NHS Improvement has published a “just culture” guide to help NHS trusts make decisions following an incident of patient harm.
The tool, which should be used alongside investigations, replaces the “incident decision tree” developed by the former National Patient Safety Agency.
The guide is designed to help managers investigating a patient safety incident to discuss a member staff’s actions and consider whether there are wider issues that contributed to the harm.
The tool is aimed at identifying where staff need support and interventions to help them work more safely in future. It prompts managers to consider questions about whether the employee’s actions were deliberate, whether they have health issues and whether there were protocols in place or training that was missed.
The guide is a significant signal from NHSI about the need to consider a “just culture” approach to incidents of harm.
There is concern that existing models of investigation and root cause analysis are too focused on individual actions and miss systemic factors contributing to mistakes. This was one reason for the establishment of new Healthcare Safety Investigation Branch last year.
Alongside the guide, NHSI has published example scenarios of incidents and how they should be approached and managed.
NHSI said “singling out” individuals was “unfair and counterproductive” where there was evidence of wider issues underlying incidents.
NHSI hopes the guide will help reduce “unconscious bias when making decisions”, which could help to decrease “disproportionate disciplinary action against black and minority ethnic staff”.
It added: “Our guide can be used at any stage of a patient safety investigation – it does not replace the need for a patient safety investigation and it should not be used routinely. It should only be used when there is already some suspicion that a member of staff requires some management to work safely.
“This is our best current understanding on how to apply the principles of a just culture in practice, and that this is a live area of both academic and practical debate. We will revisit and update this guide as necessary as our understanding develops…
“The fair treatment of staff supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame.”