Hospitals and health systems continue to operate in a turbulent, fast-changing environment with relentless pressure to improve an array of performance metrics: patient experience, clinical quality, patient safety and operating costs. While there is much interest in and discussion about structural and transformational change, the formidable barriers to such change have limited their impact. With some notable exceptions, health systems are left to reach for the same set of levers they have always pulled, working within the existing economic and operating model to extract significant improvement in operating results. And with that focus comes a familiar, and deceptively simple, refrain: “We need to increase urgency and strengthen accountability.”
There is nothing inherently wrong with seeking to build a more urgent and accountable culture. However, there are implications to the pathway a leader chooses to bring about that cultural change. The challenge is often framed as a false choice between a culture of blame, negative consequences, and fear vs. a culture of accommodation and tolerance of unacceptable performance. There is a third choice and healthcare leaders need not look very far to find it.
The Principles of Just Culture
By now, virtually every healthcare leader has heard about the principles of “just culture” in the context of the pursuit of patient safety. The guiding principle is that in order to create an environment that relentlessly pursues patient safety, every person must feel safe and empowered to “stop the line,” or raise their hand, when they become aware of a potential unsafe situation or medical error. This principle is based on the notion that most often error occurs not because of the careless disregard or negligence of a person but as a result of process failures or conditions in the environment that create the possibility of error. It is only when information flows freely and without fear that such conditions can be identified and addressed.
To illustrate the cultural shift, consider the way in which an organization responds to a medication error. In the past, it was quite common that in the event of such an error, the response was to punish the nurse responsible for giving the wrong medication or dose. But what if the error was an outgrowth of two medicines with radically different properties being stored in close proximity in like containers? What if, given those conditions, the very best, most conscientious employee could easily make the same error? If the limits of human factors were inadequate to assure no recurrence of the same outcome? Clearly in such an instance, punishment would be the wrong tool to drive corrective action. Rather than generating improvement, a likely outcome would be fear and the temptation to hide the errors or shift the blame rather than address and correct the root cause.
Some have mistakenly equated “just culture” with a “blame-free culture” which, in its tolerance of human error, could actually encourage careless behavior. If there are never negative consequences for human error, the thinking goes, then what is to stop someone from engaging in such behavior? The reality is that in a truly just culture there still is a level of individual accountability. When an individual knows, or should know, the correct process and deliberately or recklessly fails to follow that process, punishment still has its place. The difference is that, rather than being the first tool out of the toolbox, its use follows elimination of other causes rooted in the process or environment to avoid the negative consequences of its misapplication.
Applying Just Culture Principles to Other Areas of Performance Accountability
Consider the nursing unit leader whose patient experience scores are at a level that is unsatisfactory. It seems obvious that any of a number of factors, many of which reside outside of her or his direct control, contribute to the patient experience: delays in the emergency department due to inadequate bed capacity; poor communication on the part of the attending physician; old, noisy, tired facilities not conducive to a healing environment; the list goes on.
Despite this obvious reality, the response of many healthcare senior leaders is primarily to intensify the pressure on that nursing unit leader. The implication is that the failure to generate a better result is merely a matter of that leader’s individual effort or capability. As the pressure intensifies, the leader can feel more and more at risk and, acting out of fear, turn their focus to self-protection. They focus on explanations and excuses rather than engaging in the productive pursuit of systemic solutions. They lash out to shift the blame to others upon whom their scores depend, creating counterproductive conflict and division. They bury or question the data rather than using it as a tool to understand process failures and drive improvement. They despair and choose to leave or, worse yet, stay and adopt a posture of negativity or cynicism.
Consider how the just culture principles might apply in this instance. The process would focus first on seeking to understand the root cause of the variation from expected, or desired, performance. Based on that diagnosis, a process would be undertaken equipped with the expertise, functions, and resource support needed to redesign the process or conditions impeding an improved outcome. The leader would be expected, encouraged, and safe to bring forward the gap in performance as soon as it was recognized without fear of experiencing punishment as the immediate response. Data would be embraced for what lessons can be learned in the search for sustainable improvement.
Does this mean that no matter what, the leader’s performance is tolerated? Not at all. It is conceivable that the root cause may be determined to be the capability of the leader. That can come in many forms: ineffectiveness at formulating performance goals, poor execution and follow-up, failure to work effectively with stakeholders, inability to adjust to changes in circumstances, lack of skillfulness in process improvement, or failure to effectively address poor performers on the team.
Just as in the patient safety context, if the conclusion is that the gap in performance is directly tied to the ineffectiveness of the leader, that situation must be addressed through development or by acknowledging the lack of fit for what the job requires. And also like the patient safety example, a culture of healthy accountability doesn’t start from the assumption of human failure. It makes its way there after a timely and disciplined exploration of the factors contributing to the variation from expected results.
Practical Steps to Building a Fear-free, Accountable Culture
It starts with how you form performance expectations.
There is no easy answer to creating performance goals that stretch the organization to do its best, but not beyond. There is risk that goals developed from the “bottom up” will be too conservative and goals set from the “top down” will be too ambitious and fail to recognize the realities of the local environment. Consider a process in which goals are set through dialogue supported by as much data as possible, to help build shared commitment to aggressive but realistic levels of performance.
Develop a system for ongoing monitoring of predictive indicators.
An organizational climate of healthy accountability embraces data as a tool for improvement. In it lies information with which to recognize and diagnose, early on, factors impeding progress toward performance goals. Ongoing vigilance around key indicators creates a platform for meaningful inquiry and dialogue to determine the root cause of variance so appropriate corrective action can be taken.
Maintain a timely, disciplined approach to addressing signs of performance variance.
The goal of a healthy accountability is improvement, not blame or explanation. In a just culture, information indicating variation from expected performance is addressed as soon as the organization becomes aware. Too often, leaders hang back in the hopes that the situation will correct itself or believing a reasonable explanation after the fact will be sufficient to avoid blame. This misses the point. The goal is to create a timely organizational response. Leaders should be expected to come forward as soon as they see signs of unexpected variation, share their diagnosis and approach, seek support as needed, and work to adjust in time to correct or compensate for what has occurred.
Start with inquiry, not blame.
As with issues of patient safety, the response to variation in performance starts with inquiry not blame. The first level of inquiry should address whether the variation is in some way traceable to ineffectiveness on the part of the leader or if it is the product of other factors beyond the leaders real or perceived control. If it is the latter, the work, together, is to address those factors. If, for example, the root cause of patient experience scores on a nursing unit tracks back to delays in the emergency department, the organizational response should reflect that and establish a broader process to drive improvement.
In some instances, those other factors are beyond the control of anyone in the organization, e.g., competitor actions, loss of key physicians, or change in payment levels or structure. When that is the case, the focus shifts to either finding compensatory initiatives to make up for the impact or adjusting the goals to reflect the new reality.
If the issue tracks back to ineffectiveness on the part of the leader, the second level of inquiry is whether the responsible leader is misaligned and lacks the effort, will, or commitment to do what is necessary to achieve the goal. It is rarely the case that a leader is defiantly misaligned with the expectations of the organization. But it is the only scenario in which the amplification of pressure or the threat of negative consequences is the appropriate tool for corrective action. Despite that, it is often the first tool used to respond to variation. If the leader truly is unable to commit to the goal, then it makes sense to move them out of the role. But if that is not the case, an additional level of inquiry is required.
If it is a matter of competency, not alignment or effort, the third level of inquiry is whether the gap is (with a reasonable amount of direction and support) a learnable skill or whether there is a fundamental lack of “fit” between the leader’s background, skill set, or personality and the requirements of the role. If the former, the organization should invest in development and track progress to assure the leader makes expected progress. If the latter, or if the investment in development proves ineffective, then the organization must acknowledge the fit issue and transition the leader to a role for which they are equipped, inside or outside the organization.
It is crucial that organizations develop a culture which promotes reliability in achieving performance results. Too often the straightforward approach is to intensify the pressure and threat of negative consequences for the leader in question under the often-misguided assumption that the failure is one of lack of will or effort. This fear-based approach is likely to generate an array of self-protective responses that, ultimately, impede effectiveness at creating sustainable solutions to performance gaps.
The alternative is a timely, disciplined, rigorous system of addressing performance variation built around the principles of just culture. Such a system can and should be firm in its commitment to and expectation of reliable performance. Nothing about it should be tolerant or “soft.” But the pathway to performance improvement should be built in a way that is inherently safe so that leaders are positioned to share information, collaborate, and seek needed help to close the performance gap. If, at the end of the road, the root cause is the fit of the leader, the organization can credibly make leadership changes without the collateral damage of using that as the first tool of performance improvement.
The primary objection to this more measured approach is that it takes too much time. That the urgent need for improvement demands immediate action! The question one must ask is whether the cultural damage done in taking the “shortcut” is worth the theoretical increase in speed. And whether, in the end, it is truly faster given the cost and delays of implementing solutions that fail to address root causes, the resulting rework and damage repair, and the turnover of key leaders.