Reflections on “Just Culture”

by Murray Anderson-Wallace

There has been a great deal of talk about the need for “cultural change” in and around the health service in recent weeks. There has also been a great deal of publicity around the need for accountability. In the wake of the Francis Inquiry, Cure the NHS have called for the resignation of Sir David Nicholson, the NHS Chief Executive. Extensive media coverage has been fuelling the debate.

Professor Sidney Dekker, a cognitive psychologist and current Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University in Brisbane, Australia has a great deal to offer on the matter.

Dekker has focussed on the development of “Just Cultures”. He defines these as environments where learning and accountability are fairly and constructively balanced. The construct is based on a fundamental belief that when people make honest mistakes it is important to protect them from being seen as culpable.

Whilst this seems relatively simple and understandable, the concept forces us to consider the whole question of what constitutes an honest mistake, or rather, when is a mistake no longer honest?

Sidney Dekker argues that in complex human systems it is naïve to believe that there are absolute lines to be crossed or obeyed or that there can be pre-prescribed consequences for those who “cross the line”.

In his view those “lines” don’t just exist out there, but rather we – people – construct those lines; and that we draw them differently all the time, depending on the language we use to describe the error, on hindsight, history, tradition, and a host of other human, organisational and political factors.

What matters to Dekker is not where the line is drawn – but how it gets drawn and who gets to draw it. He argues that if we leave this to chance or to regulators, prosecutors or the media; or if we fail to be clear with those involved about who may end up drawing the line, then a just culture will be very difficult to achieve.

The absence of “just cultures” in an organisation, or indeed a whole industry or society he contends, will damage both justice and safety. If our responses to incidents, accidents, errors and mistakes are seen as unjust the effects will be significant.

Safety investigations will not produce deep learning but promote fear rather than mindfulness in people who do safety-critical work. Moreover they risk making organisations more bureaucratic rather than more careful, and cultivate professional secrecy, evasion, and self-protection.

A “just” approach is critical for thinking culturally about safety. Without ways of routinely talking about failures and problems, without openness and information sharing, a safety culture cannot flourish.

Key Points

• “Just Culture” is about creating a balance and between accountability and learning

• Changing the way we think about accountability and making it compatible with learning

• Clarity about WHO and HOW the line is drawn not necessarily WHERE it is drawn?

• Ensuring consistency between “story lived” and the “story told”

Conclusion

A relational approach – a multi-disciplinary concept but with its roots within social psychology – recognises that every “solution” creates the context for a new problem. Thus approaches to change that are linear, politically motivated or expedient are unlikely to yield the long-term or sustainable gains needed to establish new cultures over time.

Thinking culturally about safety is complex and multi-factorial. There are no “silver bullets” and the “myth of leverage” (i.e. the notion that one critical move in the system will create cultural change) must be resisted. It requires thoughtful, creative and sophisticated responses and an intelligent system of regulation.

Safe care is fundamentally about morally sound professional practice within ethical organisational systems. It is about high quality clinical leadership, effective team working, respect, tolerance and professional humility. It is about curiosity, inquiry and excellence in communications both with patients and between professionals.

Sustainable systemic improvements in patient safety will only come about when organisational and professional attitudes and patterns of behavior start to shift to reflect these features.

We need to concentrate our efforts on creating the conditions for the difficult, sometimes uncomfortable but ultimately honest and hopeful conversations that will build those changes.

Things to consider

• Avoid the trap of the illusion that there are absolutely clear lines between acceptable and not acceptable

• Assess the way you deal with incidents and the tools that you use to determine not just what happened but how it happened (identifying the “error producing” conditions)

• Independent reporting and investigation is a crucial aspect of the creation of a “just culture”

• How data is shared and “protected” from undue probing is a crucial part of the process for determining who is involved in “drawing the line”

• Be clear about how the internal process works – to minimise anxiety about line-drawing.

Related reading

Dekker, S. (2007) Just Culture – Balancing Safety & Accountability. Ashgate

Rowley, E. & Waring, J. (2011) A Socio-cultural Perspective on Patient Safety. Ashgate

Shale, S. (2011) Moral Leadership in Medicine. Cambridge University Press