What comes to mind when you think about the term "just culture"? Consider the following dilemmas:
- Two nurses select the wrong medication from the dispensing system. One dose reaches a patient, causing him to go into shock, and the other is caught at the bedside before causing harm. Do we treat these nurses in the same way?
- A nurse loses custody of a yet unlabeled specimen but chooses not to report the incident out of fear of discipline. Do we forgive the breach, given the nurse's fear?
- An entire surgical team defends skipping the presurgical timeout on the basis that no adverse event occurred. Do we condone this violation?
These are just a few examples of dilemmas that might be addressed with the philosophy of a just culture. Just culture refers to a values-supportive model of shared accountability. It's a culture that holds organizations accountable for the systems they design and for how they respond to staff behaviors fairly and justly. In turn, staff members are accountable for the quality of their choices and for reporting both their errors and system vulnerabilities (Griffith, 2009).
A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture also recognizes that many individual or active errors represent predictable interactions between human operators and the system in which they work. However, in contrast to a culture that touts no blame as its governing principle, a just culture does not tolerate conscious disregard of clear risks to patients or gross misconduct, such as falsifying a record, performing professional duties while intoxicated, etc.
Dr. Lucian Leape, a member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, stated that the single greatest impediment to error prevention in the medical industry is "that we punish people for making mistakes." Leape (2009) indicated that in the healthcare organizational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety:
- We need to move from looking at errors as individual failures to realizing they are caused by system failures
- We must move from a punitive environment to a just culture
- We must move from secrecy to transparency
- Care must change from being provider-centered (doctor-centered) to being patient-centered
- We must move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork
- Accountability must be universal and reciprocal, not top-down
People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. But if we find out who made the errors and punish them, are we solving the problems? No. The problem is seldom the fault of an individual; it is the fault of the system. Changing the people without changing the system will perpetuate the problems.
How can we change systems to encourage individuals to report errors and learn from their mistakes? A just culture seeks to create an environment that encourages individuals to report mistakes so that the precursors to error can be better understood in order to fix the system issues. Individual practitioners should not be held accountable for system failings over which they have no control. In a just culture, individuals are continually learning, designing safe systems, and managing behavioral choices. Events are not things to be fixed, but opportunities to improve understanding of the system.
How do you get started with a just culture initiative and ensure that all staff members feel free to report errors? There needs to be an administration that supports the concepts of a just culture and encourages staff to report errors. Highly reliable industries foster mindfulness in their workers. Mindfulness is defined by Weick and Sutcliffe (2001) as being composed of five components:
- A constant concern about the possibility of failure even in the most successful endeavors
- Deference to expertise regardless of rank or status
- An ability to adapt when the unexpected occurs (commitment to resilience)
- An ability to concentrate on a specific task while having a sense of the bigger picture (sensitivity to operations)
- An ability to alter and flatten hierarchy as best fits the situation
Health organizations are now writing and promoting just culture policies and documents. The Joint Commission leadership standards (Schyve, 2009) address leadership and safety specifically relating to the organization's governing body (the CEO and senior management and medical and clinical staff leaders). The Joint Commission (formerly JCAHO) suggests instituting an organizationwide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal.
Regular monitoring and analysis of adverse events, open discussions of safety risks and barriers to safety, and ensuring that caregivers involved in adverse events receive attention that is just, respectful, compassionate, supportive, and timely are also addressed in the standards.
Rather than only react to the actual harm involved in a discovered event, an organization with a just culture assesses the daily risk inherent in its organization and works toward maximum reliability to prevent future adverse events, relentlessly improving both system design and the quality of collective behavioral choices. One of the defining qualities of a just culture is its commitment to values, including learning cultures, open and fair cultures, safe system design, and effective management of behavioral choices. A just culture fosters an environment in which employees hunger for knowledge and eagerly seek to understand risk at both individual and organizational levels (Griffith, 2009).
A just culture is one component of an accountable care organization (ACO). These organizations have a reporting, just, and flexible culture focused on improving safety and reliability through behavioral accountability and process design. Safety in ACOs is a core value. The focus is not on blame, but transparency. They provide high-value accountable healthcare delivery for patients, communities, and the providers they serve. We should all want to be part of an ACO.
American Nurses Association. (2010). Position statement on just culture. Accessed April 3, 2010, at http://tinyurl.com/3a73yox.
Griffith, K.S. (2009). "Column: The Growth of a Just Culture." The Joint Commission Perspectives on Patient Safety 9 (12): 8–9.
Leape, L.L. (2009). "Errors in medicine." Clinica Chimica Acta 404 (1): 2–5.
Schyve, D.M. (2009). "Leadership in healthcare organizations: A guide to Joint Commission leadership standards." Accessed April 22, 2010, at www.jointcommission.org/NR/rdonlyres/48366FFD-DB16-4C91-98F3-46C552A18D2A/0/WP_Leadership_Standards.pdf.
Weick, K.E. & Sutcliffe, K.M. (2001). Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass.
Barbara A. Brunt, MA, MN, RN-BC, is the director of nursing education and staff development at Summa Health System, a multihospital system in Akron, OH.
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