Moving from Policy to Practice Principles of a Just Culture

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1 Moving from Policy to Practice Principles of a Just Culture Dr Heather Wellington 3 December 2007

2 Overview of presentation What is organisational culture? Who shapes organisational culture? Our cultural history The impact of the media The impact of tort law The 20 th century approach The 21 st century approach Critical elements of a just culture Conclusion

Our cultural history The impact of the media The impact of tort

3 What is organisational culture? 'The structure of an organization is founded upon its policies, procedures, rules and relationships. The culture of an organization is founded upon the assumptions, beliefs, values and habit - norms that shape how people think, feel and act.' (De Four and Eaker 1998)

4 Who shapes organisational culture? Health care facility Treating staff Board Quality committee Peers Patient/Family Regulator/Funder Coroner Insurers Clinical competence/performance Disciplinary Boards Defendant lawyers HSC Plaintiff lawyers Media Professional bodies

Patient/Family Regulator/Funder Coroner Insurers Clinical

5 Our cultural history When [medical] errors do surface, often with heart rendering accounts of the suffering of the primary victims the patients harmed the reaction in medical settings is most commonly an attempt to fix blame and to punish someone. This will not work. If we can take any lessons from the stunning progress in safety in aviation and other high risk industries it is that fear, reprisal and punishment produce not safety, but rather defensiveness, secrecy and enormous human anguish. Berwick D and Leape L. Reducing errors in medicine. It s time to take this more seriously. BMJ 1999; 319:

If we can take any lessons from the stunning progress in safety in aviation and other high risk industries it is that fear, reprisal and punishment

6 Our cultural history Patients and the community seek openness Professionals are fearful of: professional blame/shame impact on professional practice reprisal by employers coronial inquiry/inquest disciplinary proceedings formal and informal complaints accreditation consequences actions in negligence inquiries (e.g. Bundaberg) The challenge how to manage the fear of openness!

inquiry/inquest disciplinary proceedings formal and informal complaints accreditation

7 The impact of the media Four newspapers are more to be feared than a thousand bayonets Napoleon Bonaparte Newspapers are unable, seemingly, to discriminate between a bicycle accident and the collapse of civilisation. George Bernard Shaw

Newspapers are unable, seemingly, to discriminate between

8 The impact of the media

9 The impact of tort law Fear of actions in negligence drive secrecy and defensiveness Donohue v Stevenson (1932) the concept of negligence All of the following need to be proven: There was a duty of care owed by the health care professional to the person There was a breach of that duty of care There was an injury which was caused by the breach of the duty of care The injury was reasonably foreseeable as a result of the breach

the health care professional to the person There was a breach of that duty of care There was an injury

10 The 20 th century approach Most of the debate was about trying to engage doctors in quality assurance Recognition of the need to achieve professional engagement in quality activities if they are to be effective Some sectors of the medical profession in Australia were slow to adopt peer review/quality improvement

engagement in quality activities if they are to be effective Some sectors of

11 The 20 th century approach The Federal Minister for Health threatened, in 1976, that the Australian Government would institute peer review if the medical profession did not do so within three years Cass M, Brook CW. Quality assurance: a state perspective. Aust Clin Rev. 1990;10:129

the medical profession did not do so within three years Cass M, Brook

12 The 20 th century approach Some members of the medical profession maintain that such pressures [public and parliamentary, to bring medical practice under closer scrutiny] are to be resisted without argument and without compromise, and that we should have nothing to do with medical audit, quality control or whatever. McIntyre N, Popper K. The critical attitude in medicine: the need for a new ethics. BMJ 1983;287:1921

and without compromise, and that we should have nothing to do with medical audit, quality control or

13 The 20 th century approach A movement to openness in the public and private sectors FoI and privacy legislation Public reporting of performance in health care to promote competitive improvement and a tool to enhance consumer empowerment, individual choice and public accountability A commitment to investigation of adverse events (RCA) Enhanced media interest

competitive improvement and a tool to enhance consumer empowerment, individual choice and

14 The 20 th century approach Introduction of qualified privilege/statutory immunity: on the basis that there is an overriding public interest in maintaining confidentiality of some health care quality information prioritises the public interest in participation in quality activities by health care professionals over the public interest in access to information which is viewed by the community as important and relevant to decisionmaking accepts that doctors will only participate in individually-identifying quality improvement activities if they are assured of confidentiality

health care professionals over the public interest in access to information which is viewed by the community as important and relevant to

15 The 20 th century approach

16 The 21 st century approach Acceptance that: Approaches that blame individuals are not helpful in improving safety and quality Blaming individuals does not change factors that contributed to or caused poor quality care Fear reprisal and punishment produce defensiveness, secrecy, and anguish; safety depends not on exhortation but on proper design of equipment, jobs, support systems, and organizations Emphasis should be placed on developing systems that will support the delivery of high quality care Professional accountability is, nevertheless, important (so how do we achieve it without blame)?

safety depends not on exhortation but on proper design of equipment, jobs, support systems, and organizations Emphasis should be placed on developing

17 The 21 st century approach Clearly the hospital took seriously the right of patients and the public to be provided with factual information. Some media coverage has not been helpful. More health services should follow the example of open disclosure so that we can improve safety and quality not sweep the flaws under the carpet. Letter to the Editor, Consumer Advocacy Group

More health services should follow the example of open disclosure so that we can improve

18 The 21 st century approach The Open Disclosure Standard requires: Acknowledgement that an adverse event has occurred An expression of regret An explanation of what happened, clinical implications and treatment Steps to manage and prevent recurrence Feedback to patient and carers

regret An explanation of what happened, clinical implications and

19 The 21 st century approach System-wide commitment to open disclosure is increasing Open disclosure accords with moral and professional obligations to be honest and to foster trust In 83% cases, staff felt process discouraged sense of blame 80% staff very satisfied with OD process

obligations to be honest and to foster trust In 83% cases, staff felt

20 Critical elements of a just culture Consider these from the perspective of: The patient The health care professional The organisation

21 Critical elements of a just culture From the perspective of the patient An organisational commitment to deliver quality care An organisational commitment to monitor quality of care An organisational commitment to investigate and remediate adverse events or concerns about quality of care Openness, honesty and support if things go wrong

22 Critical elements of a just culture From the perspective of the health care professional Safe systems in which to work Support to participate in quality assurance/ improvement A presumption of competence Unbiased assessment of competence/performance No presumption of incompetence if things go wrong Support if things go wrong, not blame Transparent, evidence-based investigation of adverse events Natural justice

23 Critical elements of a just culture From the perspective of the organisation A professional culture that supports organisational efforts to improve quality and address adverse events A professional commitment to self-regulation Professional compliance with reasonable policies/procedures

24 Critical elements of a just culture In the UK, Sir Liam Donaldson found that in any 5-year period, approximately 6% of doctors will have serious performance concerns, the management of which calls for assistance from outside the local clinical unit or trust. Donaldson, L. Doctors with problems in an NHS workforce. BMJ 1994;308:

25 Critical elements of a just culture A just culture requires that if a health care professional is underperforming and the underperformance cannot be remedied through reasonable means, the health care professional cannot be permitted to continue to provide services This represents accountability, not blame

26 Conclusion The culture of an organisation is founded upon the assumptions, beliefs, values and habit - norms that shape how people think, feel and act Health care culture has been secretive, blame-based and defensive - this is not a culture that supports quality The system is moving towards a just culture that recognises and respects the reasonable aspirations of all players Accountability is a critical element of a just culture

Statutory duty of candour with criminal sanctions Briefing paper on existing accountability mechanisms

Statutory duty of candour with criminal sanctions Briefing paper on existing accountability mechanisms Background In calling for the culture of the NHS to become more open and honest, Robert Francis QC,