“The essence of Just Culture lies in that people do not judge based on the result, but based on the behaviour preceding that result. People are inclined to consider the seriousness of the outcome when judging the person who cause the outcome. Driving through a red light is punished more severely if you run someone over”.
Dr. Ian Leistikow
Doctor, senior consultant at the Dutch Health Inspectorate, and member of the advisory commission of the International Forum on Quality and Safety in Healthcare.
In the year 2016, safety is associated with concepts such as ‘strict’ and ‘no nonsense’. In a Just Culture, the core concepts regarding safety are verifiability and vulnerability. This blog describes two models that explain how to handle human errors in a manner that is in line with a just culture.
Human error in healthcare
In the quotation above, the paradox of how to address ‘human error’ is more clearly established. What remains unanswered is the question that the last two sentences raise. Do they raise a question at all? Of course, running a red light should be punished more severely if it has deadly consequences.
But what about a driver who swerves suddenly to avoid a crossing child, looks back in fear, does not see the red light, and causes a fatal accident? This strongly brings to mind the first sentence of the quote: judgement based on the behaviour preceding the result.
Do blame-free situations exist?
For the sake of clarity: blame-free situations are almost never a possibility, especially when it comes to an error. It does not match with the experience of the victim or the care providers involved. The victim blames the care professional, who often feels guilty already, even if there is no discernible guilt to ascribe. The latter is a (debatable) negative side effect of taking great pride in one’s work and having a strong work ethic, which is typical of care providers.
NPSA Decision Tree
It is important that a healthcare institution employs a transparent and respectful procedure for judging the role of someone involved in an incident as objectively as possible. Based on the ‘Swiss cheese model’ of psychologist James Reason, who thoroughly researched and described ‘human error’, the British National Patient Safety Agency developed a decision tree that can be broken down into four questions:
- Did the person deliberately cause the damage?
- Was their capacity for judgement limited? (think of depression or drugs)
- Were there sufficient, effective measures to prevent the damage?
- Would someone with the same background in the same situation have done the same?
At UMC Utrecht (a Dutch academic medical centre), this decision tree was applied to 40 patient incident reports and it was concluded that no disciplinary measures needed to be taken against the involved parties in any of the cases. This outcome lines up with the experience of the care providers, who felt responsible or guilty themselves.
Therefore, asking and answering four relatively simple questions contributes to care providers being addressed justly, which increases trust and safety in an organisation.
Behaviour of the care provider
Furthermore, it is still important to look at the behaviour of care providers during an incident. David Marx, author of the book Whack a Mole: The Price We Pay for Expecting Perfection, a witty and influential book about the meaning of accountability in our culture, distinguishes three kinds of behaviour:
With risky behaviour, the person involved is not conscious of the risk or they have exhibited reasonable deliberation. With reckless behaviour, the choice is conscious and the risk does not match the potential gain. Normal behaviour should be stimulated, risky behaviour should be coached, and reckless behaviour should be punished. Regardless of the outcome. And that is what is most important. Reckless behaviour, regardless of whether it is perceived by all parties as having been successful, cannot go unpunished.
These are useful, applicable models which, as soon as they are widely known and followed within an organisation, lead to more (mutual) trust and ultimately, to increased safety. Safety is, especially in the year 2016, associated with concepts such as ‘strict’ and ‘no nonsense’. In a Just Culture, the core concepts regarding safety are verifiability and vulnerability. As their practical applications have shown, these comparatively ‘soft’ concepts contribute to a safe environment for care providers and their patients.
Learn more about Just Culture. Download the e-book 'Just Culture, Theory & practice'.
Leistikow, I. (2013, October 17). Van “blame free” naar “Just Culture” vervolg. Retrieved from http://www.discura.nl/auteurs/dr-ian-leistikow/van-blame-free-naar-just-culture-vervolg
IGZ. (2016). IGZ Meerjarenbeleidsplan 2016-2019. Retrieved from file:///Users/tpsc/Downloads/IGZ%20Meerjarenbeleidsplan%202016-2019%20(2).pdf