Establish the principles of a just culture for staff

One of the most frequently quoted remarks in relation to the NHS’s need for improvement is Don Berwick’s famous “every system is perfectly designed to get the results it gets”.

The more I consider the systems and processes, never mind the mental models we use around patient safety, harm reduction and the associated need for candour, transparency and openness, the more it seems we may be destined to travel in ever decreasing circles. 

The process we use to extract learning from when things go wrong uses language that is punitive and undermines its purpose. When we invoke investigations, they feature disciplinary hearings, warnings and appeals, etc – all terms that are borrowed from the judicial system and that, for many, have taken on a threatening intent.

Not unsurprisingly, therefore, the process can intimidate and overwhelm staff, potentially masking the true issues and risks. But safe services rely on a will to learn, which in turn relies on open, safe reporting. We know that as per the 2015 NHS National Staff Survey only 68 per cent of NHS staff feel secure in raising concerns.

The process we use to extract learning from when things go wrong uses language that is punitive and undermines its purpose

Nearly two years ago at Mersey Care Foundation Trust, we embarked on a programme of Learning through Transparency, with risk consultants Lockton, led by our medical director, Dr David Fearnley. What has flowed from this is that both organisational and individual learning can be inhibited by a culture that often blames people for mistakes.

Compassion towards staff key to learning

The pursuit of our own Perfect Care ambitions is dependent on the development of a non-punitive culture. It comes back to the second victim in an incident – the clinical team. It is clear from our work that learning can only flourish when responses to mistakes are compassionate and the overwhelming value is respect.

We must ensure our culture is characterised by learning – not only at the personal level but also at the broader team and organisational level

Pursuing safety and absolute goals, such as zero suicide and zero restraint convinced us of the need to create a just culture across the NHS, to rekindle the motivating factor due to which the staff became part of the world’s best health system to begin with – to care and work together for the benefit of patients. That may have been lost amid the recent years of austerity.

May be too there is a call to push back from excessive regulation and its consequences and put the emphasis on training, development and learning, so that there is mutual trust among the staff to openly and willingly question the impact of its practice on safety and outcomes. 

Making a commitment to strive for zero suicide and zero restraint means that we must ensure our culture is characterised by learning – not only at the personal level but also at the broader team and organisational level. Essentially, personal responsibility and professional accountability drives organisational learning.

This is not about being “blame-free” and having the tolerance level of anything goes, but a careful calibration of accountability and learning, with a prospective outlook rather than a retrospective bias. Our work with The Risk Authority Stanford has resulted in a greater emphasis on fully qualifying the value of risk mitigations. Honing mitigations to ensure their effectiveness depends on deep consultation with staff as “end users” and this cultural shift is no different.

Share best practices

In exploring a just culture, many leaders of organisations and industries say they have achieved this. Some undoubtedly have and there is much to learn from them and we are keen to share good practice.

All boards have nothing to lose by directly asking staff what it feels like when something goes wrong in their organisation

Our journey to date suggests that the delivery of a just culture is possibly the most sophisticated, complex and demanding challenge in healthcare, and we suggest that all boards have nothing to lose by directly asking staff what it feels like when something goes wrong in their organisation. 

We’ve taken our learning wider and shared patient suicide cases with specialist teams from other trusts. This helps frontline staff and the board understand that many issues we face internally are in fact mirrored elsewhere, even if they are not systemic in nature.

Ideally this sharing can expedite learning and improvement. It is too late to identify poor care or practice when we have already begun investigating deaths and serious harm. We all need to know sooner.

A gradual change

Practically, incorporating how we see a just culture working will stem from co-produced principles with both clinical and non-clinical staff and will be incremental in implementation. It will be a central, evolving pursuit embracing respect, compassion and learning.

It will be a central, evolving pursuit embracing respect, compassion and learning

We don’t underestimate the challenges ahead but our role is to light the path, and bring colleagues with us, over time and at their pace. In December we openly explored a just culture with more than 170 staff. The response was affirming and the agenda is set for large scale consultations, which are now underway.

This is a significant but necessary shift. Every day in the NHS we expect our staff to deliver high quality, effective care within ever trying conditions. They should expect a compassionate response when things go wrong.

Staff members are our alert system. We need to listen better. A systematic focus on a fair and just approach to safety culture for staff and patients alike is needed more than ever, not just because it is the right thing to do, but because asking “what” and “why” instead of “who” will dramatically accelerate learning and improvement.

Joe Rafferty, chief executive of Mersey Care Foundation Trust