Just Culture Flashcards
What is just culture
Idea of not assuming individuals are not to blame to start with, looking at the organisation as a whole
How would an organisation use just culture
They would not hold individuals accountable for system failings over which they have no control instead use the failing to make change
Types of mistakes
Slip - when a person does something but not what they meant to fo
Lapse - when a person forgets to do something
Mistake - when a person does something they were meant to do but it was wrong
Examples of how just culture has happened in reality
Medication packaging changed so that it is not similar
What did oliver, 2018 say
NHS is more focused on the law and having someone to blame, where as should be more looking at whag will affect the patient episodes
What are the stages of questions asked in just culture
- Deliberate harm test
- Health test
- Foresight test
- Substitution test
- Mitigating circumstances
Just culture guide- Whats in deliberate harm test
Was there any intention to cause harm if yes appropriate management action if no move to health questions
Just culture guide - Whats in health test question
Are there any indications of drug abuse?
Are there any indication of physical/mental ill health ?
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If yes Get help for the person, follow policies to address
If no go to foresight test
Just culture guide - whats in the foresight test
Are there agreed protocols in place to stop the omission in question
Were the protocols accepter practice, workable and in routine
Did the individuals knowingly depart from the protocols
If yes to any singling out the person is unlikely to help, possible education and documentation necessary
If no go to substitution test
Just culture - whats in substitution test questions
Are there indications that other individuals of same level may have made same omission
Was the indivdual missed from relevant training
Did more senior members of team fail to provide supervision that should have been provided
If no singling out will not help address to help patient care
If yes go to mitigating circumstances
Just culture guide - whats in mitigating circumstances
Were there any significant mitigating circumstances
If yes help to address with the person and improve patient care episodes
If no recommendations are extra training, performance management, etc it may be needed to contact regulatory bodies
Reasons for just culture guides
- helps explain the approach
- used by all parties
- helps protect staff from unfair targeting
- helps protect patients
- not a substitute for investigation of patient safety incident
- can be used at any point
- used with HR advice and organisations policy
- looks at one action of omission at a time
Overall of the being fair (2019)
Helps leaders of health and social care organisations to understand how they can sipport staff when things dont go as planned
Points to the being fair (2019)
- avoidance of inappropriate displincary against staff, including in particular those from BAME backgrounds
- demonstrates some of the impacts on staff when support is not in place
- shows the need to ensure consistency, equitable approaches across all staff groups
- just culture is for all staff, patients and organisations about safety and how to treat each other everyday
- at heart of this are the rights of patients and their families
Idea of the just culture guide
Supports a conversation between managers about whether a staff member involved in a patient safety incident requires support or intervention
Action singling out an individual is rarley appropriate - issues usually have deeper cause
Guide highlights the important principles that need to be considerrdd before management action
