Why do we need 'the right culture'?
Getting the culture right throughout the profession is important
We know this because at the extreme, we have seen the problems caused by a wrong culture within the banking industry (LIBOR fixing, miss-selling of insurance) and within the media industry (phone hacking). These examples are the visible signs, more commonly the wrong culture can contribute to less visible, 'unseen' problems, for example, low staff morale, poor practice, staff turnover, and poor relationships.
In healthcare, the wrong culture can lead to a reduction in patient safety and quality of care.
Problems with a punitive culture
A punitive culture is based upon assigning blame and punishment.
It contributes to creating a culture of fear. People and organisations see what happens to others and if what they see is perceived to be draconian or unjust, this leads to fear, stifling reporting and stifling the raising of concerns.
We lose the opportunity to learn, and patient safety is affected.A single instance of perceived punitive action can have a wide effect on how large groups of people choose to act.
Why a no-blame culture is inadequate
'No-blame' may not be better than a punitive culture. It can breed complacency or nonchalance which can also impact upon patient safety.
At its worst it can appear unacceptable to society overall due to the immunity from accountability which can also be abused.
For example, there is a perception that at times diplomatic immunity can be unfair and abused.
We need the 'right culture'
Instead, we need the 'right culture', a culture based upon the principles of fairness, quality, transparency, reporting, learning and safety.
Underpinning the 'right culture' is just culture. This is a culture based upon fairness and achieved when attitudes, behaviours and practices are fair. A just culture promotes an open culture (transparency and discussion), a reporting culture (raising concerns), a learning culture (learning from mistakes). These cultures support each other to create a safety culture – balancing accountability and learning and leading to improved patient safety.
It also creates a just and open working environment which is rewarding to work within, professional empowerment, and enhances the quality of service to patients and patient experience.
How do we achieve a just culture?
We need all stakeholders throughout the profession to:
- Commit to the principles of getting the culture right (of which safety culture and just culture are fundamental)
- Recognise where the right culture already exists
- Get the infrastructure right where there is room to improve
- Live the right culture.
Beyond strong professional leadership, and professional empowerment, one important step in achieving the right culture is to have the necessary infrastructure in place.
Infrastructure in this context includes institutions, legislation, regulations, policies and procedures.
Getting the infrastructure right helps to achieve just culture.
Institutions, legislation and regulations
Ensure that institutions, existing and new legislation and regulations are aligned to safety culture, and just culture principles.
- Individuals and organisations
- e.g. via consultation responses to changes in legislation and regulatory standards
- e.g. challenging legal frameworks and regulatory frameworks which are not aligned to safety and just culture for improvement and review
- e.g. ensure that institutions integral to safety culture and just culture are fit-for-purpose and continue to evolve (such as national reporting mechanisms, constitution and outputs).
- Regulators, government bodies and non-departmental public bodies
- e.g. through consultation and commitment to improvement
- e.g. through introduction of internal processes that review deficiencies in the legal or regulatory framework in response to incidents and challenge.
Policies and procedures
Ensure that new and existing policies and procedures throughout the profession are aligned to safety culture and just culture principles.
Create policies and procedures that develop a safety culture for example
- Raising concerns policies
- Policies that ensure all actions, decisions, and incidents are aligned to safety culture (e.g. by use of recognised culpability models that balance safety, learning and accountability such as the NHS incident decision tree)
- Policies for the effective sharing of lessons, at a team level, at organisation level and throughout the profession
- Policies to protect people who raise concerns from victimisation (e.g. bullying and 'sharp business practices').
Living the culture: turning just and safety culture into habit
Just and safety culture documents and policies are simply words on paper if they are not 'lived' in actions and interactions. We all have responsibilities for living the culture and embedding the habit.
Individuals and organisations can do this through strong leadership and educating people about just and safety culture, appreciating when it is in action, reflection, benchmarking and commitment of time to embed the right culture.
In all actions and decisions, ask yourself is this just? Is what I am doing or what I am doing on behalf of my organisation aligned to just culture?
Contribute to educating and being educated about safety culture, just culture e.g. by distribution of learning materials, printing of raising concern details on payslips, internal messaging systems, conferences, news networks and forums also provide widespread reassurance of commitment to just and safety culture principles, removing fear and embedding the right culture.
Recognition, appreciation and celebration of instances where organisations and people 'live'safety culture and just culture provides reassurance that there is commitment to living the right culture, removes fear, and helps to create a safety culture habit.:-
e.g. appreciation for raising concerns as opportunities for learning and improvements
e.g. recognition of a fair decision made by an employer, regulator, enforcing body, pharmacy body etc.
Understanding how your own culture (individual and organisation) are aligned to safety culture and just culture principles is an important step in improving:-
e.g. Individual reflection and change
e.g. Team reflection and discussions ensuring alignment of team ethos to just and safety culture
e.g. Organisation reflection through regular benchmark survey for staff (e.g. using RPS template) to understand staff perception of organisational culture and acting upon the results.
Commitment of time
Ensure that there is time to embed safety and just culture throughout the organisation.
- Continual review and alignment of new and established policies to safety and just culture principles.
- Effectiveness of education and appreciation strategies
- Time and mechanisms for reflection and benchmarking though survey and analysis of feedback.