From a black-and-white perspective, there are two cultures that can be distinguished with regard to their approach towards ‘human error’ within an organisation. On one side you have a retributive culture, based on rules, breaking these rules, and how that is punished. On the other side you have a restorative culture, a Just Culture. In a restorative culture, openly and honestly sharing mistakes made comes first and foremost.
In this blog post we describe how these two cultures handle human error. What are the consequences of a retributive culture? And what are the conditions to realise a Just Culture?
In a retributive culture, the following questions are most important:
- Which rule has been broken?
- Who did it?
- How seriously was the rule broken and what consequences are associated with it?
- Who makes this decision?
Retribution implies guilt. Guilt can then be ascribed using three categories of negligence and a matching measure to be taken:
- Unconscious error >> No consequences for employment
- Risky conduct >> A serious warning
- Negligence >> Dismissal
However, this supposedly clear trinity requires further fundamental questioning:
- Who within the organisation determines whether a mistake was made unconsciously, as a result of risky conduct, or due to sheer negligence?
- Is this person entirely unbiased?
- Is this person familiar with the complexity of the work?
- Can this be appealed?
- Does the organisation as a whole learn from the mistake made?
Focusing on the culprit: Rules and retribution
A retributive culture is based on rules, breaking these rules, and how that is punished. Making ‘the culprit’ pay is an important feature of it. Naturally, situations can be imagined where disciplinary measures can be drawn from the trio mentioned above: when a doctor or nurse performs his or her work under the influence of drugs or alcohol, negligence is obvious, and dismissal is well deserved.
However, the lines are typically drawn far less clearly. Without falling too deeply into complicated grey areas, the following example may be good food for thought: Professor Jeffrey Braithwaite, who is also the founder of the Australian Institute of Health Innovation, performed studies into the knowledge of guidelines and procedures by healthcare staff.
The reason was the increasing bureaucratisation within healthcare. He discovered that the average nurse had to consider 600 different guidelines and procedures each day. When questioned on their knowledge of these guidelines and procedures, it turned out that the average nurse was only familiar with 3 (if that) of the 600 requirements in place. It is easy to wonder whether these 600 rules are truly practical. Or whether breaking one of these 600 rules can really still be blamed on an individual (as far as this study is concerned) nurse. Does a retributive culture ‘work’ in an environment where it seems that no one has a current knowledge of procedures and requirements? When you consider the enormous number of procedures and requirements, that should be no great surprise. These 600 rules are most likely a well-intentioned attempt ‘close off’ human error. It can be done differently, too. By creating a restorative culture, where the people are the solution.
Just Culture in healthcare
In a restorative culture, also called a Just Culture, the most important questions are in direct contrast to those asked in a retaliating culture:
- Who is the victim of the error that was made?
- What does the victim need now?
- Whose responsibility is it to provide help?
- How do we distribute this information within the company?
In a retributive culture, there is a (basic) moral debt that has to be settled. To the company, to the victims, and to society. The payment is a balanced, fair, and proportionate punishment, that burdens the perpetrator with the accountability and serves as an example.
Focus on the patient: Learning and prevention
In a restorative culture, openly and honestly sharing mistakes made comes first and foremost. The focus is not on the “offender”, but on the victim and how they can be helped as best possible. The next order of business is to take a look at the factors that led to the mistake being made. The assumption here is that in a complex organisation such as a healthcare institution, human error occurs regularly. Therefore, the origin of the error or errors has to be examined and discussed with an open mind in order to bring about a change.
The conditions for bringing about such a cultural change are described in our e-book: Just Culture, Theory and Practice.
Braithwaite, J. (1989). Crime, shame and reintegration. Cambridge, UK, Cambridge University Press
Dekker, S. Just Culture. Retrieved from http://sidneydekker.com/just-culture/
Dekker, S. [Modernisering Medische Vervolgopleidingen]. (2016, August 8). CanBetter-congres Patiëntveiligheid – Sidney Dekker [YouTube]. Retrieved from https://www.youtube.com/watch?v=Dy2awkglnTE
Spaan, W. [Modernisering Medische Vervolgopleidingen]. (2016, August 8). CanBetter-congres Patiëntveiligheid – Willy Spaan [YouTube]. Retrieved from https://www.youtube.com/watch?v=9uwg-nNhzek
Zehr, H. and A. Gohar (2002). The little book of restorative justice. Intercourse, PA, Good Books