Achieving a restorative Just Culture through the patient safety incident response framework

Despite years of calls for the adoption of a Just Culture, it has been observed that healthcare organizations still apportion blame to individuals all too easily and too frequently.^1,2 Wu and Kachalia suggest that our insights from frontline staff involved in incidents regarding the “justness” of the Just Culture framework are incomplete and highlight the need to examine the relationship between Just Culture, the appropriateness of the remedy, and workers’ willingness to uphold key characteristics of safety culture thereafter. ²

The Just Culture approach aims to strike a balance between not blaming individuals for “honest” mistakes and holding them to account for reckless behavior. ³ Kirkup outlines succinctly that while this approach might be well intentioned, its practical application via so-called Just Culture algorithms falls short of expectations and might even be counterproductive. ⁴ Kirkup argues that the approach of starting with whether an individual provider intentionally caused harm puts those involved in patient safety incidents on the defensive, leaving a taste that lingers in subsequent discussions intended to facilitate a learning response from a systems perspective.

Regardless of debate about the degree to which individuals, intentionally or unintentionally, contribute to an adverse event, evidence suggests that interventions aimed at the individual are weaker and less effective than systems-based interventions. ⁵ This reinforces that a culture (just or otherwise) that aims to foster a learning response needs to be underpinned by a systems mindset. ⁶ From this perspective, patient safety incident learning responses might shift from a specific patient safety incident to uncover and learn from everyday work. From a systems perspective, the definition of accountability should expand to account for the complexities of everyday work. ⁷

The implementation of Just Culture using tools such as Just Culture algorithms and guides can potentially facilitate learning about the particular event under analysis. However its application without parallel efforts to repair trust and relationships can perpetuate a deeper, more insidious threat to the institution's safety foundation. ⁸ While Just Culture focuses on learning from a specific patient safety incident, there is also a need to consider how the framework, processes associated with safety investigations, and structures to support safety work are received by those affected by harm, including patients, family members, and healthcare staff. It is clear that the harm from the event itself is compounded by additional harm due to an organization's lack of response and exclusion of those impacted. The 2022 Radonda Vaught trial in the US emphasized the degree to which organizational responses to harm can predispose staff behaviors, such as protests, attrition, and anxieties due to broken trust and inadequate healing after an event.^9,10

The recent independent investigation into maternity and neonatal services in two NHS hospitals in East Kent highlighted with shocking clarity how patients, family members, and staff can feel invisible, insignificant, disposable, powerless, and alienated after a patient safety incident. ¹¹ The event response efforts taken at the time were characterized by mistrust and defensiveness, ultimately compromising the ability to learn from an event and to put meaningful actions in place to improve patient safety. The independent investigation revealed numerous examples of the additional harm, beyond the initial harm event, that occurred as a result of inattention to repairing relationships and regaining trust with staff, patients, and family members. Examples of further harm done to patients and families after an event include not being told what had happened, ambiguity around the response process and how they would be involved, being left to wait without word of next steps, failure to acknowledge the distress from the harm event, minimal provision of support services after an event, and suggestions that the patient or family members were to blame for the event. The East Kent report also identified outcomes characteristic of the lack of attention on relational repair, including recrimination, learning opportunities being perceived as punishments, and knee jerk reactions to punish rather than inquire.

A Restorative Culture (also referred to as Restorative Just Culture) focuses on healing and repair of relationships. ¹² This approach places emphasis on understanding the needs of those caught up in a patient safety incident and determining who is best placed to meet these needs and how. This also feeds back into organizational learning to further improve compassionate engagement and systems-based learning responses in the future.

Under the assumption that organizations and their workers never intend to cause harm, it appears that the aforementioned disconnect is due to a lack of guidance on how to mitigate additional harm in patient safety learning response processes that are often embedded in large, Kafkaesque structures. Recognizing the importance of learning from patient safety events in parallel with restoring trust and relationships, NHS England published the Patient Safety Incident Reponses Framework (PSIRF) in August 2022 to replace the existing Serious Incident Framework. ¹³ PSIRF builds on four foundational pillars that put relationships and systems thinking at the center: (a) compassionate engagement and involvement of those affected by patient safety incidents, (b) application of a range of systems-based approaches to learning from patient safety incidents, (c) considered and proportionate responses to patient safety incidents, and (d) supportive oversight focusing on improvement. The additional PSIRF guidance on “Engaging and involving patients, families, and staff following a patient safety incident” focuses on preventing compounded harm during the safety investigation and outlines nine principles to inform the design of organizational systems and processes for optimal engagement. These principles include, but are not limited to, sincere apologies, individualized approaches, respect towards all impacted, and clarity in the process and what to expect. Providers of secondary care to NHS patients in England are required to transition to PSIRF over the course of 2023, and large-scale evaluation of the approach will be required. As written, PSIRF offers promise of increased attention to restorative Just Culture within England's safety work.

The journey towards implementing a Just Culture has only begun. The systems mindset needs to underpin patient safety incident learning responses. These responses need to go hand in hand with compassionate engagement with patients, families, and staff to rebuild trust and relationships as part of Restorative Just Culture. Increased attention at the national level is a key step forward to actualizing these principles in day to day safety work.