Have you ever wondered why there is so much finger pointing in politics? Whenever anything bad happens, everyone tries to find fault with someone else. Could a hospital take care of patients if doctors and nurses behaved like that? Actually, no. In my world, the blame game is an obstacle to the safe and effective care of patients and a recipe for failure. Let me explain with a true story. A number of years ago, a patient in our Intensive Care Unit (ICU) was being treated for respiratory failure with a mechanical ventilator. According to the report I received, the ventilator had malfunctioned, which set off an alarm to alert the nurse who could address the problem. This time, Natalie went to the bedside and discovered there was a mechanical obstruction that interrupted the flow of air. The patient was deeply sedated and therefore unable to respond. Within a scarce minute, the patient went into cardiac arrest from which he could not be revived. It was a fatal error. In our hospital, this event was the equivalent of a five-alarm fire. Physician and nursing leaders were summoned into an emergency meeting. A detailed review would commence without delay, but the explanation was already apparent. By failing to answer the alarm, Natalie had violated a principle tenet of her profession, to do her duty to keep her patient safe. We were all in agreement. The nurse must be punished.
This would most likely lead to counseling and suspension, if not outright termination. Too bad for her, but she should have known better than to break the rules. We would now to make an example of her for all the other employees. But first we had to conduct a detailed investigation, which was our usual practice after a bad event like this. The goal of this review was to dig deep into the evidence, understand thoroughly the sequence of events that led to the patient’s death, and thoroughly answer the “why” question. In other words, get to the root cause. For this reason, the detailed review was known as the Root Cause Analysis (RCA). If a floor nurse forgets to check a patient’s vital signs because she has too many patients, if a well-meaning physician overlooks a tiny detail in a laboratory result, if the respiratory therapist accidentally selects the incorrect ventilator setting, the RCA team might well conclude that it is a system problem.
The nurse should have fewer patients, the laboratory result must be presented more clearly, or the respiratory technician needs better training. The important distinction is whether this was the kind of mistake that could be made by any well-meaning staff member, or whether this particular individual was an unusually careless employee who willfully violated a standard of care – in other words, a bad apple. The distinction between a system problem and a people problem is crucial to the plan of correction. In the case of the missed alarm, our investigative team interviewed Natalie, Natalie’s fellow nurses in the ICU were eager to talk about the alarms. It was a fairly new system and quite problematic. The alarms went off constantly – mostly for minor things. The heart rate was slightly high. The patient shifted position. The patient hiccuped. The endless parade of alarms led to a predictable response in the nurses. They stopped interrupting their work to respond to this barrage of false alarms. They began to ignore the alarms altogether. They had “alarm fatigue” – a well-known phenomenon that could lead to bad outcomes like this. They also learned that they could turn the alarms off at the central station, for each other, so that they would not even need to go into the patient’s cubicle. A conspiracy of silence.
These were intelligent, competent, well-meaning professionals who found a way to solve an annoying problem that got in the way of their important work. Now this was a dilemma. If we were going to suspend Natalie for bad conduct, we really ought to suspend all the nurses for the exact same behavior. And now that we had talked to the others, who were behaving just like Natalie, she did not seem to be a bad apple after all. Thus, we arrived at a new and unexpected conclusion. This was a system problem. There is a name for this blame-free paradigm: the Just Culture.
The Just Culture describes a leadership approach that recognizes that nearly all employees are trying to perform well. That the hospital staff are not trying to make mistakes or hurt patients. By promoting the Just Culture, then, we are more likely to find that weakness and address the real root of a problem. Just as important, our employees will bring errors to our attention, knowing that we are not intent on blaming them for the outcome. This creates trust and transparency in the workplace, and helps cut through the crap to get to the truth. For a deeper dive into evidence-based politics, please check out my other video essays at www.snickersnack.com