While M&Ms focus on physician judgment, RCAs address system error, both aiming to take us to a better place. And they have one more thing in common. They are just. They do not blame. They do not punish. I can sum up the philosophy in three concise statements: Seek the truth. Tell the truth. Learn from the truth.
It is devilishly difficult to do this. To step completely outside our biased conceptual framework. To take a clean look inward with an open mind. To situate ourselves in the position of a doctor or nurse way back in time at the indelible moment of truth, looking at the situation through their eyes while pretending to forget what we know about the events that followed. Only then can we render a pure judgment about a fateful error without lacing it with the prejudicial knowledge of its eventual consequences.
There is a name for this blame-free environment: the Just Culture. The Just Culture defines a leadership approach that presumes employees are trying to do the right thing. In the Just Culture, the staff get the benefit of the doubt. The review of a poor outcome, then, is an open-minded exercise that probes for weakness in process that leads the employee astray.
Usually we find it – the stress point. Sometimes it is as simple as a minor oversight. At other times we find that a series of coincidences lined up, as in the La La Land debacle, to permit the patient’s care to follow the wrong path. In most cases, there is indeed a weakness in the process.
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.
From The Ailing Nation, Chapter Two: Forgiveness
A Root Cause Analysis (RCA) is the investigative process by which we uncover the true source of an adverse event or unexpected harm that befalls a patient in our hospital. The RCA is a pure form of inquiry; through chart reviews and interviews, we follow the facts wherever they may lead. The goal is not to punish, merely to uncover the truth. In fact, the staff member closest to the outcome is usually the star witness in an RCA, and is encouraged to tell the unvarnished truth without holding back. The RCA committee, in turn, is sympathetic to the witness and grateful for their participation. It is a cooperative venture that, when done well, leads to an accurate understanding of the cause of the event so that a recurrence may be prevented in the future, and promotes closure for the staff so that they may heal from the psychic trauma of the event. The philosophy behind this approach is known as the Just Culture.
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