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Showing results for tags 'Just Culture'.
Found 210 results
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Content ArticleDr Dan Cohen, former military officer in the United States Air Force and international consultant in Patient Safety and Clinical Quality, talks to Patient Safety Learning about how he became involved in patient safety and why he thinks human performance is an area that deserves more study. He feels strongly that leaders must stand up and share their own stories and mistakes to encourage others to start talking and sharing more openly.
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Content ArticleDespite 20 years of effort, every year avoidable unsafe care still leads tens of thousands of patients to suffer death or serious, life-changing harm. A Blueprint for Action, a report from Patient Safety Learning, furthers the analysis of the systemic causes of this harm and describes actions to make patient care safer. Last September, health and patient safety professionals and patients overwhelmingly welcomed the analysis of avoidable unsafe care offered in Patient Safety Learning’s Green Paper, A Patient-Safe Future. Matt Hancock, Secretary of State for Health and Social Care described it as “…the blueprint for action that we need.” Following widespread consultation on the Green Paper, A Blueprint for Action extends this analysis to identify actions to address the systemic causes of unsafe care.
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Content ArticleThis policy was written by Sussex Partnership NHS Foundation Trust. It is designed to ensure that concerns regarding the conduct or performance of staff which require formal investigation are investigated in a fair and consistent manner. Such an investigation may arise during the operation of other policies such as Dignity at Work, Grievance or Freedom to Speak Up. The outcome of the investigation may lead to further action such as a disciplinary hearing or use of the Managing Performance and Capability Policy. The policy identifies the circumstances in which an investigation will be necessary, the steps which should be taken in carrying out an investigation, the rights of staff during the process and potential outcomes.
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Content ArticleA candid discussion with photographer, father and patient safety campaigner, Scott Morrish, about how the NHS can create a just, learning culture and what the Ombudsman needs to do to improve its service.
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Content ArticleIn this video, the General Medical Council (GMC) discusses bullying and harassment and its impact on patient care. This is part of the Professional behaviours and patient safety training programme.
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Content ArticleThis study from Petschonek et al. published in the Journal of Patient Safety sought to develop a survey that would measure individual perceptions of Just Culture in a hospital setting. The research team created a 27-item survey, which displayed adequate theoretical structure and internal reliability.
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Content ArticleThe Institute for Safe Medication Practice shares key questions to help organisations assess their progress toward creating a Just Culture. They include results from the 2012 report on the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture to provide a national snapshot of where hospitals stand regarding certain aspects of a Just Culture.
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Content ArticleA presentation by Shelia Yates on root cause analysis and Just Culture. Shelia is trained and educated in the performance of behaviour health services through interpersonal communications and analysis.
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From 'no blame' to a 'just culture'
Patient Safety Learning posted an article in Good practice
Blog from Datix on the importance of why a 'no blame and just culture' needs to be embedded in every aspect of healthcare. -
Content ArticleThis resource supports organisations wishing to organise training exercises on how to use a 'just culture' guide. To help with the training, NHS Improvement have developed a series of case scenarios that facilitators can use to walk people through practical steps taken to achieve a just culture.
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Fostering Just Culture - a clinical leader view
Patient Safety Learning posted an article in Good practice
Amy Shaw, Clinical Leader, Specialist Learning Disability Division from Mersey Care Foundation NHS Trust, UK talks about 'fostering a just culture' in her trust. -
Content ArticleA template used by St Joseph Health, in the USA, to guide you through a just culture scenario.
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Just Culture - Podcast Radio 4
Patient Safety Learning posted an article in Culture
Margaret Heffernan, on BBC 4's podcast, explores why big organisations so often make big mistakes and asks if the cure could be the aviation industry's model of a 'just culture'. -
Content ArticleProfessor Sidney Dekker of Griffith University speaks about why things go wrong.
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Content ArticleProfessor Sidney Dekker explains Just Culture and why you need it, what it is and how you get it.
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Content ArticleRestorative Just Culture aims to repair trust and relationships damaged after an incident. It allows all parties to discuss how they have been affected, and collaboratively decide what should be done to repair the harm.
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Just Culture: The movie
Patient Safety Learning posted an article in Good practice
This film documents the amazing transformation in one organisation — Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey towards a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organisation to a place where hurt doesn’t get met with more hurt, but with healing. -
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The Just Culture Algorithm (March 2005, v1.1)
Patient Safety Learning posted an article in Culture
Infographic picturing the guide to the Just Culture Algorithm. -
Content ArticleThis case study, published in Safety Science, looks at aviation to illustrate the conflict, and double-binds, created as those in high-consequence industries negotiate the fluid lines of accountability relationship boundaries. This germane example is the crash of Swissair Flight 111, near Halifax, Nova Scotia, in 1998. The paper offers dialogue to aid in understanding the influence accountability relationships have on safety, and how employee behavioural expectations shift in accordance. McCall and Prunchnicki propose that this examination will help redefine accountability boundaries that support a just culture within dynamic high-consequence industries.
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Content ArticleThe Just Culture Guide from NHS Improvement supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely. It asks a series of questions that help clarify whether there truly is something specific about an individual that needs support or management versus whether the issue is wider, in which case singling out the individual is often unfair and counter-productive. It helps reduce the role of unconscious bias when making decisions and will help ensure all individuals are consistently treated equally and fairly no matter what their staff group, profession or background.
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Podcast: Incident reporting
PatientSafetyLearning Team posted an article in Good practice
Richard Smith is a trained paramedic who now works as Head of Quality and Safety at Addenbrooks Hospital. In this interview with East England Ambulance Service General Broadcast, Richard talks about his recent paper on incident reporting in the ambulance service. He asks if we have a blame and fear-free culture when concerns are raised, the value of feedback and highlights the importance of reporting the positive incidents too. -
Content ArticleThe National Guardian's Office (NGO) published a summary of speaking up learning and actions in response to its review into the handling of speaking up cases at Whittington Health NHS Trust. The review, carried out at the end of last year, revealed encouraging areas of good practice. There were also areas of improvement recommended by the review that highlighted issues with the wording and application of the trust policy relating to speaking up, support and feedback to those who speak up, and the way in which the trust manages grievances. The review summary details the NGO’s findings and actions of the trust.
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Content Article
If only...
Patient Safety Learning posted an article in Good practice from other industries
This documentary is about a tragic and avoidable accident which took place during a diver training course in May 2018. As with many adverse events, there were many contributory and causal factors involved. With hindsight, it is easy to spot them, but in real time, they aren't so obvious. Especially, when they happen relatively frequently without any adverse consequences. A remarkable film with many lessons relevant to health care around human behaviour, systems and just culture. -
Content Article
The right – and duty – of NHS staff to speak up
Hugh Wilkins posted an article in Whistle blowing
A blog from hub topic lead Hugh Wilkins on the recent messages from NHS England and NHS Improvement leaders reminding everyone, including those at board level, of the duty and right of staff to speak up about anything which gets in the way of patient care and their own wellbeing. Hugh highlights the real risk of reprisals against some staff who have raised concerns in the public interest, and points out that much needs to change before NHS staff can be sure that it is safe for them to speak up.- Posted
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Content ArticleStrengthening a safety culture necessitates interventions that simultaneously enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardisation/alignment.
