Leaders are responsible for establishing and sustaining the culture of an institution. They are accountable for monitoring the institution’s cultural rhythm. With strong leadership, that rhythm should vacillate only slightly, rather like the variations on a barometer as compared to those on a thermometer. The rhythm must be stable or else turbulence sets in, with associated disruptions and hazards. Safety degrades under such circumstances and patients and staff can be harmed.
A key strategy for success is for leaders to recognize vulnerabilities that may affect staff performance and to address them specifically. This is accomplished by sustaining a culture where just treatment, e.g., the Just Culture, is the norm. The Just Culture consists of two dimensions, related but also unique in character.
The first dimension concerns the treatment of staff involved in safety incidents. The causes of safety incidents are many-fold, as causality is the result of multiple contributing factors aligning to result in harm. The vast majority of people involved in safety incidents do not intend to harm patients and thus, a culture of just treatment for members of staff must be the norm. Just treatment includes both understanding and fairness regarding human errors that will occur and also the establishment of mechanisms to assist staff suffering from depression, anxiety and professional dysfunction as a result of safety incidents. There is no room for punitive treatment of staff and disciplinary action only occasionally should be warranted.
The second dimension of the Just Culture relates specifically to the treatment of professionals who cross the lines of appropriate professional behavior, often resulting in harm to patients or staff. How to manage disruption caused by unprofessional behavior, whether this disruption affects patients directly and is identified through patient complaints, or whether the disruption reflects conflicts between staff members identified in other ways, should be part of a culture that embodies justice and fairness.
Case Study:
A physician has, unfortunately, developed a reputation for being abrupt and condescending to patients and staff, often in front of others. She has been informally cautioned in the past by a colleague over a cup of coffee, but the behavior has continued. A recent incident where she was dismissive to both a patient and a nurse caused considerable consternation on the ward and resulted in a delay in diagnosis and appropriate therapy. The physician refused to listen to the patient and the nurse regarding some symptoms and therefore did not investigate the patient’s condition thoroughly. An investigation into this incident found the physician responsible for the delayed diagnosis, and this time she was specifically referred by her department head for peer to peer counseling.
In this more formal setting, the repeated instances of disruptive behavior were discussed, and it was at one of these sessions that the physician revealed marital difficulties for the first time. She was advised to get professional counseling through a resource of her choice, which unfortunately she did not do.
Sadly, a few weeks later another bullying incident occurred, resulting in severe anguish for a staff member and the incident was reported to the human relations liaison.
The Chief Medical Officer met with the physician, explained his concerns about her repetitive pattern of behavior and expressed his alarm that she had not taken to heart the previous counseling recommendation. It was clearly time for more firm intervention. He expressed concern about the physician’s ability to continue to function unless changes were made to achieve the desired outcome. He expressed continuing support for her, but voiced his disappointment that things had not improved. He created a formal plan of action that required the physician to receive counseling. Though he was sympathetic to the challenges she was experiencing in her marriage, he was more concerned that staff and patients would be harmed if changes were not forthcoming. He advised the physician that if her behavior did not improve then, regrettably, disciplinary action would be considered as a next step.
This pattern of incremental, enhanced interventions has become known as the Disruptive Behavior Pyramid and has been used effectively in many hospital settings*. Professionals deal with professionals to improve performance while keeping an eye on enhancing patient care and staff collegiality. Originally developed at Vanderbilt University, this approach has achieved widespread acceptance.
Creating and sustaining a Just Culture is a key responsibility of leadership and may contribute substantially to improving patient safety and to enhancing joy and meaning for the workforce.
Leadership owns the keys to all the doors…
Reference:
Hickson, GB. Pichert, JW. Webb, LE. Gabbe, SG. A Complementary Approach to Promoting Professionalism: Identifying, Measuring, and Addressing Unprofessional Behaviors, Academic Medicine 82, 2007:1040-1048.