Mistakes happen, especially in complex sectors delivering public services. In health & social care settings the way organisations and employees react can drive meaningful improvements in patient safety, as well as improve staff engagement and retention.
Transparency is key. The introduction of Duty of Candour₁ was key to establishing a more transparent approach in medicine nearly nine years ago. This brought the concept of being open with patients and relatives to the forefront.
Embracing a learning culture can displace potential blame related reactions so teams are supported and heard. As well as creating a more positive working environment, this can also prevent mistakes and incidents recurring.
A universal truth in health & social care organisations is that no-one wants to cause or be involved in incidents. Everyone understands the consequences can be traumatic for all those involved.
Every year, an estimated one million patients die in hospitals around the world because of avoidable clinical harm. In England, analysis by Hogan, Darzi and Black, found that 3.6% of hospital deaths have a 50% or greater probability of being avoidable₂.
Cultural shift
Adopting a culture where employees are encouraged to flag up potential issues is fundamental to changing current statistics. Central to this is embracing a just culture as an organisational and individual value. This is where resources are available to support learning from mistakes and drive continuous improvement. But it is easier said than done. The concept of a just culture has been around since the late 1970s, where it originated in the airline industry. The Civil Aviation Authority mandates it as part of its proactive safety activities.
Every year, an estimated one million patients die in hospitals around the world because of avoidable clinical harm.
Shifting to a just culture isn’t straightforward. It requires employees to feel fully supported when they report an incident, and for an organisation to embrace four values and beliefs:
- No clinician or employee comes to work intending to cause harm or be involved in an accident.
- When a clinician is involved in an incident, they’re affected too (and are often described as the second victim).
- Individuals in an organisation are a small part of a massive, complex system - and with complexity comes greater risk.
- Management teams are open and responsive to bad news. This is key to being a listening and learning organisation.
Adopting these principles and practices can help to set the right tone but for real change to occur organisations must engage frontline staff. They are the experts in their work processes, which means they are critical to creating effective safety mitigations.
Emphasising the mutual responsibility and accountability held between employees and the organisation can help. Within a productive workplace everyone understands they have professional and personal accountability around how they work and the tasks they perform. The organisation is also accountable to its employees and patients to provide an environment with effective and safe processes.
In organisations where an admission of an error would usually result in suspension pending investigation, management have to change those processes and policies and engage their workforce along the way.
Learning organisations rely on their employees feeling psychologically safe to raise concerns. Leaders and managers throughout an organisation are integral to valuing colleague’s safety concerns.
A case in point
Following the unexpected death of a patient, the CEO of a mental health organisation asked Mark Riley-Pitt and Lorraine Roberts-Rance, who have subsequently established Aon’s healthcare risk consulting service, to help identify contributory factors and other key learning points.
Mark and Lorraine worked with two separate clinical teams involved in the patient’s care, creating psychological safety to ensure everyone felt confident to speak openly and honestly about what happened and any safety concerns. By doing this, the consultants were able to gain a broader and deeper understanding of the incident and the key contributory factors. Many team members were deeply traumatised by the incident, so the consultants used an interactive investigation process to facilitate sharing and learning.
The team members felt heard, supported and confident their recommendations would be implemented. By working together to identify key factors and ways processes could be improved, they felt involved in making their workplace safer and preventing a similar incident happening to another patient, and another team.
The first step in creating safe spaces is to value the work everyone does. Emphasising the importance of people’s work and the fact that other employees, as well as patients depend on them underlines the value of what they do.
This exercise should also highlight the uncertainty and potential for error in their work. Again, this shows they are valued and encourages them to be open about any issues at work. Consider this simple question: what are the barriers to delivering safe care?
Managers and team leaders need to model fallibility. Simple things such as a team leader admitting they’re not always at their best and asking colleagues to alert them to anything they might miss, helps create a safe space for incidents and mistakes to be discussed.
In this environment, direct questions about safety issues and procedures can also encourage dialogue. Asking someone how they thought the shift had gone and whether anything could have been improved, demonstrates an open discussion on risk and safety is acceptable.
It is also important to thank colleagues for raising a concern. The feedback loop is critical for employees to know their effort is valued. Turning it into a positive experience where concerns are taken seriously and acted on will encourage more people to speak up.
Learning from incidents
In some organisations it is commonplace to suspend employees involved in an incident until an investigation is completed. This can take months, seriously affecting the employee’s mental health. Often, they ‘have no case to answer’ but will not feel valued by the organisation.
Conversely, a compassionate approach to incident fact finding and listening to those involved to identify contributory factors, can have a profoundly positive impact on individuals and teams. Financial benefits flow to the organisation too in terms of resourcing and engaging the workforce. Additionally, openly exploring risk in structured sessions can be powerfully unifying and motivating, as risk can be used as something to unite staff, not something for them to be afraid of.
The approach to considering risk in all its permutations should be multidisciplinary. Involving employees from different departments and functions ensures that more comprehensive insight is gained into safety issues. Taking this approach and asking questions such as ‘is the system or process fit-for-purpose?’ and ‘were clinicians using a work around because of the system?’ will help identify how a process can be adapted to prevent further issues.
Investing in meaningful, proactive processes around risk, learning and leadership offers many advantages. These range from safer workplaces to improved employee engagement and retention. But cultural change is incremental and needs time and consistency. Everyone can make small changes, like creating safe spaces for colleagues and taking a multidisciplinary approach to assessing concerns. However significant gains in patient and staff safety come only with strong, committed leadership.
References 1Duty of Candour, UK Government 2From a blame culture to a learning culture, UK Government