Restorative just culture significantly improves stakeholder inclusion, second victim experiences and quality of recommendations in incident responses

Abstract

Objective: Matching safety and quality improvements to the complexity of healthcare, Gold Coast Mental Health and Specialist Services implemented a new response to clinical incidents: the Gold Coast Clinical Incident Response Framework (GC-CIRF). It utilises a Restorative Just Culture (RJC) framework and Safety II principles. This paper evaluates its impact.Methods: Staff surveys measured perceptions of just culture and second victim experiences. Quality of recommendations were compared before and after implementation. For the 19 incidents that occurred after the implementation of GC-CIRF, audits of the review processes were undertaken, measuring several components.Results: Results show significant improvement in staff perceptions of just culture and second victim experiences. Review of incident review data showed several shifts in line with Safety II and RJC. The process audit demonstrated inclusion of a broad range of stakeholders, and significant improvements in the quality and strength of recommendations.Conclusions: Embedding RJC and Safety II concepts into the incident review process is associated with improved measures of culture and review outputs. The integration of Safety II concepts and support of cultural shifts will require further work and committed leadership at all levels.

The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis

“…Positive findings in relation to the recommendations generated have recently been published. 94 Given the significant lack of attention in this area, we argue the need for further research.…”

“…In relation to a proximal focus of suicide investigations, Reason 95 asserts that incidents often 'have a causal history that extends back in time and up through the different levels of the system'. Similarly, Turner et al 94 took a 'learning anything' approach to their incident response framework.…”

“…Indeed, this approach has demonstrated some early positive findings in suicide prevention outcomes. 93,94,104 The PSIRF is grounded in the concept of a 'just culture', 105 and although this has some elements of RJC, it does not mandate that learning and improvement should prioritise the healing of all involved. Turner et al 64 document their concerns about a just culture approach.…”

“…To resolve this, the authors conclude that a ZSF must be located in a RJC. 64 Turner et al 94 provide evidence to mitigate any concerns about the ZSF with their early findings that a supportive culture can be a protective factor for staff. The need for evaluation of carer experience is identified as a priority for future research by the authors.…”