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Showing results for tags 'Just Culture'.
Found 210 results
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Content ArticleThis paper, summarised in the Journal of Hospital Administration, concludes: "Embedding Restorative Just Culture and Safety II concepts into the incident review process is associated with improved measures of culture and review outputs. The integration of Safety II concepts and support of cultural shifts will require further work and committed leadership at all levels."
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Content ArticleThese slides provide the outline of a tutorial about the Causal Analysis using System Theory (CAST) and System-Theoretic Accident Model and Processes (STAMP) approaches to accident analysis, delivered at the Second STAMP Conference in 2013. The presentation slides cover: Model and method: Why STAMP and CAST? Why do accident analysis? Goals for an accident analysis technique Overcoming hindsight bias CAST worked example of emergency plane landing
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Content ArticleThe Resilient Surgeon is a podcast by The Society of Thoracic Surgeons in the US. In this episode, Dr Michael Maddaus interviews Dr Amy Edmondson, a scholar of leadership, teamwork and organisational learning. Dr Edmondson defines psychological safety as a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. It makes a team a safe place for interpersonal risk-taking. In this podcast, she explains how psychological safety is the key to unlocking high quality conversations that result in improved team outcomes.
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Content ArticleHealthcare organisations have struggled to move from a culture of blame to a ‘just culture’, despite this being stated as a goal for several years. As a result of this cultural inertia, the original principles of a just culture require critical examination. A just culture is still seen primarily as a linear mechanism to apportion liability. Within our complex healthcare organisations, this approach is inadequate. In this article, Paul Stretton proposes a revised approach to creating a just culture, which enables learning from all events, irrespective of outcome. There should be a focus on learning, rather than liability, with a presumption of good intention until proven otherwise. This more compassionate and respectful approach can help to move healthcare organisations towards a just culture and create an atmosphere of trust.
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Content ArticleSKYbrary is an electronic repository of safety knowledge related to flight operations, air traffic management (ATM) and aviation safety in general. It is also a portal, a common entry point, that enables users to access the safety data made available on the websites of various aviation organisations – regulators, service providers, industry.
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Content ArticleAs highlighted by NHS England with the NHS People Plan[, healthcare organisations that prioritise workforce wellbeing will be better placed to put lessons learnt from the coronavirus pandemic into practice. Phil Taylor of RLDatix outlines the benefits of introducing a just culture not a blame culture and shares a methodology for positive change.
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Content ArticleIn September this year, as part of World Patient Safety Day, Patient Safety Learning asked people, via social media and the hub, to name three things staff most needed to be safe. We gathered your responses and are now pleased to present an image which shows the most common themes. According to the responses we received, the four themes that became most obvious – the four things you think staff most need to be safe – are: Compassionate leaders and role models who prioritise their staff’s wellbeing A respectful, supportive team with good communication and united by a common purpose A safe and just culture that invites staff to speak up Psychological safety, protecting staff from burnout.
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Content ArticleIn his latest blog, Steven Shorrock explores what humanistic values and human decency means in management and organisational behaviour. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
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Content ArticleWhen things go wrong, we seem to display a reliable tendency to do one thing: blame those at the ‘sharp end’. No matter how complex the system, how uncertain the situation, or how inadequate the conditions, our attention post-accident seems to turn to those proximal to the consequence, whom we judge to have failed to control the hazard in question. The notion of ‘just culture’ has developed over the past decade or so in response to this and is highly valued by front line staff. Just culture is, however, borne of the Safety-I mindset. Since the advent of ‘just culture’, the Safety-II perspective has emerged. Safety-II defines safety not as avoiding that things go wrong but as ensuring that things go right. Safety-II views the human not as a hazard, but as a resource necessary for system flexibility and resilience. In light of this, it has been proposed that the idea of just culture should be abandoned. If we take a Safety-II view, ‘just culture’ might indeed seem unnecessary. Steve Shorrock explores this further in his latest blog.
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Content ArticleWhy is it hard for a highly trained professional to speak or report about mistakes made by him or her? Jean-Pierre Kahlmann, a retired Military and Airline Pilot, and now Co-owner and CEO of Yes Human Factors Ltd, believes that every staff member in an organisation should feel safe to use her or his voice to speak about safety issues, mistakes and how to learn and improve. In this TEDx presentation, Jean-Pierre takes you on a trip through his Airforce and civil aviation career to show the added value of Just Culture in high reliability organisations. He talks about his, initial, internal resistance against speaking about his mistakes and he sees the same resistance within the culture of health care professionals.
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The problem with policies – a blog by Lynne Williams
Lynne Williams posted an article in Improving patient safety
How can we turn the good intentions of a policy into a working model that people use? How can we ensure policies are translated into real, practical solutions? In this blog, Lynne Williams discusses why effective policy implementation is as crucial and important as the content and why we need to look at policies as a collaborative project, headed up by Governance, but written in partnership with the staff that use them to ensure we provide consistent, safe care. -
Content ArticleSuzette Woodward is a Senior Advisor for the Department of Health and Social Care and NHS Resolution. She is one of the authors of Being fair: Supporting a just and learning culture for patients and staff following incidents in the NHS. These slides and accompanying commentary give an idea of the content of the report and it’s purpose.
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Content ArticleA concept called “psychological safety” is especially crucial to a team’s success, according to Amy Edmondson, professor of leadership and management at the Harvard Business School. Psychological safety describes “a workplace where one feels that one’s voice is welcome with bad news, questions, concerns, half-baked ideas and even mistakes,” Edmondson tells CNBC Make It. People should feel like they can ask questions, raise concerns and pitch ideas without undue repercussions. This article gives a good introduction to what psychological safety is and how to achieve it in the work place.
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Content ArticleThis Health Service Journal (HSJ) article explores how executive leaders can drive improvement by focusing on developing an organisational culture, building up staff in an open, just, and empowering environment, thereby enabling organisations to meet the challenges of the new and uncertain healthcare environment.
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Flight Safety Foundation: Just Culture Manifesto
Patient Safety Learning posted an article in Culture
“Just Culture” is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. Organisations are run by people. In tens of industries – transportation, healthcare, energy, internet, and more – thousands of occupations, and millions of organisations around the world, it is people who make sure that things normally go well. And they nearly always do. But sometimes, things go wrong. Despite our best efforts, incidents, accidents and other unwanted events happen. Following such events, there is a need for support and fairness for those involved and affected, and learning for organisations, industry and society as whole. In the absence of intentional wrongdoing or gross negligence, these obligations should not be threatened by adverse responses either by organisations or States. The Flight Safety Foundation outline their Just Culture Manifesto and invite all who support the principles in this Manifesto to join them, and to help make Just Culture a reality in all countries, industries, and occupations. -
Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without a blame and shame approach.
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Nigeria: World Patient Safety Day 2020
Patient Safety Learning posted an article in Staff safety
Nigeria joined the rest of the world to celebrate World Patient Safety Day on 17 September 2020. This event was jointly organised this year in Nigeria by the Occupational Health and Safety Managers (OHSM), Medical and Health Workers Union of Nigeria (MHWUN), OSHAfrica, International Trade Union Congress (ITUC-Africa), Nigeria Labour Congress (NLC), Patient Safety Movement Foundation (PSMF) and the World Health Organization (WHO). -
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Mersey Care NHS Foundation Trust: Staff Charter
Patient Safety Learning posted an article in Good practice
At Mersey Care NHS Foundation Trust, care and compassion is at the heart of everything they do. Their ambition is to deliver perfect care to become the world’s leading organisation in holistic health and well being. They strive to work side by side with their colleagues, the people who use our services, carers and families, and the communities they serve. The Mersey Care Staff Charter has been updated collaboratively and it highlights what is expected of their staff in supporting our Just and Learning Culture and what their staff can expect from the Trust in return. -
Content ArticleThis survey, a collaboration between the International Society for Quality in Healthcare (ISQua) and the International Hospital Federation (IHF) was designed to frame the WHO Global Consultation on Patient Safety, which was held from 24-26 February 2020 to kick off the development of the Global Patient Safety Action Plan. Already then, the pandemic-to-be was affecting various regions, before striking health systems worldwide. The question of patient safety is a critical one in the discussion about COVID-19: hygiene and hospital-acquired infections, non-suitable hospital architecture, delayed surgeries and procedures, lack of personal protective equipment (PPE) and much more affected the safety of patients as well as of health workers, to whom the World Patient Safety Day 2020 is dedicated. In February 2020, the IHF disseminated a short survey on national safety plans to its Full Members, hospitals’ national/regional representatives. At the same time, ISQua disseminated their survey asking how well incident reporting is in place, and if the outcomes improve the 'no blame no shame' approach to their Individual and Institutional Members. The surveys were repeated in July 2020 to see if the onset of COVID-19 had made any positive or negative changes to the responses.
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Content ArticleMany mental health service providers around England are meeting complex challenges with exceptional innovation, energy and creativity. NHS Improvement has drawn on this experience, skill and expertise to develop a national model to support continuous improvement in service delivery. This practical resource offers experience from those that have travelled the journey already, in the hope of supporting and encouraging other mental health trusts or any healthcare provider wishing to improve its services. Chapter 7 looks specifically at safety, clinical audit and clinical governance. It shows that a structured approach to improvement supported by an open and just culture can make safer ways of working part of an organisation’s DNA. It recognises that organisations also need robust and transparent governance to keep services safe during major change.
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Content ArticleThe US-based Institute for Healthcare Improvement (IHI) reviewed available evidence for interventions that can help protect staff mental health in the face of extreme working conditions such as natural disasters, terrorist attacks, and previous pandemics. They synthesised this research into evidence-based “psychological PPE” recommendations for use by staff providing care during the COVID-19 pandemic.
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Content ArticleOn Thursday 30 July 2020, NHS England and NHS Improvement published the NHS People Plan for 2020/21. Building on the Interim NHS People Plan released in 2019, it describes itself as focusing on “how we must all continue to look after each other and foster a culture of inclusion and belonging, as well as action to grow our workforce, train our people, and work together differently to deliver patient care”. In this blog, Patient Safety Learning looks at the People Plan with specific reference to its approach to tackling the blame culture in the NHS, which is a significant factor in the safety of patients and staff. It highlights where we think the People Plan has not addressed these well-known concerns and what more needs to be done urgently.
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Amy Edmondson: The importance of psychological safety
PatientSafetyLearning Team posted an article in Staff safety
As a leader how can you foster a work environment where people feel safe to speak up, share new ideas and work in innovative ways? In this video from the Kings Fund, Amy Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, talks about the importance of psychological safety in health and care and what leaders can do to create it. -
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The challenge of culture change in the NHS
Claire Cox posted an article in Culture
Connection, inclusion and compassion are certain, unchanging, and provide a safe refuge to deal with what feels frightening and isolating for so many. The challenge set by the Francis Inquiry Report – to create a compassionate, inclusive organisational culture – is now amplified in the COVID-19 era, which the NHS entered with pre-existing record levels of staff stress and chronic excessive workloads. This workshop from the University of Manchester, explores the problems and opportunities associated with changing healthcare organisation cultures. -
Content ArticleReport from the Saudi Patient Safety Center on: 1. Hospital Survey on Patient Safety Culture National Recommendations Cycle 2: (2019), and 2. National Supplementary Recommendations related to COVID-19.
