Dana-Farber Cancer Institute
Principles of a Fair and Just Culture

Background
It is inevitable that people will make mistakes or experience misunderstandings in any work environment. When events occur that cause harm or have the potential to cause harm to patients or staff members, or that place the Institute at legal, financial or ethical risk, a choice exists: to learn or to blame. Dana-Farber Cancer Institute is committed to creating a work environment that emphasizes learning rather than blame.

Dana-Farber Cancer Institute recognizes the complexity and interdependence of the work environment in all aspects of its operations, including patient care, clinical operations, research, support services and administration. The intent is to promote an atmosphere where any employee can openly discuss errors of commission or omission, process improvements, and/or systems corrections without the fear of reprisal.

It is well documented that most errors, whether or not they cause harm, are due to breakdowns in organizational systems; however, when an error takes place, individual culprits are often sought. Blaming individuals creates a culture of fear and defensiveness that diminishes both learning and the capacity to constantly improve systems.

Most errors take place within systems that themselves contribute to the error. In spite of this, it is difficult to create an institutional culture that integrates the understanding that systems failures are the root cause of most errors. Learning from errors often points to beneficial changes in systems and management processes as well as in individual behavior.

In the context of promoting a fair and just culture, what does it mean? A fair and just culture means giving constructive feedback and critical analysis in skillful ways, doing assessments that are based on facts, and having respect for the complexity of the situation. It also means providing fair-minded treatment, having productive conversations, and creating effective structures that help people reveal their errors and help the organization learn from them. A fair and just culture does not mean non-accountable, nor does it mean an avoidance of critique or assessment of competence. Rather, when incompetence or sub-standard performance is revealed after careful collection of facts, and/or there is reckless or willful violation of policies or negligent behavior, corrective or disciplinary action may be appropriate.

Applying these principles creates an opportunity to enact the core values of the Dana-Farber Cancer Institute. In order to have the greatest impact and achieve the highest level of excellence, staff must be able to speak up about problems, errors, conflicts and misunderstandings in an environment where it is the shared goal to identify and discuss problems with curiosity and respect. To achieve excellence, unwanted or unexpected outcomes and inefficiencies of practice must be used as the basis for a learning process. Respect must be shown to all people at every level of the organization.

Principles of a Fair and Just Culture
 

1. DFCI strives to create a learning environment and a workplace that support the core values of impact, excellence, respect/compassion and discovery in every aspect of work at the Institute.
   
    
2. DFCI supports the efforts of every individual to deliver the best work possible. When errors are made and/or misunderstandings occur, the Institute strives to establish accountability in the context of the system in which they occurred.
   
    
   • We commit to creating an institutional work environment that is least likely to cause or support error.
   • We are proactive about identifying system flaws.
     
      
3. DFCI commits to holding individuals accountable for their own performance in accordance with their job responsibilities and the DFCI core values. However, individuals should not carry the burden for system flaws over which they had no control.
   
    
4. DFCI promotes open interdisciplinary discussion of untoward events (errors, mistakes, misunderstandings or system failures resulting in harm, potential harm or adverse outcome) by all who work, visit or are cared for at the Institute.
   
    
   • We commit to developing and maintaining easily available and simple processes to discuss untoward events.
   • We commit to eliciting different points of view to identify sources of untoward events and to use the information to improve the working and care environment.
   • We commit to fostering an interdisciplinary teamwork approach to the analysis of untoward events and to the actions taken to address them.
   • We believe that individuals are responsible for surfacing untoward events and for contributing to the elimination of system flaws.
   • We commit to analyzing episodes of institutional or patient harm or potential harm in an unbiased fashion to best determine the contributions of system and individual factors.
   • We seek solutions that promote simplification and standardization wherever possible.
     
      
5. DFCI acts to improve all areas of the workplace by implementing changes based on our analysis of problems and potential or actual harm.
   
    
   • We know that actions designed to address the root causes of untoward events will improve the effectiveness of our work environment and the safety of care. We commit to identifying and assigning responsibility for implementing those actions to specific individuals or groups.
   • We commit to developing timely and effective follow-up and an effective organizational culture through education and systems for ensuring on-going competency.
     
      
6. DFCI commits to a culture of inclusion and education.
   
    
   • We commit to fostering a culture that is concerned with safety in research, clinical care and administration through continuous education, proactive interventions and safety-based leadership.
   • We believe that patient input is indispensable to the delivery of safe care and we commit to promoting patient and family participation.
     
      
7. DFCI will assess our success in promoting a learning environment by evaluating our willingness to communicate openly and by the improvements we achieve.
   
    
   • We commit to monitoring actions and attitudes for their effectiveness in supporting a culture of safety and modifying actions as needed.

[Principles adapted from Allan Frankel, M.D. and the Patient Safety Leaders at Partners Healthcare System]