Restorative just culture significantly improves stakeholder inclusion, second victim experiences and quality of recommendations in incident responses

This paper explored the impact of a new response to clinical incidents, which utilised a Restorative Just Culture (RJC) framework and Safety-II principles.

Impacts were evaluated via staff surveys of perceptions of just culture and second victim experiences, quality of incident recommendations were compared before and after implementation and assessed via a healthcare hierarch of control, and process audits were also undertaken.

Providing background:

·??????“Current approaches to improving healthcare safety and quality are not unequivocally successful” and one reason is that “our growing understanding of the complexity of healthcare is yet to be adequately reflected in our approaches to adverse event investigation and in our safety and quality improvements” (p8)

·??????This is influenced by some current approaches that see complex systems as componential and linear, thereby reducing adverse events to simple causes or broken parts which can be fixed with “a policy, rule or poster” (p9)

·??????They further argue that in the context of mental health, this approach “can drive restrictive practices, risk secrecy and underreporting because of the backward-looking accountability of traditional, retributive just cultures that are organized around individual actions, transgressions and consequences” (p9)

·??????As a counter, they argue that openness about potential harm and psychological safety allow all parties to tell their stories, which provides a strong driver for learning and improvements; facets associated with lower mortality rates

·??????Restorative Just Culture (RJC) “sees safety (“Safety II”) coming from the resilience and adaptations to respond to challenges …even if these fall outside the scope of design, training or quality initiatives” (p9)

·??????RJC is said to promote healing, learning and quality improvement “by asking what needs to be done to set people up for success, including consumers, families, clinicians and organizational stakeholders.[19] It tends to capture the complexities of both “causes” and improvements because of the broader, forward-looking conversations it engenders” (p9)

Too many findings to present in whole, so I’ll pick a few but you should check out the whole paper if you’re interested.

Results

Overall, they note that the results demonstrated:

·??????Improved just culture and second victim experiences

·??????Performance of reviews of a much larger range of incidents and near misses

·??????A deeper understanding of what is going well

·??????Improved stakeholder engagement, in line with RJC

·??????An increase in number, strength and quality of recommendations

To their knowledge, “no other policy changes, adoptions or cultural shifts that may have occurred and could account for the effects we have observed” (p14).

For some specific findings, statistically significant changes were observed pre- and post-intervention:

·??????Fewer staff reported being afraid of disciplinary actions (27.3% vs 34.9%) or of being blamed when involved in an event (16.5% vs 20.3%)

·??????Higher proportion of staff expressed trust in the hospital to handle events fairly pre and post (25.3% vs 40.3%) and believed the hospital to see clinical incidents as opportunities for improvement (43.2% vs 56.8%)

·??????Greater proportion of staff felt that the organisation understands they need help with effects of their involvement in incidents (54.9% vs 61.1%)

·??????50% of staff disagreed that the organisation does not show concern for the well-being of staff involved in incidents (an increase from 39.3% pre-intervention)

·??????Statistically significant associations for the staff’s ability to actively participate in incident review processes, and more positive perceptions on all domains of just culture, less distrust and negative impacts following incidents, perceived higher levels of support from work and non-work related sources and lower turnover intentions and reported absenteeism

Regarding the characteristics or quality of recommendations following incidents:

·??????All reviews of incidents in the analysis post-intervention included recommendations compared to 78.1% of reports including recommendations pre-intervention

·??????Average number of recommendations per incident was significantly higher than before implementation (1.9 pre to 3.9 post)

·??????The greatest change was seen in the effectiveness/evaluation domain of recommendations. 96% of recommendations post-int included a plan to determine if the recommendations had been implemented (an increase from 84.8%) and a plan to evaluate effectiveness of the recommendation (22.7% post vs 7% pre)

·??????Auditors considered 81% of recommendations post-int as making a different to the identified issue; an increase from 64.8%

·??????The intervention contributed to the development of more specific recommendations with clear aims and more measurable recommendations that included substantive measures of performance improvement

Some differences pre- and post-intervention, particularly when assessed via auditors rather than the incident teams were not statistically significant.

In discussing the findings, they note that despite many significant improvements in the quality and strength of recommendations post-intervention, few were still classified as strong (according to the auditors vs incident team).

However, they note despite this finding “there were substantial changes away from modifying procedures and rolling out education, and towards more resilient responses such as enhancing team coordination, engaging with families, and simulation exercises to understand work as done” (p14).

Further, the “learn anything” principle, rather than focusing on incidents, aligned with feedback from families about the previously limited scope of incident review processes. Here they argue that families raise issues about care and engagement or suggest improvements that may appear, on the outset, as unrelated to internal system performance, but “can address issues including demand and capacity misalignments which could have proactively reduced risk rather than only responding once harm had occurred” (p15).

In concluding they state “Embedding RJC and Safety II concepts into the incident review process is associated with improved measures of culture and review outputs. The integration of Safety II concepts and support of cultural shifts will require further work and committed leadership at all levels” (p8).

Link in comments.

Authors: Turner, K., Sveticic, J., Grice, D., Welch, M., King, C., Panther, J., ... & Dekker, S. (2022). Journal of Hospital Administration, 11(2).