SHP hears from Dom Cooper on accountability in the workplace, error reporting and the meaning of ‘just culture’…
There is a lot of chatter on social media these days about not blaming people for any errors or for their contribution to adverse incidents; common refrains are ‘it’s the systems fault’ and/or ‘it causes under-reporting’. These views often spark a debate about the merits or otherwise of accountability, and are usually accompanied by the notion of a ‘just culture’.
A ‘just culture’ refers to an aspect of a ‘culture of safety’ that most people would consider to be morally fair and reasonable. Speaking to both a reporting and an accountability culture, James Reason[i] defined it as “an atmosphere of trust in which people are encouraged, and even rewarded, for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.”
As learned writing the psychological safety blog, error reporting is mostly determined by a good safety culture/climate, safety knowledge and motivation, trust, consistency of supervisory enforcement, quality of the error/incident reporting systems and severity of the potential impact of an error.
Defining what is acceptable and unacceptable can be difficult, but culpability models, as shown in Figure 1, can help shape thinking and guide action. These include James Reason’s focus on unintentional errors and intentional behavioural choices. Patrick Hudson[ii] extended Reason’s work to include a greater number of violation types (I would argue volition not violation). David Marx[iii] distinguished between inadvertent human errors, negligent conduct where there is a foreseeable risk of harm to others, reckless behaviour (gross negligence) where the risk of harm is patently obvious to any reasonable person, and intentional willful violations where it is obvious someone could get hurt, but the action is undertaken anyway. David’s language reflects that contained in legal frameworks.
Figure 1: Just culture culpability models combined
It is striking that, by and large, each culpability model appears aimed at front-line workers, given 80 percent of process safety disasters are due to managerial behaviour[iv]. Similarly, up to 50 percent of medical malpractice suits are caused by around two-three percent of medical doctors[v]. Such findings beg the question of whether current culpability models are actually suitable for use, and if they would be better aimed at managerial behaviour? After all, employee behaviour is a direct reflection of leadership’s behaviour[vi].
Applying accountability procedures and apportioning culpability might follow one, or a combination, of the culpability models. Table 1 shows that holding people accountable using these models almost entirely depends on determining the intentionality of those involved.
Table 1: Perspectives on the intentionality of people’s actions to determine culpability
Contrary to the common assertion that accountability means a blame culture[vii], Table 1 shows culpability is not automatically assigned to those involved in an incident. This viewpoint is supported by a retrospective patient safety study showing no blame was apportioned in 55 percent of reported medical incidents. Those where blame was assigned were primarily related to the possibility of formal medical complaints with legal ramifications (It wasn’t me guv, honest, it was ..…… ) [viii].
Searching the academic databases for evidence that a just culture led to either increases in incident reporting or decreases in adverse events proved fruitless. Ninety percent or more of the topic literature simply urges entities to develop a just culture, with no actual evidence available to show whether or not it makes a difference to error reporting or incident reduction. The survey evidence linking patient safety cultures per se and incident reporting also lacks statistical significance[ix]. Accordingly, this could indicate that the quality of the reporting system and other situational aspects, such as consistency of leaderships safety role-modelling and safety enforcement, are much more relevant solutions. Addressing these may prove more fruitful in improving incident reporting levels than trying to influence hazy cultural norms.
Surprisingly, given the voluminous scale of the extant literature, it appears a just culture is a construct lacking substance; much rhetoric and exhortation surround its use as a panacea for fixing under-reporting problems. However, there is a distinct lack of evidence showing that a just culture will lead to an increase in incident or error reporting. The construct seems to be based solely on ‘blind faith’.
Trust is at the centre of a just culture[x]: it is thought to promote the reporting of incidents by instilling confidence that people will not be unfairly ‘blamed’ for an adverse incident. Certainly, people fear being blamed for an adverse event more than they fear being punished[xi], and perhaps it is this fear, rather than anything else, that drives and perpetuates the idea of a just culture.
Intentionality is the key aspect of apportioning accountability. Like many, I don’t believe it is unjust to hold people responsible and accountable for their intentional roles and contributions to an adverse workplace event. However, the constraints and influences from a variety of situational elements impacting those involved must also be determined and acknowledged[xii]. In my view, this is a much better way to address people’s fears about blame that will, perhaps, result in tangible benefits such as an increase in error or adverse-event reporting. Ultimately, holding people responsible and accountable, especially for breaches of critical risk controls, should lead to much lower levels of harm[xiii].
References
[i] Reason, J., (1997). Managing the Risks of Organizational Accidents. Ashgate Publishing Ltd., Aldershot, Hants.
[ii] Hudson, P. T. W., Bryden, R., Vuijk, M., Biela, D., & Cowley, C. (2008, April). Meeting expectations: A new model for a just and fair culture. In SPE International Conference on Health, Safety, and Environment in Oil and Gas Exploration and Production. OnePetro.
[iii] Marx, D. A. (2001). Patient safety and the “just culture”: a primer for health care executives. Trustees of Columbia University.
[iv] Cooper, M.D. (2016). Navigating the Safety Culture Construct: A Review of the Evidence. BSMS: Franklin.
[v] Levitt, P., 2014. When Medical Errors Kill: American Hospitals have Embraced a Systems Solution that Doesn’t Solve the Problem. LA Times, 10.
[vi] Cooper, D. (2010). Safety leadership: application in construction site. Giornale Italiano di Medicina del Lavoro ed Ergonomia, 32(1 Suppl A), A18-23.
[vii] Waring, J. J. (2005). Beyond blame: cultural barriers to medical incident reporting. Social Science & Medicine, 60(9), 1927-1935.
[viii] Cooper, J., Edwards, A., Williams, H., Sheikh, A., Parry, G., Hibbert, P., Butlin, A., Donaldson, L., & Carson-Stevens, A. (2017). Nature of blame in patient safety incident reports: mixed methods analysis of a national database. The Annals of Family Medicine, 15(5), 455-461.
[ix] Jang, S. J., Lee, H., & Son, Y. J. (2021). Perceptions of patient safety culture and medication error reporting among early- and mid-career female nurses in South Korea. International Journal of Environmental Research and Public Health, 18(9), 4853.
[x] Cox, S., Jones, B., & Collinson, D. (2006). Trust relations in high‐reliability organizations. Risk Analysis, 26(5), 1123-1138.
[xi] Gorini, A., Miglioretti, M., & Pravettoni, G. (2012). A new perspective on blame culture: an experimental study. Journal of Evaluation in Clinical Practice, 18(3), 671-675.
[xii] Parker, J., & Davies, B. (2020). No blame no gain? from a no blame culture to a responsibility culture in medicine. Journal of Applied Philosophy, 37(4), 646-660.
[xiii] James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122-128.
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Very good article. Thank you