We recently took part in a webinar hosted by the HSE National Quality and Patient Safety Directorate (NQPSD) about building a just culture and how we can support staff and treat them in a just and fair manner, and support them to respond to patients and their families when an incident happens.
Clinical Director of CervicalCheck, Professor Nóirín Russell, joined the webinar to share some learnings and reflections on how we can all support a just culture.
Setting the scene
Assistant National Director Incident Management with the NQPSD, Lorraine Schwanberg, explained that a just culture is critical for the safety of our patients, and for the wellbeing of our staff.
Demonstrating where ‘just culture’ has come from, Lorraine said that past dialogue was centred around a blame culture, and incident management would establish ‘who did what’ in an incident. “This does not show an appreciation of the different contributing factors as to why an incident might happen,” Lorraine said.
A no-blame culture is not ideal either, Lorraine explained. “There has to be a level of accountability and professionalism.”
Just Culture in the HSE’s Incident Management Framework, Lorraine said, is described as a values-based, supportive model of shared accountability.
Lorraine described the importance of an atmosphere of mutual trust, of ensuring that systems are in place to create that “psychological safety for persons to speak up” without fear of reprisal, so that we can get to the bottom of what happened and identify the learnings and improve safety.
Communications should be “strong and robust” and “open and transparent with patients and their families”, with regular updates, when responding to an incident. Ongoing communications should be maintained, Lorraine said, “so that we don’t lose trust. This is where accountability comes into the fore and is important for the organisation. It’s not about blaming individuals.”
CervicalCheck: looking back to learn
Prof Nóirín Russell, having had the opportunity to reflect on the CervicalCheck crisis, shared some learnings from this time. “These are observations of how we can do better in times of crises,” Prof Russell said. “This is not a story about blame. This is a story about humans – humans who receive healthcare; humans who provide healthcare. At the centre of all our responses to adverse events is that human piece.”
Incident management
Prof Russell explained that whenever there is an incident there is an immediate need for the system to determine:
- if immediate actions need to be taken to stop more patients coming to harm
- the facts of the incident and the implications
There is a need for coordinated communications, with a mix of expertise:
- to keep the person/people at the centre of the incident informed of what is happening
- to ensure patients have access to senior HSE staff (clinical and non-clinical), and
- to ensure that front line staff, their managers and senior HSE staff are in regular communication.
In the management of the CervicalCheck crisis there was “an incredible sense of urgency”, Prof Russell said, which led to the open disclosure process being rushed. She said that it wasn’t understood that disclosure of audit results would not change the care of patients, and that “we needed to reflect on that and what that felt like for patients and for staff”.
Listening to the patient perspective
Prof Russell spoke to the consultation co-designed with patient advocacy group 221+ to understand what the disclosure process felt like. Patients described the overall process as confusing and disorganised; communications as lacking and unclear; and the emotional impact as painful and frustrating. The consultation report includes a process for improvement and cultural change in communicating screening information to patients who get a cancer diagnosis after screening. The resulting personal cervical screening reviews offer an open, patient-centred process for this communication to take place.
Listening to the staff perspective
Prof Russell referenced our ongoing research with the colposcopy community that shows how a lack of good communications and clear explanation on the audit results and their implications negatively affects staff. Colposcopists felt unprepared and did not feel confident participating in disclosure meetings. One colposcopist said: “We had to contact all our patients… It was hard because no one explained why it was happening, and why it was instigated. We did not have the language to do it and were not prepared for it at all.”
Reflections
Prof Russell said it is evident that rushing the disclosure process can cause harm to patients and to staff. “It’s important we listen to patients who have been through an open disclosure process, and that we care for our staff so that they can care for the patients. We need to keep humans and humanity at the centre of all our processes.”
Prof Russell presented some reflections on how we can do better, and how we can learn from the CervicalCheck crisis to the benefit of patient and staff care:
- Communication needs to focus on reassurance: determine who is and who is not at risk and communicate it clearly; determine the facts and clearly explain these to stakeholders; keep the affected patient/people involved at the centre of communications; ensure information is consistent, clear, timely and based on credible evidence; and address misperceptions to maintain trust and confidence.
- Plan robust internal and external communications: identify and support the clinical lead(s) with communications expertise; identify the key messages and how best to communicate them; create a multi-stakeholder expert group to ensure clear internal communications involving frontline staff as well as senior management; train and maintain communications with frontline staff to ensure clear external communications with patients and the wider public.
- Open disclosure needs careful planning: ensure all stakeholders are involved in planning patient meetings; establish clear links between HSE management and frontline staff; ensure staff are trained and supported – supporting staff supports the patients.
These learnings have been incorporated into the World Health Organisation’s best practice recommendations for cervical screening programmes globally. Its strategy for crisis communications in a screening programme is applicable across healthcare settings.
Closing the webinar, the panel agreed that a just culture emerges from having clear values and demonstrating them through actions. Honesty, humility, humanity and ensuring patients and staff are heard, are some of those important values.