Just culture

Just culture is a concept used primarily in health care and aviation. It relates to how mistakes should be addressed. It advocates taking into consideration human error and systemic problems in addressing the conduct of individual people instead of universally applying blame and punishment. It advocates fair punishment for conduct that is deliberately reckless or that flouts safety rules and precautions. Just culture is seen as a way to encourage accountability and identify problem areas that need correction.

Background

The just culture concept originated in the late 1990s and was brought to the forefront by David Marx, a lawyer and former engineer, in 2001. The concept recognizes that it is human nature to make errors; in some circumstances, however, those errors can have dire consequences. This is particularly true in health care and aviation.

Marx and others who advocate the idea of just culture have said that the typical initial reaction to seek out and punish the person who made the error is sometimes unfair and often does little to help improve the system or the ultimate safety of the situation. Marx has endorsed looking at the cause of the mistakes and finding ways to correct them systemically. The idea of just culture takes into account that people who are afraid of consequences are often encouraged to hide errors rather than report them, opening the way for additional problems.

At the same time, just culture calls for a clear line to be drawn between legitimate mistakes and behavior that can be identified as at-risk or reckless. Under just culture, those who inadvertently make a mistake are treated differently from those who skip safety steps on purpose or who deliberately take risks. At-risk and reckless behaviors are to be addressed with consequences even if they do not lead to adverse effects or problems.

The concept was originally applied mostly to aviation, where mistakes and shortcuts can have devastating effects, such as equipment failures, that can lead to catastrophic consequences. In health care, physicians, nurses, and technicians who make mistakes through error, risk taking, or recklessness can cause harm to or even kill a patient. Just culture concepts are aimed at finding ways to prevent the mistakes caused by errors and discouraging a culture where risks and recklessness are tolerated.

Overview

Just culture recognizes that people are human and can make mistakes. It also recognizes that sometimes the system can contribute to these mistakes. The goal of just culture is to find the causes of these mistakes and address them to prevent future mistakes.

For example, a nurse may mistakenly misread the physician's directions and administer too much medication to a patient. This can happen because of simple error on the part of the health-care professional. Perhaps the nurse was in a hurry, or maybe the physician's handwriting was sloppy. These are examples of simple human error. Under just culture, the health-care facility would want to address these situations with coaching without necessarily ending or permanently hampering the professional's career over an isolated error.

If the nurse was hurrying because the hospital was understaffed or the physician's writing was sloppy because they worked too many hours in a row, then the system contributed to the errors. The health-care facility should identify these problems and take steps to address them in an effort to prevent similar errors in the future. The idea of just culture allows the nurse to speak up and acknowledge the error and why it happened without fear of career-altering punishments.

The just culture concept recognizes that sometimes patterns of behavior develop that do not meet acceptable standards for safety. These patterns sometimes start innocently; a nurse does not complete the full check of patient identity before a procedure on a busy day but then slips into a habit of not completing full checks because nothing bad happened. Behaviors like this, where corners are cut and full safety precautions are not followed, are considered at-risk behaviors. These require more stringent consequences because they are not accidental behaviors. The just culture concept would consider these opportunities for coaching and other remedial efforts, however, especially if the behavior is found to be common enough in the facility that it has become an unofficial "normal" behavior. Just culture takes into account the human tendencies related to group behavior.

At-risk behavior can also be behavior that starts out as an innocent mistake but moves into a deliberate violation. For example, if a technician legitimately forgets to administer a test requested by the physician, that would be considered a simple error. If the technician then lies and gives the physicians results for a test that was never completed, that would be at-risk behavior.

The final type of behavior addressed under just culture is reckless behavior. This is behavior that deliberately and intentionally flouts the rules of safety; for example, a physician who operates while under the influence of drugs or alcohol would be recklessly risking the patient's life. Sometimes reckless behavior is less clear-cut. For instance, if a physician enters the surgical suite without adequately washing their hands, that can be considered reckless behavior because they clearly know the importance of cleanliness and choose to ignore it. However, skipping or shortening handwashing techniques may result from the hospital's failure to schedule adequate time between surgeries or failure to have sufficient staff on hand. It then becomes more difficult to assign blame for the recklessness.

Another factor in just culture is that punishments are meted out based on the severity of the infraction rather than on the seriousness of the outcome. Mistakes are accepted with appropriate action to prevent future errors, but reckless behavior is not tolerated. Thus, a physician who risks a patient's health by operating while impaired will face severe disciplinary action even if the operation is a success, while a nurse who accidentally administers the wrong medication may face only minor discipline, such as coaching or increased supervision, even if the dose proves fatal. This is because the ultimate goal of just culture is to provide a work environment with accountability and improved safety.

Bibliography

Boysen, Philip C. "Just Culture: A Foundation for Balanced Accountability and Patient Safety." The Oschner Journal, vol. 13, no. 3, 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/. Accessed 30 Aug. 2024.

Brewer, Katie. "How a 'Just Culture' Can Improve Safety in Health Care." American Nurse Today, vol.6, no. 6, 2011, www.americannursetoday.com/how-a-just-culture-can-improve-safety-in-health-care/. Accessed 30 Aug. 2024.

Brunt, Barbara A. "Developing a Just Culture." HealthLeaders Media, 18 May 2010, www.healthleadersmedia.com/nurse-leaders/developing-just-culture#. Accessed 30 Aug. 2024.

Dekker, Sidney, et al., editors. Restorative Just Culture in Practice: Implementation and Evaluation. Routledge, 2022.

"In Conversation with . . . David Marx, JD." Patient Safety Network, Agency for Healthcare Research and Quality, US Department of Health & Human Services, 1 Oct. 2007, psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd. Accessed 30 Aug. 2024.

"Just Culture." CMPA, May 2021, www.cmpa-acpm.ca/en/education-events/good-practices/the-healthcare-system/just-culture. Accessed 30 Aug. 2024.

Lewis, Harriet. "Patient Safety in a 'Just Culture': Encouraging Reporting and Learning from Errors." WTW, 20 Aug. 2024, www.wtwco.com/en-us/insights/2024/08/patient-safety-in-a-just-culture-encouraging-reporting-and-learning-from-errors. Accessed 30 Aug. 2024.

Reason, J. T. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Ashgate Publishing, 2008, pp. 90–94.