At a recent conference on health and social care risk management in healthcare, we were introduced to the idea of a ‘just culture’. The ‘just culture’ is all about ‘creating an open, fair and just culture, creating a learning culture, designing safe systems and managing behavioural choices’. In the context of healthcare, the ‘just culture’ is strongly associated with maximizing patient safely. The ‘just culture’ theory identifies three distinct types of behaviour:
- human error
- at-risk behaviour
- reckless behaviour.
Each of these is explained, and theoretically allows managers to differentiate based on behaviour (not outcome) and manage individuals differently depending upon the behaviour displayed. But do those working on the front line – doctors, nurses, therapists, carers – really understand what is expected of them?
Being honest about one’s behaviours is difficult. Understanding what is needed behaviourally in an abstract way is equally difficult. And having a conversation with a colleague or subordinate about their behaviour can be even harder. For more information, see Patient Safety and the “Just Culture”.
photo | HowardLake
One of our clients recently articulated the critical behaviours expected of their people. These comprised short, memorable and simple statements such as ‘speak up’. From a distance this seems sensible, perfectly valid and useful. But when you examine it more closely how clear is it? What does ‘speak up’ actually mean in the context of work? What should I speak up about? Who should I speak up to? Am I safe to speak up about my manager? What about other peoples’ behaviours I’ve noticed?
Within many organisations, there are myriad reasons not to speak up. These include:
- explicit issues | if I speak up against my boss, this will damage me as s/he writes my appraisal
- perceived issues | no one will listen to me if I speak up because I am junior
- cultural issues | we support each other and stick together
And then there are the nameless concerns and fears arising from ‘received wisdom’, old memories, rumours and canteen gossip. During a course of interviews for one client, fear of losing their job if they spoke up was a repeated concern articulated by interviewees. No one had been fired or made redundant for eight years within that division, and most of the management team from ‘the firing days’ had long since moved on. But memories can be long. For another take on speaking up, see speaking out: would you?.
Opening the difficult conversation about behaviours – in this case, about ‘speaking up’ - can be greatly eased if the personal element is removed, and people are given a different frame within which to explore the idea and express concerns. In this instance we provided the safe frame by helping create some factional stories [by factional we mean fact-based fiction] where the critical behaviours were in evidence or missing.
Debates around these factional situations allowed individuals to explore in a non-threatening way the actions taken in the story and then create the right space for a discussion about what that meant for them personally. The conversation then naturally progresses to what ‘speak up’ might mean for the individual in a similar – but real life – situation. In this way, how I might need to change my own behaviour is no longer a rather abstract concept being imposed upon me (which I am likely to resist), but a clearly illustrated reality, which I can take back to the front line and apply to my daily work. And when many people do the same, the culture begins to shift.
Dialogue is a tool that promotes the ability to shape and shift organisational cultures. It is likely to be difficult to make the ‘just culture’ a reality if the current norm of behaviour is to cover up mistakes since people don’t feel safe enough to speak up. Stepping into factional spaces can encourage people to have more challenging dialogues, be more open about underlying issues and raise issues in a safe space where the discussion doesn’t have to get personal. It also offers the opportunity to follow the natural link to what might be needed in terms of their own personal approaches and mindsets.
We hope that if this ‘just culture’ becomes central to thinking through how to manage risk in healthcare. And that time and space are given to thinking through the cultural pillars that will support it from the perspective of those crucial delivery staff.