A just culture guide

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This guide encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way.

The fair treatment of staff supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame. 

Supporting staff to be open about mistakes allows valuable lessons to be learnt so the same errors can be prevented from being repeated. In any organisations or teams where a blame culture is still prevalent, this guide will be a powerful tool in promoting cultural change.

About our guide

This guide supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely.

  • it asks a series of questions that help clarify whether there truly is something specific about an individual that needs support or management versus whether the issue is wider, in which case singling out the individual is often unfair and counter-productive 
  • it helps reduce the role of unconscious bias when making decisions and will help ensure all individuals are consistently treated equally and fairly no matter what their staff group, profession or background. This has similarities with the approach being taken by a number of NHS trusts to reduce disproportionate disciplinary action against black and minority ethnic staff

Our guide can be used at any stage of a patient safety investigation - it does not replace the need for a patient safety investigation and it should not be used routinely. It should only be used when there is already some suspicion that a member of staff requires some management to work safely.

This is our best current understanding on how to apply the principles of a just culture in practice, and that this is a live area of both academic and practical debate.  We will revisit and update this guide as necessary as our understanding develops.  

A just culture guide will be reviewed later this year in light of any recommendations from the Professor Sir Norman Williams Review

A just culture guide PDF, 670.7 KB

This guide supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely.

Scenarios to support training in using a just culture guide PDF, 230.4 KB

To help with the training, we have developed a series of case scenarios that facilitators can use to walk people through the tool.

This guide updates and replaces the incident decision tree (IDT) developed by the National Patient Safety Agency (NPSA) around the work of James Reason, an expert in human error and its drivers.

A just culture guide helps NHS managers ensure staff involved in a patient safety incident are treated fairly, and supports a culture of openness to maximise opportunities to learn from mistakes.

Our partners

This guide is supported by a number of national healthcare organisations, patient groups and professional bodies including:

  • Academy of Medical Royal Colleges
  • AvMA
  • BMA
  • Care Quality Commission
  • Freedom to Speak Up National Guardian
  • General Medical Council
  • NHS England
  • NHS Wales
  • Nursing and Midwifery Council
  • Royal College of Nursing
  • Royal Pharmaceutical Society
  • UNISON
  • Unite the Union

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