By Heidi Raines
I’ve always had a predisposition for what’s called “systems thinking.” This approach to problem-solving involves taking a broad view of structures and patterns to understand the ways individual parts fit together as a whole.
My career has revolved around understanding and supporting the well-being of healthcare organizations, healthcare workers, and patients. More specifically, I’ve made it my professional life’s work to identify the roles that systems and processes play in creating safety incidents and to find solutions that improve the environment of care and support overall patient well-being.
I have had the privilege of working to create systemic change within healthcare organizations, from rural community clinics to national health systems, and for specialized care models like telehealth, behavioral health, and social services. What all these healthcare organizations have in common is that they embrace event reporting as a pathway to preventing harm – to achieving greater patient and employee safety and a higher quality of care for the communities they serve.
Overcoming the fear of blame, focusing on prevention
A just culture of care creates and sustains a mutually supportive and safe environment for patients and caregivers. Proactive organizations reframe outdated attitudes around reporting to arrive at the shared belief that incident, event, and near-miss reporting is a tool for understanding processes, learning from near misses and safety incidents alike, and pursuing improvements in systems and procedures that yield measurable and ongoing improvements in the environment of care.
Recognizing and implementing actions to prevent patient and employee harm has the greatest potential effect on the quality of care delivered in our healthcare systems, just as preventive care and wellness efforts slow or stop the progression of disease. Barriers to reporting, such as fear of blame or retaliation, can deter reporting, but organizations that encourage reporting incidents show that it is possible to incorporate incident reporting tools and quality-rounding checklists in a way that prevents harm and gives voice to patients and to employees who are the eyes, ears, and heartbeat of a healthcare organization.
Healthcare leaders are placing modern emphasis on “just culture” as a foundation to prevent patient and employee harm. The term was first used in healthcare in a 2001 report by David Marx, which popularized the term in the patient safety lexicon. A just culture refers to a system of shared accountability in which organizations are responsible for the systems they design and for responding to the behaviors of their employees in a fair and just manner. Employees are accountable for the quality of their choices and for reporting incidents and system vulnerabilities. In a just culture, safety incidents are seen as opportunities to share observations about system risks and organizational behaviors.
A just culture is one in which people recognize both that competent professionals make mistakes and that the discovery of multiple or repeated incidents indicates solvable issues that arise between humans and the systems in which they work. A just culture accounts for all factors contributing to an incident, from the human to the environmental, technical, and so on.
To the contrary of a punitive system, a just culture creates and sustains an atmosphere of trust in which healthcare workers are supported and treated fairly when safety incidents occur in patient care. It creates an environment in which healthcare workers and patients feel safe to share observations and report concerns. Reports are acknowledged by all to be important sources of information about weaknesses in the system that need to be understood and addressed to improve patient safety.
In addition to encouraging reporting, just cultures also use data to identify patterns; they begin with the assumption that many individual incidents represent predictable interactions between humans and the systems in which they work.
Here are the five key components of a just culture:
- Adopting one model of shared accountability and shared goals, versus relying on multiple individual perceptions and attitudes toward goals and accountability.
- Learning from events, versus blaming individuals.
- Distinguishing among and managing behavioral choices, including human error, at-risk behavior, and reckless behavior versus assuming the worst in every instance.
- Recognizing that incidents represent predictable interactions and provide opportunities for learning and prevention, versus assuming each incident is a system anomaly and pursuing no preventive measures.
- Designing safety into all clinical systems and processes and continually monitoring for systemic breakdowns, versus attending only to individual actions and declining to collect and analyze data.
Many of us in healthcare entered the profession because we wanted to help, heal, and serve. At our core, we have compassion, empathy, and a drive to enable people to live their best lives. If we want to achieve a more just, proactive, and equitable culture in our U.S. healthcare system, a culture that truly places the health and safety of patients and employees at the forefront, then we must work together to shift our organizational cultures. That means they encourage reporting, focus on learning from observations, identify and resolve systemic issues and, to the greatest extent possible, prevent those issues from occurring at all.
Heidi Raines is the Forbes Books author of Shared Voices: A Framework for Patient and Employee Safety in Healthcare. She also is the founder and CEO of Performance Health Partners (www.performancehealthus.com), a software company providing patient safety, employee health and quality improvement solutions to healthcare organizations. In addition, Raines is the Board President of the American College of Healthcare Executives’ Women Healthcare Executive Network and holds Preceptor Faculty positions at Tulane University’s Master of Health Administration (MHA) and University of New Orleans’s Bachelor of Healthcare Administration program. Raines has received awards for innovation and executive leadership, including City Business’ Innovator of the Year and Woman of the Year awards.