Why Just Culture Matters: A safer system for Quality Improvement

This is article six in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

Everybody knows the spine chilling, nauseating feeling when you realise you have made a mistake, irrespective of professional experience. The slow-motion moment where the clippers roll off the table and smash onto the floor because you were rushing and didn’t put them back properly, or the terrible realisation that you miscalculated the sedation you drew up and have just overdosed your patient. Head in your hands you count the cost, panic rising, knowing that you need to talk to someone, fess up and put it right whilst drowning in the fear that you will be in big trouble…... struck off, fired, or financially liable. 

Being able to freely admit to inadvertent error, without fear of punishment, ensures that incidents can be investigated, and the causes understood to guarantee that safety can be improved. Therefore, embracing a ‘just’ culture is essential in practice:

‘A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution’ (Williams, 2018 ¹)

Moving towards a just culture encourages us to ask, ‘what went wrong?’ rather than ‘who caused the problem?’ It is important to remember that what people do makes sense to them at the time and that the person involved in the incident who caused the harm is a victim too: the guilt, trauma and powerlessness that is felt if left to fester can be ruinous².

Hidden (1989) states that human action or decisions look more flawed and less sensible in the misleading light of hindsight³. However, significant event auditing tools can improve safety, by helping to understand the contributory factors that caused an event to occur and highlighting improvements that need to be made to practice systems, structures and local working conditions. 

Employing a just culture facilitates open and honest team debriefs after a challenging day or significant event occurrence. RCVS Knowledge (2020) have produced a practical veterinary relevant tool to help improve communication between shift teams, identify areas that need to be improved and highlight points that can be learned⁴.

A just culture also holds people appropriately to account where there is evidence of gross negligence or deliberate acts’, and occasionally it is necessary for managers to discuss whether a member of the team requires individual support or intervention to work safely. NHS Improvement has produced a framework to help to do this⁵.

Ensuring that a just culture is employed in practice means that if the clippers smash, the patient receives an overdose or, despite your best efforts, the worst thing you can imagine happens. You know that you can share the experience in a non-judgemental and supportive environment, without the fear of recrimination and will have the support of the team to work together to make suggestions for improvement.

You can take a deep breath, exhale all the awful feelings, and know that everything will be ok……. They have your back.

To fully understand the importance of just culture, please listen to the RCVS Knowledge podcast: QI, Safety Systems and Just Culture: the thought-provoking account of Anita Malana leaves the listener in no doubt as to how essential embracing just culture in practice is⁶.

Checklist: What you can do next?

• Make the most of RCVS Knowledge’s free Significant Event Audit course, Significant Event Audit template, and Root Cause Analysis tools (including the Contributory Factors Checklist template).
• To improve communication between shift teams, identify areas that need to be improved and highlight points that can be learned, start using the rolling-take-5 questions in your practice.
• Listen to Alice Bird talk through a Significant Event Audit in equine practice.
• Listen to Chief Executive Officer of the RCVS, Lizzie Lockett, talk about Improvement not disapproval: quality improvement in veterinary regulation.
• Listen to Margaret Mary Devaney and Anita Malana give their emotive presentation covering just culture in the NHS.

References

¹Williams, N, 2018, June 2018, Gross Negligence Manslaughter in Healthcare report available at www.gov.uk/government/groups/professor-sir-norman-williams-review. Accessed September 2020

²Ozeke, O, et. al 2019,  Second victims in health care: current perspectives, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697646/. Accessed December 2020

³ Hidden, A., 1989, Investigation into the Clapham Junction Railway Accident [Report]. - London: Her Majesty's Stationary Office, available at www.railwaysarchive.co.uk/docsummary.php?docID=36. Accessed September 2020

⁴RCVS Knowledge 2020, Rolling take 5, available at https://knowledge.rcvs.org.uk/document-library/rolling-take-5/. Accessed December 2020

⁵NHS, A just culture guide, available at https://improvement.nhs.uk/documents/2490/NHS_0932_JC_Poster_A3.pdf. Accessed December 2020

⁶RCVS Knowledge (2019), QI, Safety Systems and Just Culture [podcast], available at https://rcvsknowledge.podbean.com/e/margaret-mary-devaney-and-anita-malana-qi-safety-systems-and-just-culture-in-the-nhs/. Accessed December 2020

About the author

Helen Silver-MacMahon PGDip PS&CHF, Cert VNECC, Dip AVN(Surg), Cert SAN, RVN

Helen is an RCVS Knowledge Champion for her role in the sustained training and use of a surgical safety checklist within the small animal theatre at the former Animal Health Trust. 

In 2018, Helen began an MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh. The programme supports healthcare professionals in using evidence-based tools and techniques to improve the reliability and safety of healthcare systems. 

It includes how good teamwork influences patient outcomes, key concepts around learning from adverse events and teaching safety, understanding the speciality of clinical human factors, as well as the concept of implementing, observing and measuring change, monitoring for safety, and it focusses on quality improvement research and methodologies. 

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