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Being Fair Supporting a Just and Learning Culture for Staff and Patients Following Incidents in the NHS

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Being Fair Supporting a Just and Learning Culture for Staff and Patients Following Incidents in the NHS Being fair Supporting a just and learning culture for staff and patients following incidents in the NHS Advise / Resolve / Learn Advise / Resolve / Learn Contents Contents Key messages 5 Examples of practices used across the NHS – see details in examples 9 Example 1 – Just learning culture charter 10 Example 2 – Mersey Care - a restorative approach 13 Example 3 – Barts Health NHS Trust - pre-disciplinary checklist 14 Example 4 – NHS Improvement - A just culture guide 17 Background to guidance 18 Section 1 – Introduction and purpose 19 Section 2 – Context and theory 20 Section 3 – Impact on staff 25 Inequity 25 Fear 26 Incivility and bullying 27 Section 4 – Claims 28 Claims related to staff and bullying 28 Table 1: Numbers of all claims by date of notification an annual cost 28 Table 2: Numbers and value of claims by type of NHS organisation 29 Figure 1: Claims notified to NHS Resolution 2013 to 2017 (n=317) 30 Descriptions of harm within these claims 31 Section 5 – Suspension, exclusions and professional regulation 32 Suspension / exclusion 32 Professional regulation 33 Conclusion 34 References 36 3 NHS Resolution Being fair Key Forewordmessages 4 Key Forewordmessages Key messages A just and learning culture is the balance of fairness, justice, learning – and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong. It is also not about an absence of responsibility and accountability. The vast majority of people We recommend using a who work in health and social balanced approach to safety, In order to achieve a just care wish to provide the very i.e. that we learn from when and learning culture when best care they can, given the things go wrong and learn care has not gone as circumstances they are working from when things go right. expected or planned, three in. There is very rarely intent If we progress this thinking questions (Dekker 2017) by staff to provide care that then the definition of safety should be asked: did not go as expected or shifts from ‘avoiding something • who is hurt? planned. While this guidance that goes wrong’ to ‘ensuring • what do they need? is predominantly about how that everything goes right’. • whose obligation is it staff are treated, this is with Then we can help people to meet that need? the intent to ensure that the succeed under the varying benefits of a just and learning conditions so that the number A Just and Learning Culture culture for staff will have a of intended and acceptable Charter is provided (see significant and positive impact outcomes is as high as possible. example 1) for you to on patients and their families. adapt and adopt which A resilient organisation helps includes many of the key All actions should be staff work safely every day. messages that organisations understood before being Resilience also provides the can consider. judged and staff should be ability for an organisation supported to learn from their to sustain its operations actions. Furthermore they under both expected and should be asked for their unexpected conditions. advice and help to design the systems that could help change things for the better. Those responsible for managing incidents should use the science of human factors, including investigative techniques, skills, expertise and methods that help us fully understand what happened in order to learn from errors or harm in the future. 5 NHS Resolution Being fair Co-designing the solution to developing a just and learning culture A roundtable workshop of work is actually done and HR directors, regulators, NHS not the work that people The overarching aim of the arm’s length bodies and some (leaders, policymakers, group was to provide the patient safety experts was regulators) imagine is NHS with the latest thinking convened by NHS Resolution or could be happening together with guidance on in February 2018 to explore how to replace blame with • Identifying what good the concept of developing a learning, and to ensure practice looks like just and learning culture and that there is equity for all staff and a proportionate to share best practice. • The importance of role response to concerns about modelling and leadership Participants discussed the performance or behaviour by example need for: for all staff, regardless of • Creating ways in which race, ethnicity, disability • Linking patient safety staff can be listened to or sexual orientation. with staff engagement, and using staff stories health and wellbeing Central to the approach at Board level and other in the future, the group • The balance of learning, senior leadership meetings agreed three aims: accountability and • Building a strong partnership responsibility 1 To prioritise learning with ‘staff side’/staff about how to minimise • An understanding of why representatives and the conditions and or whether a disciplinary involvement of staff behaviours that can investigation is the right diversity networks underpin or lead to error response following an • Tackling incivility and the rather than apportion incident bullying culture within individual blame. • Use of the science of health and social care 2 Build a consistent human factors and the • Where appropriate, using approach for all staff, no latest thinking on third-party advice (e.g. matter what profession creating a just culture Practitioner Performance or what background. • In addition, a focus on Advice service – within 3 A determination to behavioural change and NHS Resolution). avoid, wherever possible, understanding more about inappropriate suspension, a ‘safety II’ approach in exclusion and disciplinary terms of learning what action unless there is works and the specific wilful intent. aspects of working in health and social care, i.e. the difference between how 6 Co-designing the solution to developing a just and learning culture What we need is a restorative the right conditions to • Early intervention by just culture (Dekker 2018) help people work safely trained and committed that is about repairing and by truly understanding senior staff to distinguish building trust and relationships what work is like and not between blame and when things have not gone as how it is imagined to be accountability based on a planned. This means we need (Hollnagel 2013) thorough understanding to develop working practices of human factors, patient • An emphasis on ensuring that move people away from safety, the restorative just that new staff (whatever fear and blame, including and learning culture, and their background, and tackling incivility and bullying, behavioural psychology especially if trained overseas) and addressing the health are supported and are aware • Speedy interventions to and wellbeing needs for staff of the organisation’s values determine whether any to help them work safely. and the behaviours they form of disciplinary Ensure everyone’s needs are should expect for themselves investigation is needed and met, no matter who they are. and from others timely resolution for all Treat everyone fairly, no matter what their background is, • An acknowledgement that • The use of a tool such as a and help them speak up. excessive and inappropriate triage approach, checklist disciplinary action may be or prompts simply to help To create a just and learning taking place in respect of reflection and challenge culture the group considered staff from all backgrounds prior to any disciplinary a need for: and especially, unwittingly action– and to use these • All staff, patients and their or otherwise, those from with caution to ensure families to be provided BAME (black, Asian and that they do not lead to an with appropriate support minority ethnic) backgrounds inappropriate focus on the at all times individual or individuals, • Reduce the need for i.e. that they in themselves • To ensure that the culture inappropriate disciplinary do not perpetuate a blame is restorative for all and not investigations culture in some way retributive or adversarial • Using staff data related (Dekker 2018 and 2017) • Accountability of decision to disciplinary action, makers throughout the • A challenge in the current suspensions and exclusions system to learn. thinking and a change to check if any patterns of in mindset in relation to high (or disproportionate) healthcare and how it could levels of disciplinary action be safer, with a focus on exist and why, and whether, learning rather than blame over time, they are reducing and with a focus on creating 7 NHS Resolution Being fair 8 Examples of practices used across the NHS Examples of practices used across the NHS The following are just a few examples of what people are doing in the NHS as a way for others to see the kinds of ways in which a just and learning culture could be built. Organisations are at different However the use of an stages, and are still learning agreed tool or framework about what works. There by organisation is helpful are a variety of approaches in supporting a more being taken, with no single consistent approach approach recommended over towards all staff groups. another (further examples of best practice may also be helpful to consider). Example 1 - Just and learning culture charter. Example 2 - Restorative approach: Mersey Care NHS Trust and the use of a restorative approach adopted from and influenced by the work of Professor Sidney Dekker (2017). Example 3 - Triage system: Barts Health NHS Trust and the use of a triage system to determine whether disciplinary action is necessary or inappropriate. Example 4 - A just culture guide: NHS Improvement ‘just culture guide’ which also acts as an aide memoire for people to assess the appropriate response when something goes wrong (NHS Improvement 2018). 9 NHS Resolution Being fair Example 1 Just and learning culture charter The following is a suggested ‘Just and Learning Culture Charter’ for organisations to adapt and adopt.
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