A Just Culture: Relevance, and Challenges of Implementation

Paul E. Phrampus, MD FACEP

The importance of developing “A Just Culture” within a healthcare setting is one of the critical components of helping to improve the overall culture of safety at a given institution. A just culture is simply trying to win the hearts and minds of health care providers and have them believe that they are part of a system that recognizes several important tenets of the work environment related to patient safety. One being that humans are fallible, systems are fallible, errors and near misses occur, and when they do, the humans in the system are treated fairly or just. They also have to believe that organization wants to learn from the events.

For decades in healthcare, errors and/or near-miss occurrences invoke a punitive orientated focus to investigations that largely seek to assign blame to the healthcare providers involved in the event. Many times investigations are conducted with a mission to find “who” is to blame, instead of understanding 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 that should be attributed to the system that provides the infrastructure in which the healthcare providers carry out their mission.

The end result is one that creates an environment of mistrust in and amongst groups of professionals or teams that provide the daily care of patients and fosters the perpetuation of 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 dialogue about the incident introduces bias into the final report. Thus, it decreased the ability to be able to rely on, and learn from the information that is obtained or highlight interventions that would likely reduce the chance of a similar occurrence in the future.

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. Establishing “A Just Culture” is a journey that requires attention to all of these factors regarding professionals in our community.  Changing cultures in an organization is a challenge. It requires a commitment from the most senior leadership down to the individual providers who actually perform patient care on the frontline.

Senior leaders need to be committed to a fair and just investigation process as well as a reconciliation process that allows people to be treated consistently and fairly in the setting of an adverse event regardless of the magnitude of the error or the group(s) of professionals involved. Senior leaders also need to understand that poorly designed systems likely have a role in facilitating adverse events. They need to establish, educate and create an environment for managers to understand the importance of following a prescribed pathway or process, that allows for an impartial investigation, and the fact that after a seemingly tragic error, there may not be an individual person to blame. This is a challenging concept for both managers and senior leaders to embrace.

The complexity of this should not be underestimated. It is important to realize the personal bias of the manager of a particular care environment to personalize, or feel a sense of failure when an event occurs in their unit. This element of bias cannot be eliminated, so it must be accounted for when designing new systems of investigations and fact-finding associated with incidents.

Frontline care providers need to be committed to the fact that they are performing patient care in a system that cares about the underlying causes of errors and near misses and seeks to learn from the events that occur. They need to believe that it is everyone's professional responsibility to be vigilant for things that could potentially cause harm to patients. They need to be committed to personal accountability in the decisions they make which affect care, as well as speaking up when they have concerns.

The establishment of “A Just Culture” is part of transformation of culture that allows for an organization to move from a punitive response to errors to one in which it expects healthcare professionals to: speak up and report potentially unsafe conditions to speak more freely about errors; and to help to create a safer environment for the future. It is important to realize that this can only occur in a setting of trust amongst all of the people involved in a given institution.

“A Just Culture” does not free individuals of personal accountability. Healthcare professionals make hundreds, if not thousands, of decisions on a regular basis that affects the care of patients. They're expected to make these decisions in accordance with their professional training, protocols, guidelines, and known best practices that exist. However, organizations with a high functioning  belief of the existence of “A Just Culture” recognizes that many times healthcare professionals are making decisions based on professional judgment, situational awareness as well as the real-time interactions and needs of the patients within the given resources that are available. “A Just Culture” assumes from the start that individual healthcare professionals have a desire to deliver the best care within their purview.

Additionally, “A Just Culture” environment recognizes that workarounds, shortcuts and other seemingly “careless” behaviors become inculcated into clinical practice at the frontline. It is further recognized that this occurs because of impaired systems, poorly designed systems, protocols, guidelines, communications errors, and other factors that emerge as a result of the pressure and clinical demands associated with the current model of the delivery of healthcare. Thus when a deviation occurs in association with an error or near miss it is important that several other non-managerial peer providers be queried about the practice to determine if it is something that is embedded in the everyday way of doing business in a given work environment.

This is a critically important recognition in any organization trying to shift towards “A Just Culture.” While many managers put pen to paper to create protocols and guidelines, the net result is often regulations or guidelines that are ideal in the minds of the managers and leaders, but is not actually practiced on the frontlines. This is commonly referred to as imagined practice. In Emergency Medicine, a common example of this exists when protocols are designed to work ideally in the middle of a weekday when there are many resources around the typical hospital, but the event triggering the investigation occurred during a resource constrained timeframe in the middle of the night on the weekend.

Non-clinical administrative leaders who are not engaged in truly working collaboratively with practicing healthcare professionals can easily envision that caring for patients falls in the black-and-white decision making realm of protocols and guidelines. However, experienced clinical providers of healthcare fully recognize that many of the decisions, tasks and workflow that are carried out on a day-by-day basis actually exist in a gray zone that doesn't fit within a defined protocol. This is particularly true in high intensity areas of the hospital such as care that is carried out in the emergency department but easily extends to intensive care units, operating rooms and other environments of acute care.  It is important that this understanding be recognized and factored into the adoption of “A Just Culture” environment by an organization. Leaders from the clinical environment core teams, ancillary services, human resources, and the legal department need to work collaboratively to establish a mutual understanding and approach that can be uniformly agreed upon. 

Bringing together the stakeholders of an organization from the leadership to the frontline care providers and facilitating a common understanding and commitment to the response to errors and near misses is a major journey for any organization regardless of the size. Tackling entrenched ideas, factoring in a natural reluctance to change, and pushing the envelope of leadership’s uncomfortableness with assigning portions of responsibility to the system in which people provide care is complex. However, any healthcare institution would recognize the benefit to creating an environment where frontline care providers were able to openly discuss errors and near misses, learn from them, and then participate in system redesigns to ensure a safer future for their patients would have to conclude it is worth the investment.


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