The Restoration of Accountability

Over the past week a nurse, RaDonda Vaught, has been criminally prosecuted for a fatal drug error. She faces between one and six years imprisonment. The prosecution described her erroneous injection of a powerful paralyzer instead of a sedative was akin to a drunk driver, driving with their eyes closed and killing a bystander. In a separate hearing before the Tennessee Board of Nursing, Vaught stated she had become complacent and distracted, adding “there won’t ever be a day that goes by that I don’t think about what I did.”

Within days The Ockenden Report into Maternity Safety at Shrewsbury and Telford Hospital Trust was published. The report states over 200 babies died due to a toxic fixation on natural births. The report also reveals that there were cover ups and warnings missed for nearly two decades. Nine mothers died avoidably due to repeated failures during the same period.

Two events and multiple tragedies. The families of all the people affected by these events should be foremost in our thoughts. For every interaction, every day, that a healthcare professional shares with a patient, that same interaction may be the most important part of the most significant day in the patients life. No discussion or analysis of these events should start from an alternative start point.

Discussion and analysis should, however, follow. It is imperative we learn, reflect and improve. When healthcare looks towards establishing a Just Culture, what does this mean for accountability? A question that is difficult to answer when both concepts of Just Culture, as well as accountability within this context, are not fixed.

Dekker’s Restorative Just Culture redefines accountability as “forward looking. Together, you explore what needs to be done and who should do it. An account is something you tell and learn from.” From this the argument is made that any approach that holds people responsible for their actions and applies proportional sanctions is the road to blame and retribution. The treatment of Vaught would appear to support that assertion, although one would be well served considering what constitutes proportional sanctions and if there is a real cause and effect relationship between that and unfair retribution.

It is not, however, clear why there ought to be an issue with the idea of accountability. An important aspect that work provides countless people across the world is a sense of responsibility and purpose. Work does not, therefore, have an accountability problem. Indeed, from her testimony and statements, it appears Vaught accepts the importance of professional accountability. Too frequently, it does, have a significant application delta. Accountability is not a synonym for scapegoating. To be clear, scapegoating and blaming workers is unacceptable and counter to creating the conditions that enable people to be and perform at their best. In dynamic, complex environments, where the right decision is often judged with the benefit of hindsight, attributing cause to human error is essentially the reading of safety runes. Professional people deserve to operate under the assumption of good intention until proven otherwise. Decisions considered once the system as a whole has been analysed, and only then to understand why those decisions made sense at the time. A poor organisational response does not mean we have an accountability problem. It means we have a management weakness. Neither is accountability a wicked problem that has to be redefined so that it is fit for use. Amy Edmondson’s research demonstrates that the best organisations will create the environment where people have a healthy relationship with accountability operating in the absence of fear.

Moving away from fear and blame towards fairness and learning is not a choice between valuing relationships or responsibilities. The barrier to improvement is not individual accountability (the research shows quite the opposite). While both James Reason and Sidney Dekker have excellent contributions to improvement, it is not clear that they are enough currently in isolation. Encouragingly, a less tribal and binary perspective is emerging. One that argues for incident responses “conceived within a relational as well as regulatory framework.” This is why a broader, holistic view of Just Culture has been advanced. One that is based upon developing an environment that enables both individuals and the organisation to learn, grow, heal and excel. As risk management continues to migrate from an approach founded on industrialised failure avoidance to one of professionalised high performance, a broader, collaborative and unifying perspective will become inevitable.

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