Basic Concepts of a Just Culture
Originally published in Forum Magazine
Originally published in the Winter 2009 Federation Forum Magazine.
Just culture is the process, the concept, of attempting to manage human fallibility through system design and behavioral choices that we have within our organization.
Just culture has been successful at a number of different organizations. One airline cut its maintenance errors by 50%, while another airline reduced its ground damage by 50%. A hospital’s hand hygiene compliance rate went from 65 % to 95 % and it was attributed directly to the work done around just culture. One of the results of just culture implementation at the Medical Malpractice Insurance Company in Minnesota was that a member of the staff realized he/she could admit to a mistake and have the entire staff benefit from it.
In the medical industry today, prevention consists of punishing people for making mistakes. Therefore, when someone does make a mistake, we don’t have the ability to learn from it. The ability to learn from our mistakes is our starting point, and it is one that varies from hospital to hospital and from healthcare system to healthcare system.
The Federal Aviation Requirements – rules that guide all pilots and mechanics – dictate that no person should operate an aircraft in a careless or reckless manner so as to endanger the life or property of another. We have a sense of reckless, but what is careless? The NTSB, the governing body for aviation, defines it as the most basic form of simple human error or omission. It is the simple human mistake. If we say that you cannot make a mistake and we are going to hold you accountable for your mistakes and punish you, will you raise your hand when you make a mistake?
Healthcare is falling into the same track as aviation in the sense that we too often hold people accountable by punishing them for human error. That’s not going to advance the culture of learning. As regulatory bodies, we have to be careful about what we want to regulate and how we are determining accountability. That doesn’t mean we can’t hold people accountable for human error. Just culture is about the most effective way to hold someone accountable. Punishing someone for a mistake may not be the most effective way to help them to learn from that mistake. Reviewing all the things that occurred to cause the error may further the reliability and the advancement of the operation.
Noncompliance of hand hygiene is pretty important. But what if we fired or punished every person for noncompliance? Human resources would be busy and there would certainly be a shortage of nurses and doctors! It’s not necessarily the wrong way to go, but it is at one end of spectrum - blame the people involved. Find out the person who made the error, punish them and you’ve solved the problem. Others may say that the problem is seldom the individual but rather the fault of the system. Change the people without changing the system and the problems will continue. However, sometimes people make bad choices. Just culture attempts to find the most effective way to hold both the people and the system accountable.
Sometimes our system puts the employee, the staff member or whoever it might be between a rock and a hard place. It’s going to turn out badly either way. Most pick the lesser of two evils. People do not come to work wanting to do a bad job or wanting to have a bad event happen. They come to work wanting to do things right but they drift.
As managers, executives and regulators, there are things we can control. We have to decide if we need to make changes to have a greater impact on our human errors and our adverse events. We must balance our input with our output, and decide how we can be proactive. Missed events are a precursor to bad events. It is very important to look at those missed events and examine the system design and behavioral choices that occurred. Risk exists. To err is human. To drift is human. We will all make mistakes.
We are taught to drive with our hands at 10 and 2. We drift to 9 and 3. I am an 8 and coffee kind of guy. My wife is 8 and makeup. Others are 8 and cell phone. That’s drifting. I have as much control of my car at 8 and coffee as I do at 10 and 2. But, in a blizzard, I am not at 8 and coffee. I’m at 10 and 2 with the radio shut off and no distractions, because I perceive the risks. My drifting has stopped.
Risk is everywhere. It can be a perception, it can be an absolute and it is not essentially bad. Physical therapy involves risk. Is the risk worth it? I think probably so. Surgery is risky. Is it worth it? Absolutely. There are many things that we do in healthcare that are extremely risky but they are worth it when we manage and support our values. We must also examine the severity of risk versus likelihood of a good outcome. It’s a gamble that we face many times in healthcare. How we regulate and manage that risk is another tough question. Safety is just one of our values. Integrity, collaboration and innovation are all values that must be supported and in some way put on an equal plane.
As a CEO of a healthcare system, your resources are not infinite, so you have to make decisions. Is a patient’s only concern safety? No, there are other values, such as privacy and comfort. There are a lot of competing values, and we are accountable across all departments, across all positions and across all behaviors. We are all accountable for human error, at-risk behavior and recklessness. That’s what makes the just culture effective. Everyone sees that we are all working to support these values, from the CEO on down.