Just Culture
“Just Culture” aka “Blameworthy”
(Responsibility/Accountability)
Content draws heavily from the excellent
work of David Marx, JD and James
Reason, PhD
Just Culture
• Emphasizes learning over blaming
• We want to promote open discussion of
near misses and harm. (Culture of
Safety)
• Assume people want to do reasonable
things and help patients….then look at
why there is a performance gap.
Learning Institution
• Yeah, we blow it
from time to time.
• Learn from it, and
then pursue
excellence.
Accountability
• 80% of errors are from system failures
• 15% human cognitive factors
• 5% practitioner negligence
• View accountability in the context of
individual and system influences.
• Individuals are accountable for their
own performance but not for the system
flaws.
Reporting Systems
All providers – first and foremost constant
goal is systems improvements and
decrease harm to the next patient.
Individuals are responsible for reporting
untoward events and contribute to the
elimination of system flaws.
Part of CLER/NAS initiative
Just Culture
Blaming individuals creates a culture of
fear and defensiveness which decreases
learning and capacity to improve systems.
Single greatest impediment to error
prevention is that we punish people for
making mistakes.
- Lucian Leape, M.D
Accountability
• Disciplining people for honest mistakes does
little to improve system safety.
• Discipline does detour those who consciously
disregard risks and intend harm to others.
Just Culture
Inverse relationship between discipline and
reporting.
• Increased discipline = decreased reporting
• Decreased reporting = decreased learning
• Decreased learning = less opportunity to
improve systems = ongoing errors = eventual
patient harm.
Paradigm Shift
Not reporting one’s error, which prevents
the system and others from learning, is
the greatest evil of all. We are held
accountable to make our system and
profession safer to decrease harm to the
patients who entrust their care to us.
Lucian Leape, M.D. Harvard University
Just Culture
Emphasizes learning over blaming
Paradigm shift in due process
Paradigm Shift
Proven in aviation and industrial injury
prevention programs to increase
reporting, decrease errors, and improve
safety.
Just Culture
Shame and Blame
Learn or Lean
Just Culture
• Culpability based on intent and risk
taking behavior….not outcome based
which brings in severity bias.
• Replace “blame free” to “responsibility
and accountability”
Reporting Systems
• Purpose of reporting system is to learn.
• Purpose of surveillance system is to
monitor. (Trust but verify - accountable)
• If seeking accountability then monitor,
don’t do through reporting
• If seeking to learn then spontaneous
and stimulated reporting.
Accountability
• Individuals are responsible for surfacing
errors, near misses, potential harm and for
contributing to the elimination of system
flaws.
• Failure to report error or mishap witnessed or
personally done can lead to discipline.
Accountability
Even small errors are to be reported.
– Normative deviation – from walk-a-rounds
accounts for 50% of aviation errors.
– To determine policy/procedure changes or
system redesign.
Just Culture
• No blame unless:
– Premeditated or intentional acts of
violence towards people or damage
to equipment or property.
– Reckless disregard towards the
safety of patients, employees, or sig.
economic harm to hospital.
– Failure to report safety incidents or
risk exposures.
Destruction of Hospital
Property
Just Culture
Disruptive behavior = individual action =
willful engagement of unsafe behavior =
discipline
Squealer
Repeat Offender/Negligence
• Is it secondary to poor system design,
policy or procedure?
• Personal traumatic events in person’s
life?
• Inadequate training, inappropriate
granting of privileges, or bad hire?
• Proper orientation?
Overall Definition of Just
Culture
• Environment which is:
– Transparent
– Non-punitive
– Supportive
– But accountable
Don’t Judge Too Quickly
• First party seems
right……..until you
talk to the other
side.
• Policy to include
speak with physician
before finality
determined.
• Level 2.5
Just Culture
Please read!!
– Patient Safety and the “Just Culture”:A
Primer for Health Care Executives; David
Marx, JD
David Marx, JD and Reason J, Managing the
Risks of Organizational Accidents. Ashgate
Publishing; 1997; Fig 9.4 pg 209
Reason’s Diagram
• Modified with permission
• May use internally without publisher
permission.
• If produced >200 copies for external
teaching need to notify publisher for
permission.
Differentiate Human Error vs.
Unsafe Behavioral Choices
• Human error: “Console”
• “At Risk” Behaviors: “Coach”
• “Reckless” Behaviors: Consider
disciplinary action
Outcomes Engineering/David Marx
28
Commitment to Change
Statement
Second Victims
• Two parties involved…twin casualties
– Patient and family
– Healthcare Worker
• “Second Victims”
– Dr Albert Wu – Johns Hopkins Bloomberg
School of Public Health
– Live with the aftermath of making an error
Second Victims
• Anxiety – two-thirds
• Insomnia
• Self-doubt about their professional
abilities
• Decreased job confidence and
satisfaction - 50%
• Surgeons 3X more likely to consider
suicide
Second Victims
Above symptoms often last for years.
Shanafelt T, et. Al.; Archives of Surgery 2011;146(1):54-62 2008 7,905 participant survey
Waterman, A; Joint Commission Journal on Quality and Patient
Safety, August 2001 Vol. 33 Number 8; 467-475. - 2,989
participants
Healing Together
• Medically Induced Trauma Support
Services (MITSS)
• Non-profit organization founded in June
of 2002 by patient and physician
• Mission: “To Support Healing and
Restore Hope” to patients, families, and
clinicians who have been impacted by
an adverse medical event.
Teamwork to Prevent Errors
and Second Victims
Just Culture
• An atmosphere of trust in which people
are encouraged (even rewarded) for
providing essential safety-related
information.
• Individuals trust they will not be held
accountable for system failures; and are
also clear about where the line must be
drawn between acceptable and
unacceptable behavior.
References – Just Culture
• Patient Safety and the "Just Culture": A
Primer for Health Care Executives.
http://psnet.ahrq.gov/resource.aspx?resou
rceID=1582
• www.justculture.org
Further Resources
• Reason J, Managing the Risks of
Organizational Accidents. Ashgate
Publishing; 1997; Fig 9.4 pg 209