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Building an Organisation with a Memory on Just Culture?

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Sixteen years after an Organisation with a Memory was published, Jonathan Hazan Director at Datix considers how people and processes are at the heart of a Just Culture in healthcare.
Reflecting on the last sixteen years since the publication of Sir Liam Donaldson’s report “An organisation with a memory” it becomes apparent that the slow progress of the NHS to modernise its approach to learning from failure could well be the result of the lack of a supportive culture, where staff can report and openly discuss errors. This is often referred to as a Just Culture. To create an organisation with a memory an environment needs to be nurtured where incidents are reported for the purpose of learning. A culture where people feel they will not be unfairly blamed and have the right tools and technology available to report and analyse near misses, incidents and serious events when they happen.
Where healthcare professionals perceive a blame-seeking response to incidents and error, the conditions for learning can never exist. It is essential that the NHS can strike the right balance between ensuring accountability where appropriate, while fostering a culture where staff can report and openly discuss error, with the confidence that they won’t be blamed without justification.
The Francis report in 2013 pointed to the problems of leadership and culture in the NHS where feedback from frontline staff, patients and families was often ignored. Egos need to be set aside with a determined focus on what is best for patients by listening and learning to understand what matters most to them. In the same way, staff at all levels should be listened to when it comes to patient safety and the results of investigations fed back to reporters without delay.
It is a common perception that doctors are the healthcare professionals least likely to report incidents and safety concerns or to be included in incident analysis. Why is that? In his book “Late Night Reflections on Patient Safety: Commentaries from the Front Line” my colleague at Datix, Dr Dan Cohen, lists the main reasons why doctors fail to engage with patient safety incident reporting. These include:
Lack of a just culture environment – where errors are analysed for disciplinary action rather than learning
Lack of leadership – an absence of highly respected doctors taking management roles and therefore a lack of leadership by example
Complacency – where doctors see themselves as solely benevolent and are not aware they may also be sources of harm
The protective guild – where physicians are protective of themselves and colleagues and fear recrimination
The hierarchy of respect – when fault-finding, or the fear of blame, may hamper relationships and loss of perceived prestige
Perceived complexities with incident reporting processes – where reporting processes are time consuming and seen as yet more non-clinical administration
Lack of feedback after reporting – when the results of investigations are not shared with reporters and there are no perceived improvements in processes
Lack of support for doctors as second victims – where there is a lack of support for doctors who may be burdened by guilt and sense of failure
All of these reasons could just as easily be applied to all people involved in healthcare. It is not enough to simply say the NHS has a just culture. The culture of any organisation is strongly influenced by what happens in practice. Feedback of investigations should be given to staff following safety incidents and feedback needs to include details of the learning and changes made. Importantly, it should visibly demonstrate that staff involved have been treated fairly and not blamed.
Only when this point is reached can we truly say that the NHS is an organisation with a memory, built on just culture for the benefit of patient and staff safety.
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