How a Just Culture in the Workplace Contributes to Quality

Quality is a complicated concept in the service industry and particularly in healthcare. Why? Customers, clients and patients depend on the skills, decisions and actions of human beings for service and to help them solve problems that require specialized skills and expertise. It can be easy to forget that these experts are still people and can make errors, especially in a complex environment.

Thankfully, there are many ways to nurture a culture in a service-based workplace that focuses on quality and safety, and to allocate resources for preventing errors. I see this day-to-day at Banfield Pet Hospital, where my role is to help make sure our associates have the proper tools and environment to deliver quality care to pets.

One way to lower the likelihood of mistakes is to look at an individual’s potential for making errors.  Hospitals can support their staff with in-depth training/retraining and managing shifts to avoid causing physical or mental fatigue. That said, these methods have resulted in only minimal effectiveness in ensuring workplace quality. Why? We tend to focus on supporting individuals, rather than the environment they work in, which is likely to be more responsible for errors occurring.

Strictly focusing on the individual may encourage people to ask who’s to blame when something goes wrong, rather than what is at fault.  In the advancement of quality of care, we seek a “just culture” - a fair and reasonable process that looks at the whole picture to determine an error’s root cause. This entails a deep and broad examination of the structure and systems surrounding the individual for possible flaws, and altering this environment to help prevent future errors as needed, while ensuring individuals are appropriately held accountable for their actions.
Relative to patient safety, approaches that focus on the system are more effective than those that focus on people. Below is an action hierarchy/guide to quality improvement created by designer Cassie McDaniel during her time at the Centre for Global eHealth Innovation. While it offers an overview of the interventions that organizations often take in tackling error, aligned with the effectiveness of those interventions, it more importantly shows that individual responsibility must be balanced with a strong focus on the systems that people use in performing various job functions to achieve optimal effectiveness. 

What Defines a “Just Organization”?

Organizations and individuals share responsibility for ensuring quality in a just culture. Individuals are educated about the importance of sticking to protocol and their role in preventing error, in addition to ensuring that the workplace is designed to prevent error to the greatest extent possible. If there’s an error the organization could have anticipated or prevented, a just culture would never hold an individual solely responsible.
My role in the veterinary profession is to improve patient outcomes in part by reducing the occurrence of human error as much as I can. In terms of medical quality, error can be dismissed as - “we’re all human” – but it can also be lessened and managed by such things as streamlining a process or requiring review/approval by multiple people. By focusing our commitment on medical quality – establishing, testing and refining new ways to diminish the possibility of error in the medical environment – we help increase the chances that an error in diagnosis, dosage or recommended care will be found and fixed before it affects a patient.
Practitioners and patients alike are ensured fairness in a just culture - a physical environment where policies and procedures are laid out, and when followed correctly, designed to prevent harm and improve outcomes.

How Can We Tell the Difference Between Process a Error and an Individual Error?

Is it possible to determine whether an error could have been prevented by using a different process or having established safety measures? When should an organization make changes? When should an individual be retrained, reprimanded, suspended or terminated? 
In many cases, it can be hard to tell. A thorough assessment of the situation is needed to understand where the error stems from. I remember a sad story from human medicine. During a scheduled procedure to remove a portion of a patient’s gangrenous limb, the wrong leg was amputated by the surgeon. No one could ever envision this happening, and understandably, the first reaction from the public was to have the surgeon’s license to practice revoked.

A thorough examination of the event showed that the patient’s records tracked the need for surgery on one leg, but the surgical documentation indicated that the other leg be removed. Not one of maybe a dozen medical staff studying those documents spotted the error. There were no visual signs that the wrong leg had been prepped for surgery since both patient’s legs were gangrenous. Ultimately, there was no action against the surgeon from the review board. In this case, the person hadn’t failed; it was the process.
Banfield tries to use this question to guide us in our evaluations: Could someone else doing the same task under the same conditions make the same error?
If you determine a co-worker could follow the same course, or you discover that other co-workers are making the same kinds of errors, it’s safe to say that your processes should be evaluated and adjusted as necessary. The associate’s actions (or unintentional inactions) probably don’t require disciplinary action. What’s more, we are beginning to understand that associates involved in an error may also need help to recover from the error’s impacts. 
To reduce the possibility of errors occurring, we’re committed to both ensuring careful review of significant errors and ensuring organizational accountability for our processes. This allows Banfield to constantly evolve our systems, including how we ask associates to perform their duties and how we ask questions and collect information. We hope to establish a safe and open culture where associates are encouraged to share their challenges and ideas. This will help us recognize opportunities for evaluation and strengthen the processes followed before errors happen.

We Can Only Reach Quality Together

As veterinarians and medical professionals, we make choices daily that can greatly affect our patients’ well-being, not to mention their lives. By bringing their pets to our hospitals, people are entrusting us to help them live full lives.
Making a promise to help our clients and their pets also requires making ourselves and our organization better, recognizing that fairness is often less about retraining or disciplining people for errors and more about fixing the flaws and faults in the systems that let errors happen in the first place. Every day we are committed to reaching this goal.

Karen Faunt, VP of Medical Quality Advancement, Banfield Pet Hospital

Dr. Karen Faunt is responsible for leading Banfield’s veterinary medical quality advancement while developing a system that supports the quality goals of the practice. Dr. Faunt joined Banfield in 2002 as a medical advisor. She earned her veterinary medical degree from the Colorado State University College of Veterinary Medicine and is board certified in Small Animal Internal Medicine.