering the birth of highly competent teams.
Second, as architects of workplace culture and keepers of the learning system, leaders must, through their actions and influence, design and shape systems that allow for ongoing risk monitoring, identification, and management. Every patient safety incident and near miss can provide valuable insight into potential system improvements, but only if the events are reported and discussed without fear of reprisal.
When they occur, patient safety incidents can be dealt with in several ways. In the “name-blame-shame” model, we discipline and single out those involved in the incident and make them “examples” to improve the system overall. This approach breeds fear and may lead health care providers to cover up their mistakes, thus depriving the system of valuable learning opportunities and improvement. Top
An alternative approach, the “systems” model for addressing adverse events, was conceptualized to account for the multiplicity of factors that contribute to such events.12 In this model, the provider is viewed as but one element of a much more complex system that creates the conditions for an adverse event to occur. Although this method challenges our thinking about adverse events and their prevention, care must be taken not to minimize the individual provider’s role in the incident.
The just culture model seeks to emphasize accountability by striking a balance between these two approaches. In a just culture, we acknowledge that adverse events are typically the result of various combinations of system design flaws and the behavioural choices of the health care providers operating within the system.13 In a just culture, both the health care organization — and, by default, its leaders — and frontline providers are accountable. Leaders are accountable for the design of the system they operate and for managing health care providers’ behavioural choices. For their part, individuals are accountable for their own behavioural choices as well as for reporting system flaws, including their own errors, as they encounter them.
Implementing a just culture model promises to minimize health care providers’ fears of unfair reprisals by making expectations clear and ensuring that behavioural choices are managed transparently and fairly according to expectations, without bias based on the outcome of the event. Top
Three situations, three interventions
The just culture model recognizes three broad situations that can lead to adverse events: human error, at-risk behaviour, and reckless behaviour. It also dictates three distinct approaches to managing these situations.
Human error is, by definition, inadvertent and unavoidable. As such, the appropriate managerial intervention is to console the health care provider involved. Because its prevalence may be influenced by both system and personal factors, leaders dealing with human error should consider whether a contributing factor was at play and how it could be addressed so that similar errors can be avoided in the future. Top
At-risk behaviour is an unconscious choice to act in a given fashion, born out of a misguided perception of the risk involved. Behavioural drift is the unconscious process that usually gives rise to at-risk behaviours. For this reason, at-risk behaviour represents a significant threat to patient safety.
It also provides leaders with the strongest opportunity to effect change, through coaching. Coaching is a values-supportive positive conversation designed to help health care providers identify an unperceived risk or to recalibrate their perception of a known risk. Its goal is to help providers use the organization’s values as the guiding framework within which to ensure that their decision-making favours an expected behaviour over one that may at first glance seem easier, equivalent, or more efficient in helping them accomplish their daily mission. Top
The key to successfully managing at-risk behaviour does not lie in reminding people of the rules. Rather, it lies in improving health care providers’ choices by making them aware of the risk (if they did not see it) or by changing their perception of it (if they have misinterpreted it). In addition to coaching, as with human errors, due consideration should be paid to personal and system-based performance modifying factors — those factors that shape a person’s choices and that can be addressed and modified when identified.
Taking disciplinary action for at-risk behaviour does not serve the cause of establishing a just culture, as it may discourage disclosure of adverse events and near misses and greatly diminish opportunities to coach and reframe risk. That said, there are situations where the management of at-risk behaviour may require escalation to disciplinary action, typically when coaching has been ineffective or the behaviour is repetitive despite efforts at addressing personal and system performance modifying factors. Top
The third situation is reckless behaviour. Infrequent in occurrence, it involves intentional risk-taking and reckless disregard for a known, substantial, and unjustifiable risk. Because reckless behaviour is an intentional choice, the appropriate managerial intervention involves disciplinary action as a means of sending a clear message that such behaviour is not tolerated.
Disciplinary action should follow due processes of natural justice and can take many forms, as dictated by the circumstances. Formal meetings with high-level executives, letters of reprimand, remedial learning, undertakings to improve behaviour, suspensions, and termination of privileges are all potentially effective, escalating methods of addressing reckless behaviours.
No harm, no foul?
Not all at-risk or reckless behaviours lead to patient safety incidents or even to near misses. In fact, although data for health care are sparse, as in other industries, the large majority of such behaviours do not lead to harm.4 Nevertheless, each observed episode of at-risk or reckless behaviour should be managed according to the above principles. Top
A “no harm, no foul” attitude is a significant obstacle to the establishment of a culture of accountability. Outcome bias — the tendency to take action based on the severity of the outcome — may cause leaders to punish human errors that have had disastrous outcomes, such as death, and ignore reckless behaviours that have resulted in no observable harm. Such an internal lack of consistency will instill a sense of cynicism and disengagement among a unit’s staff and undermine leaders’ efforts to create accountability for everyone. Leaders’ strongest tools for conveying the message that they are serious about accountability are reliability and standardization of approaches when dealing with the three situations described above.
Promoting safe care
Caring providers take the outcomes of the patients they treat to heart. They do their best to manage workloads and numerous competing demands. As leaders, we can help health care providers develop insight into their actions by always providing feedback on how well these actions align with our values. A just culture approach helps to create a stable supportive workplace in which we can assess our work, improve on what we see, and create a system that minimizes the risk of harm. Top
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Steven Bellemare, MD, FRCPC, CPE, is senior physician advisor at the Canadian Medical Protective Association, Ottawa.
This article has been peer reviewed.
Editor’s note: Dr. Bellemare will be co-presenting a workshop entitled “Managing physician performance: the importance of natural justice” at the 2019 Canadian Conference on Physician Leadership.