Just Culture in Healthcare

 

Just Culture in Healthcare

The single greatest impediment to error prevention in the medical industry is “that we punish people for making mistakes.”   

- Dr. Lucian Leape Professor, Harvard School of Public Health Testimony before Congress on Health Care Quality Improvement

“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.”

- Don Norman, Author, “The Design of Everyday Things

Traditionally, what happen to the staff who made an error? 

 coach or re-educate 

 formal written warning in their file

 immediate suspension until investigation complete

 termination

What is a Just Culture

A “Just Culture” is an open and fair culture in which all members of an organization are accountable, in a fair and just way, for making safe behavioral choices.

“Just Culture” strives to be the balance between “blame-free” and “punitive”.

The emphasis is to maintain individual accountability for unsafe behaviors, while acknowledging that most errors occur as a result of system flaws.

 Principles of Just Culture

It will require a Just Culture, where all staff feel comfortable reporting errors–including their own

 feel that their errors will be judged fairly

 feel they won’t get blamed and punished for system errors

 know about unsafe/risky choices and try not to make them

 know that Reckless and Disruptive Behavior is unacceptable

Behaviors that Undermine a Culture of Safety

Disruptive Behavior is any conduct or behavior including but not limited to, sexual harassment, 

ethnic or racial slandering, and/or any forms of unacceptable behavior

Unacceptable Behaviors includes:  Belittling criticism in front of other staff, patient, or visitor  Slamming or throwing of objects  Retaliation against any person for reporting a violation of the code of behaviors/policy

Not only are these behaviors unacceptable, but these behaviors also undermine a culture of safety. A staff person who has been criticized or belittled may not speak up when a next event happens.

THE JUST CULTURE PROCESS

References:

Quality & Safety: ‘Just Culture’ Provides Process to Review, Correct Mistakes for Optimal Patient Care | Department of Medicine (arizona.edu)