Defining Just Culture

A just culture requires the establishment of a psychologically safe environment where individuals trust that they can and should report errors without blame. When errors are reported they should be explored organizationally as a learning opportunity and examined for operational components that can be improved. A culture of learning and safety is the result of the cohesive interaction of four essential organizational elements:

Environmental structures and processes within the health care organization,
The perceptions and attitudes of individuals with the health care organization,
The behaviors of individuals, and
Buy-in and support from all levels of the administration.^{32, 47}

Barriers to Implementing Just Culture

Unrealistic Expectations of Perfection

As health care organizations transition to a just culture environment, they must dedicate resources and personnel to the process. Organizations must let go of the misconception that clinical perfection is an attainable goal and that good clinicians do not make errors. Desiring high standards of care from clinicians is both acceptable and desirable but allowing a culture of expected perfection is harmful to the safety of an organization. Management often assumes that all errors are due to inattention, carelessness, poor decisions, or indifference. Most errors are due to a system issue that can be corrected once identified. When clinicians operate under a culture of expected perfection they feel shame and reluctance to report errors. When clinicians operate under a fair and just culture they are more likely to report errors without fear. The expectation of perfection is harmful to an organization because it leads to hiding or covering up of errors which does not allow for learning from the incidence or changing the root cause of the error. Transformation to a just culture and away from a culture of expected perfection, shame, and blame requires extensive training, education, and support at all levels of the health care organization.^{49, 5, 27, 46, 48, 39}

Regulating Boards & Litigation Practices

Regulatory boards, licensing boards, and litigation practices often perpetuate the harmful myth of clinical perfection. The focus falls largely on individuals rather than system problems when licensing boards of nursing, medicine, pharmacology, and regulatory boards such as state and local health departments are involved. Individual clinicians are often fined, sued or fired for human errors which creates a seemingly insurmountable disincentive to report errors. There needs to be buy-in from regulatory boards and licensing agencies to explore a just culture when looking at human error. The constant threat of legal liability inhibits voluntary error reporting. Organizations must focus on designing safer systems to build a safer organization and to shift focus from individual blame to organizational responsibility if they hope to prevent future errors. The institute of Medicine Report, To Err Is Human addresses these disincentives and identifies two steps health care organizations can take to alleviate them as they design their internal reporting system. Health care organizations can ensure the confidentiality of error reporting and any information contained within an error report by obtaining and storing the data in an anonymous way that protects the information of the reporter. The health care organization can either have a system where reporting errors is anonymous or a system where once reported, any identifying information is redacted from the report.^{27, 39, 40, 32}

Just Culture Requires a Long-Term Commitment

Developing and implementing a just culture requires an organization’s long-term commitment. Changes in structures and processes require organizational buy-in at all levels and changes in beliefs, attitudes, and behaviors surrounding errors and near misses. It can take up to five years for a just culture to be fully integrated and effective in an organization. Do not let this deter you from pushing forward, improvements can be seen immediately and without a just culture the situation will not improve.³⁹

Need for Federal Legislation

To Err Is Human also points to the need for federal legislation that protects health care organization’s peer review process and the data collected during it that are for the purpose of improving safety outcomes. State laws exist giving these protections but they vary in vigor and scope. Federal legislation could provide a clear uniform protection for the creation of just cultures in health care organizations. The Medicare Payment Advisory Commission has recommended Congress enact legislation that would protect the confidentiality of individuals related to reporting of errors in the health care delivery system when the information is used for safety and quality improvement purposes. Other countries such as New Zealand and Australia currently have legal protections in place for health care error reporters.^{19, 32, 35}

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Stages of Just Culture - Where Are You?

Take the quiz to see which stage your organization is in!

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Stage 1 - Organizational culture is based on rules and regulations

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Stage 2 - Just culture becomes an organizational goal

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Stage 3 - Organizational culture is seen as dynamic and continuously improving

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