Trust is the Achilles’ heel of quality improvement.
It happens time and time again. The management team of a lab carefully customizes an electronic non-conforming event management system complete with all of the bells and whistles. The staff are trained and the software is rolled out following a strategically devised project plan. All of this effort and then … hardly anyone uses it, nothing gets reported. Why does this occur?
The answer is simple. The human component is often overlooked. It has to do with trust, or more specifically, the lack of trust. In order to be expected to report things that are going wrong in the laboratory, the staff need to feel safe doing so. I can’t tell you how many times I have observed departments praised for reporting zero non-conforming events. Does anyone really believe that nothing went wrong in the lab for an entire month? I have seen staff directly and indirectly punished and retaliated against for reporting issues. Staff are blamed for carrying out faulty processes and procedures given to them by the very management who now seek to punish them. Staff are also ostracized for bringing forth legitimate quality concerns to management. These instances are gut reactions of management and, to be honest, they are not uncommon. A culture of blame can organically develop when forethought has not been put into creating a culture of quality.
In order to successfully establish a reporting culture where a spirit of continuous quality improvement is embraced, it is critical that staff feel comfortable and empowered to bring issues forward. It is not enough to say, “Trust me, I am a manager.” Trust truly is earned. So how do you go about earning trust to build a reporting culture? There are some useful tools that your laboratory can utilize in your quest to gain the trust of your staff.
People will make mistakes. They are inevitable. Of course, these mistakes may hurt others or cause harm. Just Culture, also referred to as the Workplace Accountability model, is a system designed to catch those errors before they become critical. If they do become critical, they have designed recoveries to stop or reduce the bad outcome. In this model, three behaviors are delineated: Human Error, At Just Risk Behavior and Reckless Behavior. Using these categories, the Just Culture Algorithm provides a framework for determining management course of action following an event.1
“A culture of blame can organically develop when forethought has not been put into creating a culture of quality.”
Just Culture balances a blame free culture and accountability. It sets lab managers free from the propensity to find the culprit, allowing for the identification and elimination of the root cause. Just culture establishes trust in event reporting as it ensures consistency and fairness in handling of events. It is as much a set of management skills as the tools that make it possible.1 Just Culture provides fairness and justice, which is something staff desire. Staff do not want to be blamed for those things that are not “their fault.” Staff do want careless and negligent people to be held accountable.
The application of systems thinking in the management of non-conforming events allows laboratories to focus on flaws in the design of systems that allow non-conforming events to occur rather than individuals involved. This frees management from the tendency to blame people. The only way to correct a flaw in a system is to redesign the system so the event cannot occur again. It follows that the strongest response to an event is the elimination of the root cause of that event through a new policy, procedure or process.
By and large, lab professionals work in the lab because they want to help people. It only follows that it is not appropriate to automatically assume that these well-meaning employees are to blame when something goes wrong. A systems thinking approach helps establish trust between staff and management, which improves reporting and collaboration on continuous improvement projects.
If your lab is going to take advantage of the benefits of an event management system, it is important to encourage reporting of near misses. A near miss is an event that could have occurred, but didn’t. Before an event actually occurs, employees will often recognize potential failures or “holes” in a system or process. A proactive approach to event management requires resolution of near misses before they become a problem for patients, employees and the business.
Near miss reporting is a good stepping stone into fostering a reporting culture as the events have not yet occurred, so staff feel more comfortable bringing the issues forward. This is an opportunity for management to positively reinforce reporting utilizing issues that are more comfortable for staff to discuss than instances where patients or employees have been harmed or the laboratory has suffered a financial loss. Employees can be incentivized to report near misses through a “Good Catch” program, an employee recognition effort that highlights the best near-misses reported. At my labs, I have also included the percentage of near misses reported as a percentage of total non-conforming events as a measure of how proactive the laboratory is in event reporting on quality reports.
Whatever philosophies and tools your laboratory decides to employ in order to build a reporting culture, the critical steps are to shift from a blame culture to a fair and just culture and to empower your employees. No matter how well designed and implemented your non-conforming event management system is, do not lose sight that gaining the laboratory staff’s trust is key to its success.
Tips for Managers to Build a Culture of Trust
- Empower employees
- Demonstrate trust
- Lead by example
- Be accessible
- Listen to understand
- Admit mistakes
- Communicate regularly
- Tackle issues head on
- Keep people accountable
- Celebrate success
- Outcome Engenuity. What does our model of accountability look like? Available at: outcome-eng.com/getting-to-know-just-culture/