Guest blog on our new Just Culture approach

Clare Parker
Executive director of
nursing, healthcare professionals
and quality governance

Your best teacher is your last mistake.

That was my opening message for our Just Culture conference last week. I also talked about Tom Hanks and an error I made which has stayed with me. But more of that later.

Almost 200 staff packed the room to hear about our new Just Culture initiative, which is ultimately all about improving patient care. We also had the honour of welcoming Dr Bill Kirkup CBE as our guest speaker.

Bill was Chairman of the Morecambe Bay Investigation and has previously led investigations into the Oxford paediatric cardiac surgery unit and Jimmy Savile’s involvement with Broadmoor Hospital, as well as being a member of the Hillsborough Independent Panel. He spoke about his experiences and eradicating a blame culture in a honest, moving and inspiring speech.

Although a Just Culture approach is already being used in the airline and nuclear industries for example, it’s new to the NHS and I’m proud that we’re one of the first Trusts in the country to adopt it.

It’s basically based on an approach where staff aren’t blamed for honest errors. Instead we feel supported and encouraged to come forward and share our experiences to allow lessons to be learned. It aims to get to the heart of what, not who, was responsible for the error. 

Healthcare is risky; it always has been and always will be. When humans interact with humans its always complex, and in addition to that, we have limited resources and often have to make speedy decisions in a fast paced environment.

So mistakes are a fact of life, but they are an opportunity to learn.

No-one likes owning up to mistakes, and it’s even harder when people are harmed.   How we respond and learn from when things don’t go as we would have liked is fundamental to good patient care.

When an incident or near miss happens, it’s incredibly rare that it was intentional, malicious or someone not learning from mistakes. So supporting people positively is the only way we can make progress.

Often when we investigate, we miss the human factor. If you’ve seen Tom Hanks in the brilliant film Sully, which is about the pilot Chesley Sullenberger who dramatically landed his plane on the Hudson River in New York, saving all 155 passengers, you’ll know what I’m talking about.

If you’ve not seen this film, I highly recommend it. Not only is it a thrilling film, but within it is a powerful message about human factors.

Everything is unprecedented until it happens for the first time.

I pride myself in engaging and involving people, but I will always remember in a previous job when I met with a family to talk about our response to their complaint about one of our nurses.  Three days later I received an email from the nurse who was upset that I had never met with her or told her what I was going to say to the family. She felt her reputation, built over many years through consistently good care, had been ruined because of this complaint.

Her email floored me. She was absolutely right and I arranged to meet her and apologised. I used it as piece of reflective practice for my revalidation, and told the nurse I was doing this. 

I certainly learned from this and it has influenced my practice ever since.

There’s no easy or quick fix to eradicate a blame culture, but a positive and open workplace culture, with trust and respect among colleagues can help. This will form part of the wider piece of work around our culture and values.

We’ve got over 5500 staff and we care for thousands of patients every month, so we also need to always remember to put any incidents in context. Amazing work is taking place every day which is changing people’s lives.

We mustn’t carry our mistakes around with us, or jump to a blame game, but use them as stepping stones for us all instead.

Best wishes
Clare
Clare Parker
Executive director of nursing, healthcare professionals and quality governance