A Just Culture in a health care setting is one of the cornerstones of the overall culture of safety at a given institution. It exists when the staff understands that they are part of an organization that recognizes several important tenets of the work environment related to patient safety.
Those tenets include recognition that humans and systems are fallible and that errors and near misses occur. When they do, the humans in the system are treated fairly. Additionally, care providers need to know that the system hears their voice of concern and has a true desire to learn from such events.
The establishment of A Just Culture is part of a cultural transformation that allows an organization to move from a punitive response to errors to one in which health care professionals are expected to speak up and report potentially unsafe conditions. Such an environment allows health care providers to speak more freely about errors and to help create a safer environment for the future.
A Just Culture does not free individuals of personal accountability. Health care professionals make hundreds if not thousands of decisions on a regular basis that affect the patient care. They’re expected to make these decisions in accordance with their professional training, protocols, guidelines, and known best practices. A Just Culture should give people the confidence that when errors do occur, however serious, those involved will be treated fairly and equitably.
Organizations like ours with a high-functioning belief of the existence of A Just Culture understand the complexity of health care decision making. We recognize that many times health care professionals are making decisions based on professional judgment and situational awareness as well as the real-time interactions and needs of the patients within available resources. From the start, A Just Culture assumes that individual health care professionals have a desire to deliver the best care within their purview.
For decades in health care, errors and/or near miss occurrences invoked a punitive-orientated focus to investigations that largely sought to assign blame to the individual health care providers involved in the event. Many times, investigations are conducted with a mission of finding someone to blame instead of looking for the true cause(s) of the event. Investigations and remedies that focus on a punitive, pervasive thought process will also tend to fail to assess responsibilities and causes attributable to the system providing the infrastructure for the health care providers.
The end result is one that creates an environment of mistrust in and amongst groups of professionals or teams that provide patient care daily. This perpetuates a “shame and blame” response to the errors. In such circumstances, it is not hard to understand the natural response to push the responsibility or blame to others involved in the incident. This creates a natural barrier to productive inter- and intra-professional dialog about the incident and inputs bias into the final report that attempt to deflect blame. Thus, it decreases the ability to be able to rely on, or learn from, information obtained in terms of attempting to create solutions or interventions that would likely reduce the chance of a similar occurrence in the future.
Investigations in a high functioning organization embracing A Just Culture will look for causes of incidents beyond the focus on an individual and seek to identify the many elements of system breakdown that often accompany errors and mistakes. Those of us working in patient safety truly understand to be able to improve systems to a level that would proactively prevent an error from occurring.
The foundation of culture is people. How people interact within a community is partly based on custom, tradition, trust, mutual respect, and some vision of purpose. A Just Culture is a journey that requires attention to all of these factors regarding professionals in community. In healthcare leaders must develop a strong commitment to maintain the principles of A Just Culture from the most senior leadership down to the individual providers who perform patient care on the front-line.
Keeping Patients Safer 