Just culture and civil liability
This article supports physician leaders in creating a positive workplace culture in which patient safety incidents are reported and disclosed, and where organizations promote learning from past events to improve care. It suggests an approach to manage behaviour that enables delivery of safe medical care. The suggested approach does not, however, assume the determination of civil liability in which a defined set of legal principles is applied.
A patient undergoing a carotid angiogram is injected with isopropyl alcohol instead of contrast medium. She suffers a massive stroke and dies.
Consider three different possibilities that could have led to the same event:
- Scenario 1: The radiology technologist pours the wrong solution into the sterile steel container on the procedure tray because the isopropryl alcohol and contrast bottles look similar and are kept side by side on the storage shelf.
- Scenario 2: Although the procedure calls for it, the radiologist and technologist do not take the time to confirm that the correct solution is being used, because this is the third case of the day and the others went well.
- Scenario 3: Despite the technologist’s reminder to complete a pre-procedure checklist, the radiologist, who is rushed, refuses to verify with the technologist that she is using the correct solution.
As a physician leader, how would you respond to each of these situations?
Understanding human fallibility
Human beings have been described as "inherently self-serving, occasionally altruistic, happiness-seeking, inescapably fallible pack animals, blessed (or cursed) with free will and a mis-tuned ability to see and avoid hazards in the world around it."1 For the physician leader, reflecting on and accepting this statement creates the foundation on which a culture of accountability can be built. That culture enables lessons to be learned following patient safety incidents and near misses, and allows highly reliable clinical outcomes to be achieved.
To create a culture where everyone on the team is accountable and open to learning, healthcare leaders and providers alike must begin by acknowledging human fallibility. Building and nurturing teams that are accountable and engaged, and that can identify and fix problems before harm occurs, requires leaders to accept five universal tenets:
- To err is human.
- To drift is human.
- Risk is everywhere.
- We manage in support of our values.
- We are all accountable.
Culture rooted in values
A culture of accountability results from the consistent application of the just culture model. It is characterized by a values-supportive system of shared accountability where organizations are accountable for the systems they have designed and for responding to the behaviours of their employees in a fair and just manner. Employees [and others in the workplace including physicians], in turn, are accountable for the quality of their behavioural choices and for reporting both errors and systems vulnerabilities.2
To create and support a culture of accountability, leaders must clearly articulate their organization’s mission and its values. Having a clear understanding of their organization’s values allows healthcare providers to embody and protect those values through their behavioural choices, and provides a foundation for any needed interventions by the organization’s leaders.
Defining organizational missions, values
A mission is the organization’s reason for being (e.g. provision of safe medical care), while its values are the guiding principles that help it achieve its mission. Values convey to healthcare providers what is important to an organization as it serves its mission.
When facing undesirable behaviours among the healthcare team, leaders can take a punitive approach, often based on the severity of the outcome, or a blame-free approach where individuals are not held to account for their behaviours owing to systemic issues. When championing a culture of accountability, leaders will want to strike a balance between the two approaches.
Within a culture of accountability, three types of human behaviour are recognized as affecting the ability of providers to fulfill their duties in support of their organization’s mission: human error, at-risk behaviour, and reckless behaviour. Leaders must use appropriate interventions to promote behavioural choices that reflect the organization’s values.
In the context of fostering a culture of accountability, human error is an unintended action which is, by definition, inevitable and unintentional. Consequently, the appropriate response from leaders when human errors occur is to accept them and to console the healthcare provider who made the mistake. Accepting errors, however, does not preclude the organization from learning from events to identify ways of reducing the risk of recurrences.
Healthcare providers typically receive training about the rules and procedures set by their organizations. But over time, as they acquire competence and learn to cope with increasing demands and pressures of clinical practice, individuals inevitably develop shortcuts, workarounds, and heuristics in their daily tasks.3 Thus, the provider drifts from accepted behaviours into more dangerous patterns that he or she regards as being more efficient but that are still within the spectrum of what may be considered safe. Behavioural drift (e.g. using a clean, rather than a sterile technique for a minor procedure) is a normal aspect of human behaviour. It is an unconscious choice to deviate from training, stemming from a lack of perception of risk or a mistaken belief that the risk is justifiable. As providers become more comfortable with their tasks, drift is further reinforced by the fact that any resulting harm is relatively rare, thus obscuring the link between drift and potential harm.
Drift is considered to be at-risk behaviour. Within a culture of accountability, it is generally recognized that behavioural drift is the single greatest threat to patient safety, owing to its unconscious nature and to its pervasiveness in everyday practice.
For healthcare leaders who have identified occasional at-risk behaviour, an appropriate intervention is to coach the healthcare provider back toward safe practice. Coaching is a positive discussion that may include pointing out the drift, reminding the provider of the risks, and redirecting the provider’s choices toward accepted policies and procedures. Repeated at-risk behaviour can be managed by evaluating performance-shaping factors at both the provider and system levels. Disciplinary action can be considered when coaching and modification of performance shaping factors have been exhausted.
One of the biggest challenges in managing at-risk behaviour occurs when drift is identified but no patient safety incident or near miss has resulted. Many leaders in this circumstance adopt a "no harm, no foul" approach and fail to provide the necessary coaching. This approach, however, represents a missed opportunity for learning and ultimately imperils a culture of accountability by tacitly reinforcing drift. Leaders should instead strive to coach as many episodes of drift as reasonably possible, whether or not these incidents result in adverse outcomes.
Reckless behaviour represents intentional risk-taking. It is a conscious disregard to act without regard to a known, substantial, and unjustifiable risk. While often egregious, this type of behaviour is rare and thus poses a lesser threat to overall patient safety in the healthcare system.
Regardless of whether or not a patient safety incident or near miss occurred, the appropriate management response to confirmed reckless behaviour is to take action with the individual care provider. Before determining a course of action, leaders should first consider all the facts and circumstances of the case. There may be situations, for example, where the social benefit of a conscious choice to deviate from a procedure would justify an otherwise reckless behaviour. Factors such as insight, cooperation, and commitment to change are often relevant to the severity of the chosen intervention.
Addressing recurring undesirable behaviours
When an individual repeatedly makes errors or exhibits recurring at-risk or reckless behaviours, these may be symptoms of broader system or provider issues. Leaders in these circumstances may want to identify and help to address these performance-shaping factors which may be compromising the delivery of safe medical care.
The bottom line
A culture of accountability seizes opportunities for learning from otherwise undesirable behaviours. When leaders identify the causes of human error and at-risk and reckless behaviours, use appropriate behavioural interventions and modify processes when needed, the organization’s learning system is strengthened and team members become more engaged. The result is a reliable healthcare system that supports safe medical care.
What the case scenarios can teach us
After the radiologist promptly discloses the patient safety incident to the family, the hospital initiates an accountability review.
- Scenario 1 is most likely to be a human error. The technician is consoled and a search for contributing factors leads to changes in bottle storage and labelling.
- Scenario 2 in most cases represents at-risk behaviour. The radiologist and technologist are coached about drift and the fact that their choice to not verify the solutions represents drift from an established policy. They are reminded of the reason for, and importance of, following procedures.
- Scenario 3 is an example of reckless behaviour by the radiologist. The chief of diagnostic imaging initiates an investigation into the incident which helps inform the hospital’s accountability review. The chief meets with the radiologist to discuss potential sanctions and to set clear expectations for future performance. The chief also discusses the matter with the technologist, who is coached about the importance of speaking up and stopping the line when required. The hospital provides training for the team to promote psychological safety in the radiology suite.
- Marx D. Console, coach or punish: How reactions to behavioral choices influence culture. In: 2017 Michigan Health and Hospital Association Patient Safety and Quality Symposium; 8 March 2017; Dearborn
- Griffith KS. Column: The growth of a just culture. Jt Comm Perspect Patient Saf. 2009 Dec;9(12):8-9
- Amalberti R, Vincent C, Auroy, Y, et al. Violations and migrations in health care: a framework for understanding and management. BMJ Qual Saf, 2006;15:i66-i71