Blame in organizations

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Blame in organizations may flow between management and staff, or laterally between professionals or partner organizations. In a blame culture, problem-solving is replaced by blame-avoidance. Blame shifting may exist between rival factions. Maintaining one's reputation may be a key factor explaining the relationship between accountability and blame avoidance. The blame culture is a serious issue in certain sectors such as safety-critical domains.

Contents

Blame culture

The flow of blame in an organization may be a primary indicator of that organization's robustness and integrity. Blame flowing downwards, from management to staff, or laterally between professionals or partner organizations, indicates organizational failure. In a blame culture, problem-solving is replaced by blame-avoidance. Blame coming from the top generates "fear, malaise, errors, accidents, and passive-aggressive responses from the bottom", with those at the bottom feeling powerless and lacking emotional safety. Employees have expressed that organizational blame culture made them fear prosecution for errors, accidents and thus unemployment, which may make them more reluctant to report accidents, since trust is crucial to encourage accident reporting. This makes it less likely that weak indicators of safety threats get picked up, thus preventing the organization from taking adequate measures to prevent minor problems from escalating into uncontrollable situations. Several issues identified in organizations with a blame culture contradicts high reliability organizations best practices. [1] [2] Organisational chaos, such as confused roles and responsibilities, is strongly associated with blame culture and workplace bullying. [2] [3] Blame culture promotes a risk aversive approach, which prevent from adequately assessing risks. [2] [3] [4]

When an accident happens in an organization, its reaction tends to favor the individual blame logic, focusing on finding the employees who made the most prominent mistake, often those on the frontline, rather than an organization function logic, which consists in assessing the organization functioning to identify the factors which favored such an accident, despite the latter being more efficient to learn from errors and accidents. [2] [5] A systematic review with nurses found similar results, with a blame culture negatively affecting the nurse's willingness to report errors, increase turnover and stress. [6] Another common strategy when several organizations work together is to blame accidents and failures on each other, [2] [7] or to the last echelon such as the implementing actors. [8] Several authors suggest that this blame culture in organizations is in line and thus favored by the western legal system, where safety is a matter of individual responsibility. [2] [5] [9] Economic pressure is another factor associated with blame culture. [2] Some authors argue that no system is error-free, and thus focusing efforts in blaming individuals can only prevent actual understanding of the various processes that led to the fault. [9]

A study found that the perception of injustice is influenced by both the individuals assertions of their morality domain, and by their identification to the organization: the higher one identifies with the organization, the less likely one will see the organization's actions as unjust. Individuals were also increasingly suspicious when observing their peers being affected by injustices, which is a behavior in line with deontic ethics. [10]

Typology of institutions and blames

According to Mary Douglas, blame is systematically used in the micro politics of institutions, with three latent functions: explaining disasters; justifying allegiances, and stabilizing existing institutional regimes. Within a politically stable regime, blame tends to be asserted on the weak or unlucky one, but in a less stable regime, blame shifting may involve a battle between rival factions. Douglas was interested in how blame stabilizes existing power structures within institutions or social groups. She devised a two-dimensional typology of institutions, the first attribute being named "group", which is the strength of boundaries and social cohesion, the second "grid", the degree and strength of the hierarchy. [3]

Mary Douglas' typology of institutions [3]
Low groupHigh group
High gridIsolateBureaucracy
Low gridMarketClan

According to Douglas, blame will fall on different entities depending on the institutional type. For markets, blame is used in power struggles between potential leaders. In bureaucracies, blame tends to flow downwards and is attributed to a failure to follow rules. In a clan, blame is asserted on outsiders or involves allegations of treachery, to suppress dissidence and strengthen the group's ties. In the 4th type, isolation, the individuals are facing the competitive pressures of the marketplace alone, in other words there is a condition of fragmentation with a loss of social cohesion, potentially leading to feelings of powerlessness and fatalism, and this type was renamed by various other authors into "donkey jobs". It is suggested that the progressive changes in managerial practices in healthcare is leading to an increase in donkey jobs. [3] The group and hierarchy strength may also explain why healthcare experts, who often devise clinical procedures on the field, may be refractory to new safety guidelines from external regulators, perceiving them as competing procedures changing cultures and imposing new lines of authority. [4]

Blaming and transparency

The requirement of accountability and transparency, assumed to be key for good governance, worsen the behaviors of blame avoidance, both at the individual and institutional levels, [11] as is observed in various domains such as politics [12] and healthcare. [13] Indeed, institutions tend to be risk-averse and blame-averse, and where the management of societal risks (the threats to society) and institutional risks (threats to the organizations managing the societal risks) [14] are not aligned, there may be organizational pressures to prioritize the management of institutional risks at the expense of societal risks. [15] [16] Furthermore, "blame-avoidance behaviour at the expense of delivering core business is a well-documented organizational rationality". [15] The willingness of maintaining one's reputation may be a key factor explaining the relationship between accountability and blame avoidance. [17] This may produce a "risk colonization", where institutional risks are transferred to societal risks, as a strategy of risk management. [15] [18] [19] Some researchers argue that there is "no risk-free lunch" and "no blame-free risk", an analogy to the "no free lunch" adage. [20]

Sectors

Healthcare

Blame culture is a serious issue in safety-critical domains, where human errors can have dire consequences, for instance in hospitals and in aviation. [21] [22] However, as several healthcare organizations were raising concerns, [16] studies found that increasing regulatory transparency in health care had the unintended consequence of increasing defensive practice and blame shifting, [13] [23] for example by obfuscating errors reporting. [24] Following rare but high-profile scandals, there are political incentives for a "self-interested blame business" promoting a presumption of "guilty until proven innocent" [13] [25] A literature review found that human resource management plays an important role in health care organizations: when such organizations rely predominantly on a hierarchical, compliance-based management system, blame culture is more likely to happen, whereas when employees involvement in decision making is more elicited, a just or learning culture is more likely. [26]

Blame culture has been suggested as a major source of medical errors. [26] The World Health Organization, [27] the United States' Agency for Healthcare Research and Quality [28] and United Kingdom's National Health Service [29] [30] recognize the issue of blame culture in healthcare organizations, and recommends to promote a no-blame culture, or just culture, in order to increase patients' safety, which is the prevention of errors and adverse effects to patients. [5] [26] [27] [28] [29] Other authors suggest to also provide emotional support to help healthcare professionals deal with the emotions elicited by their patients. [31] Yet others have pointed out the lack of nomination among healthcare staff as directors, so that those on the field are excluded from the decision processes, and thus lack intrinsic motivation to enhance patients safety processes. [32]

In the United Kingdom, a 2018 survey of 7887 doctors found that 78% said the NHS resources are inadequate to ensure patients safety and quality of services, 95% are fearful of making a medical error and that the fear has increased in the past 5 years, 55% worry they may be unfairly blamed for errors due to systems failings and pressures, and 49% said they practice defensively. [33] A sizeable proportion of these doctors recognized the issue of bullying, harassment or undermining, 29% declaring it was sometimes an issue and 10% saying it was often an issue. [33] Dozens of UK doctors under fitness-to-practice investigations committed suicide. [9]

In 2018, an investigation into the cases of 11 deaths in Gosport War Memorial Hospital led to the discovery of an institutionally-wide inappropriate administration of powerful painkillers without medical justification, leading to the death of hundreds of patients since the 1990s. This scandal is often described as an example of the consequences blame culture, with the NHS pressuring whistleblowers, which prompted officials to address more actively this issue to avoid seeing it repeated elsewhere. [34] [35]

Aviation

Aviation pioneered the shift from individual blaming to systems failure investigation, and incentivized it with the Aviation Safety Reporting System, a platform to self-report safety incidents in exchange of immunity from prosecution. [9] Since 15 November 2015, the European Occurrence Reporting Regulation (EU Reg. 376/2014) exhorts the aviation industry to implement a just culture systematically. [36]

Politics

Blame avoidance is an often observed behavior in politics, which is worsened when meeting the doctrine of transparency, assumed to be key for good governance. [12]

When politicians shift blames under polarized conditions, the public sector organizations are often the target. [37]

Social workers

For social workers, by emphasizing the professional as being autonomous and accountable, they are considered as individual workers with full agency, which occludes the structural constraints and influences of their organizations, thus promoting a blame culture on the individuals. [38] This emphasis on individual's accountability is similarly observed in healthcare. [39] In UK, blame culture prevented the adequate collaboration necessary between social workers and healthcare providers. [40]

See also

Related Research Articles

Blame is the act of censuring, holding responsible, or making negative statements about an individual or group that their actions or inaction are socially or morally irresponsible, the opposite of praise. When someone is morally responsible for doing something wrong, their action is blameworthy. By contrast, when someone is morally responsible for doing something right, it may be said that their action is praiseworthy. There are other senses of praise and blame that are not ethically relevant. One may praise someone's good dress sense, and blame their own sense of style for their own dress sense.

A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

<span class="mw-page-title-main">Electronic health record</span> Digital collection of patient and population electronically stored health information

An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.

Clinical governance is a systematic approach to maintaining and improving the quality of patient care within the National Health Service (NHS) and private sector health care. Clinical governance became important in health care after the Bristol heart scandal in 1995, during which an anaesthetist, Dr Stephen Bolsin, exposed the high mortality rate for paediatric cardiac surgery at the Bristol Royal Infirmary. It was originally elaborated within the United Kingdom National Health Service (NHS), and its most widely cited formal definition describes it as:

A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

An after action review (AAR) is a technique for improving process and execution by analyzing the intended outcome and actual outcome of an action and identifying practices to sustain, and practices to improve or initiate, and then practicing those changes at the next iteration of the action AARs in the formal sense were originally developed by the U.S. Army. Formal AARs are used by all US military services and by many other non-US organizations. Their use has extended to business as a knowledge management tool.

<span class="mw-page-title-main">Safety culture</span> Risk-averse attitudes

Safety culture is the element of organizational culture which is concerned with the maintenance of safety and compliance with safety standards. It is informed by the organization's leadership and the beliefs, perceptions and values that employees share in relation to risks within the organization, workplace or community. Safety culture has been described in a variety of ways: notably, the National Academies of Science and the Association of Land Grant and Public Universities have published summaries on this topic in 2014 and 2016.

In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs. Integrated delivery systems where insurers and providers share in the cost are intended to help align incentives for value-based care.

Health technology is defined by the World Health Organization as the "application of organized knowledge and skills in the form of devices, medicines, vaccines, procedures, and systems developed to solve a health problem and improve quality of lives". This includes pharmaceuticals, devices, procedures, and organizational systems used in the healthcare industry, as well as computer-supported information systems. In the United States, these technologies involve standardized physical objects, as well as traditional and designed social means and methods to treat or care for patients.

Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

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The healthcare error proliferation model is an adaptation of James Reason’s Swiss Cheese Model designed to illustrate the complexity inherent in the contemporary healthcare delivery system and the attribution of human error within these systems. The healthcare error proliferation model explains the etiology of error and the sequence of events typically leading to adverse outcomes. This model emphasizes the role organizational and external cultures contribute to error identification, prevention, mitigation, and defense construction.

Health information technology (HIT) is health technology, particularly information technology, applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on a 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands, the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.

<span class="mw-page-title-main">Health technology assessment</span> Field of policy analysis

Health technology assessment (HTA) is a multidisciplinary process that uses systematic and explicit methods to evaluate the properties and effects of a health technology. Health technology is conceived as any intervention at any point in its lifecycle. The purpose of HTA is to inform "decision-making in order to promote an equitable, efficient, and high-quality health system".  It has other definitions including "a method of evidence synthesis that considers evidence regarding clinical effectiveness, safety, cost-effectiveness and, when broadly applied, includes social, ethical, and legal aspects of the use of health technologies. The precise balance of these inputs depends on the purpose of each individual HTA. A major use of HTAs is in informing reimbursement and coverage decisions by insurers and national health systems, in which case HTAs should include benefit-harm assessment and economic evaluation." And "a multidisciplinary process that summarises information about the medical, social, economic and ethical issues related to the use of a health technology in a systematic, transparent, unbiased, robust manner. Its aim is to inform the formulation of safe, effective, health policies that are patient focused and seek to achieve best value. Despite its policy goals, HTA must always be firmly rooted in research and the scientific method".

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Kiss up kick down is a neologism used to describe the situation where middle-level employees in an organization are polite and flattering to superiors but abusive to subordinates. The term is believed to have originated in the US, with the first documented use having occurred in 1993. A similar expression was used by Swedish punk band Ebba Grön in one of their songs, on an album released in 1981. The concept can be applied to any social interaction where one person believes they have power over another person and believes that another person has power over them.

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<span class="mw-page-title-main">Cultural competence in healthcare</span> Health care services that are sensitive and responsive to the needs of diverse cultures

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The Health Services Safety Investigations Body (HSSIB) is a fully independent arm's length body of the Department of Health and Social Care. HSSIB came into operation on 1 October 2023. It investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care.

Just culture is a concept related to systems thinking which emphasizes that mistakes are generally a product of faulty organizational cultures, rather than solely brought about by the person or persons directly involved. In a just culture, after an incident, the question asked is, "What went wrong?" rather than "Who caused the problem?". A just culture is the opposite of a blame culture. A just culture is not the same as a no-blame culture as individuals may still be held accountable for their misconduct or negligence.

References

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