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Leadership and the Just Culture – Holding the Keys to Safety, Joy and Meaning

Leaders are responsible for establishing and sustaining the culture of an institution. They are accountable for monitoring the institution’s cultural rhythm. With strong leadership, that rhythm should vacillate only slightly, rather like the variations on a barometer as compared to those on a thermometer. The rhythm must be stable or else turbulence sets in, with associated disruptions and hazards. Safety degrades under such circumstances and patients and staff can be harmed.

A key strategy for success is for leaders to recognize vulnerabilities that may affect staff performance and to address them specifically. This is accomplished by sustaining a culture where just treatment, e.g., the Just Culture, is the norm. The Just Culture consists of two dimensions, related but also unique in character.

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Enabling Joy and Meaning – Contributing to Safety and Quality

There is another element of leadership that relates very poignantly to the concept of authenticity I raised in the January commentary1. This is the relationship between hospital culture and the workforce experiencing joy and meaning in what they do. Everyone wants to experience joy, meaning and professional satisfaction. Commitment to a healthcare profession is particularly driven by this as it is both an honor and privilege to care for others. Frankly, if I did not experience a sense of joy and meaning in my work, I could never have remained engaged in clinical medicine for so many years. The responsibilities of clinicians are great, the workload is often demanding and stressful, and the impact on family life can be substantial. Joy and meaning is the payback that really counts, knowing that one’s efforts as a clinician have made a difference in improving someone’s well being.

The responsibility for developing and sustaining a hospital culture that nurtures joy and meaning resides with leadership. Where leadership is lacking, things can go wrong very quickly. Sadly, morale amongst healthcare professionals is at a low point, with many retiring early or leaving the profession for other opportunities. Though there are many reasons for this, the fact is that experiencing a lack of joy and meaning is a major contributor to this trend. If healthcare workers are unhappy, feel disregarded, undervalued, powerless and/or when bullying and unprofessional behavior is tolerated, then the stage is set for error and harm, both for patients and staff2

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Keeping Eyes on the Prize – Engaging all the Moving Parts for Higher Reliability

Higher Reliability Organizations are those that anticipate things may go wrong and have developed cultures focusing on safety and continuous improvements. A key element in such industries is strong leadership that sets and sustains the culture, leading by example and valuing the contributions of stakeholders working on the frontlines. Leaders of such organizations understand the risks of failure and keep their eyes on the prize: safety and highest quality outcomes!

The aviation industry is the quintessential example of a high reliability industry, but in my view achieving high reliability in aviation is much easier than in healthcare. Aviation primarily involves the interaction of personnel with continually improving technologies that incorporate numerous fail-safe mechanisms. Healthcare is different because achieving best outcomes requires engagement not just with technologies but most important, with patients, not simply as recipients of healthcare services, like passengers sitting on an airplane receiving the services of the flight crew, but rather as fully-fledged partners in healthcare.

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Keeping Patients Safe – Leadership and Medical Ethics

I am a physician and therefore obliged to my patients. I was nurtured on this during my training, and the guiding principles of medical ethics have served as the foundation for my professional life. The three key principles of medical ethics are:

  1. Respect for patient autonomy and decision making
  2. The intended actions of beneficence
  3. Those of non-maleficence*

We must engage our patients in respectful decision-making. We must always act in beneficial ways, carefully explaining risks and benefits, and we must avoid harming patients or putting them at unnecessary risk of harm.

Executives in hospitals, regardless of their own professional backgrounds, also must adhere to these principles, even though these leaders may be far removed from direct patient care. They must create and sustain cultures focused on patient safety as the highest priority. They also should be held responsible when patient safety, as measured by the actions of staff, is not the highest priority.

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