Bad Apples and a Just Culture

Gary Kantor

February 2017

It’s tempting to conclude that MEC Mahlangu, Dr Selebano and Dr Manamela are the sole culprits in this distressing affair. After all, to quote Professor Makgoba, their “fingerprints” are “peppered throughout the project”.  This would be comforting, for if we simply get rid of the culprits – those who are to blame – the problem is solved, and a tragedy like this will never recur.

Unfortunately, even if the three officials are permanently removed from their positions, patients in the Gauteng public health system are unlikely to be safer the next day and thereafter. Let’s explore why.

In health care, adverse events (incidents in which harm results to a person receiving health care), are usually not crimes, even when patients die, and those responsible are not considered criminals. It’s clear from studies of healthcare systems, and from everyday experience, that the vast majority of health professionals come to work intending to help people, not harm them.

However, hospitals and clinics aren’t perfectly safe, and in all healthcare systems around the world, even the best, patients are sometimes harmed. Infections acquired in hospital, medication errors, falls, blood clots, surgical misadventures, these things occur, and some patients die as a result. All healthcare organisations therefore strive, or should strive, continually to improve their safety and effectiveness. A new science of patient safety is now contributing to a better understanding of the complexity of healthcare delivery systems, of how errors and harm may be prevented, and how greater safety and reliability can be achieved.

So, it’s reasonable to assume that when patients are harmed, as in the Life Esidimeni (LE) case, the system as a whole needs to be examined and we should not jump to the conclusion that any single individual, or individuals are culpable.

A useful concept in this regard is the idea of a “just culture”[1] which recognises that “individual errors represent predictable interactions between human operators and the systems in which they work”. In a just culture, frontline staff feel comfortable disclosing errors – including their own – while maintaining professional accountability. A just culture recognizes that competent professionals make mistakes but also has “zero tolerance for reckless behavior”.

It’s possible to consider the failures associated with transfer of the LE patients as honest errors caused by system issues. For example, in this case, conceivably, the educational system is part of the problem; it failed to provide these individuals with the skills and judgment they needed to safely implement a fine policy, that of de-institutionalising chronically ill patients, with the intention of restoring those patients to a fuller life, in society, and saving public money in the process.

On the other hand, decisions were made by the principals (Mahlangu, Selebano, and Manamela) in the face of clear facts, advice from experts, and protests by many others who argued against the course of action they pursued. Leaving aside the evidence of lies and falsification of records and licenses, all clearly unacceptable, the NGOs to which patients were sent appear to have been utterly inappropriate settings of care for mental health patients, or any other type of patient for that matter – and the principals knew it. While Mahlangu and the others probably did not intend at the outset to deliberately harm these vulnerable patients, by the standards of a just culture their actions were unacceptable, can probably be characterised as reckless, and there is culpability.

While its clear therefore, from Prof Makgoba’s report, that the behavior of the principals fell outside what could be regarded in a just culture to be reasonable, the tendency to blame individuals – the ‘bad apple’ approach to quality – is still a problem and will generally not take us toward solutions. It is instructive to continue to apply a broader health systems perspective to other aspects of this case.

Many healthcare providers, and other participants, would have seen up close the conditions to which the LE patients were exposed. Some tried to stand in the way, but others stood by in silence. Why did the events progress to their fatal conclusions? Perhaps what we see in this extreme set of events explains and applies to the poor quality of care unfortunately experienced by our citizens in other facilities that only occasionally receive the attention that these tragic events have had. The underlying system factors that surely played a part, and are continuing to play a role in other health facilities include:

• Absence of a culture of safety in which staff, patients, and families can speak up to voice their concerns.
• Variable and unreliable clinical processes such as transfer of care, and of patient data/records that need redesign.
• Failure to fund facilities adequately and in a timely fashion, even where the budget exists.
• Lack of timely outcomes data with which system managers could facilitate early action.
• Inadequate skills and training of registered professionals, care givers and others.
• Lack of capacity i.e. sufficient numbers of trained nurses and other health professionals
• Lack of management action to improve facilities already known to be out of line with core standards.

In summary, what’s needed beyond finger-pointing and “fingerprinting” is an appreciation of the system issues that generate these and other terrible health outcomes. Many, as above, are well known. Then, most importantly, we need practical steps to devise, test and spread solutions.

When harm does occur we should offer an immediate apology to affected patients and families. There should be a thorough explanation of how the harm occurred, and a promise to address the underlying deficiencies so similar failures don’t reach another patient. In most cases of inadvertent harm, these three actions – apology, explanation, and a promise to act on system issues should be our default behaviours. This recommended approach, accompanied by reasonable financial compensation for resultant healthcare costs, would probably take many cases out of the lengthening queues of injured patients and families currently seeking billions of Rands in restitution via the courts around the country. In the LE case we have, thanks to the Health Ombud, a refreshing new sense of accountability, but sincere apologies have not been forthcoming and we have not yet heard much about systemic solutions.

[1] See: https://psnet.ahrq.gov/glossary/j