A Just Culture

“Curmudge, when one thinks about a ‘just culture’ as the opposite of a punitive culture, its meaning is pretty obvious; but I know that there’s a lot more that you intend to say about it.”

“That’s for sure, Jaded Julie. The ‘just culture’ approach to patient safety is so important that even screaming from the top of the parking ramp, ‘Read what I write!’ is not sufficient. We both must shout in unison, ‘Read what I write about!’ That means that this blog will only scratch the surface, and that one should read the publications referenced below.”

“Sounds like fun, Curmudge. I’d wear my high school cheerleading uniform, but it probably wouldn’t fit. Anyway, after we have finished screaming, maybe you can give me a more complete definition of ‘just culture’? And while you are at it, you might also tell me what this has to do with Lean.”

“As you know, Julie, a Lean culture is one in which we continuously learn to do our work better. In a just culture, we learn to do things more safely. Both are learning cultures. That is this blog’s raison d’être.”

“(’Raisin debt?’ Oh well, sometimes the Old Guy talks funny. I guess it’s a justification for the blog’s existence.) So what is a ‘just culture’?”

“A just culture is one ‘that is supportive of system safety by facilitating open communication within the organization, while working with a system of accountability that supports safe behavior choices among staff.’(1) In health care, this boils down to being able to safely report errors and near misses so that their root cause can be discovered and the system improved to avoid the error’s recurrence. But there is more to it than that; a culture that is free of blame is not necessarily a culture that is free of responsibility. We’ll talk more about that in a moment.”

“Here’s another question. Sometimes I see ‘Just Culture’ capitalized, and it’s not in a title. Is that different from ‘just culture’?”

“Good catch, Julie. The Just Culture Community was formed by representatives from high-risk industries like aviation and health care to control the hazards of human and organizational error. Their website, http://www.justculture.org, is moderated by the firm, Outcome Engineering. The site is an extremely valuable resource.”

“As I understand it, Just Culture classifies errors and the organization’s response to them in terms of personal responsibility. They use a tool called the Just Culture Algorithm.” (2)

“Now aren’t you glad, Julie, that we explained algorithms on October 23? In this algorithm, error-producing behaviors are classified as Human Error, At-Risk Behavior, and Reckless Behavior. Human Error reflects the fact that no one is perfect and that some errors are truly inadvertent. The appropriate organizational response is to console the person and to manage the system to minimize the risk that human errors will harm the patient.”

“I’ll bet that the other classifications are more serious. Right?”

“Right. At-Risk Behavior is unintentional risk-taking, such as taking a shortcut to get necessary work done on time. The organization needs to establish whether the employee had a good faith but mistaken belief that the violation was insignificant or justified. If so, the employee should be coached and the incentives for at-risk behavior removed.”

“And finally we get to a situation where punishment may be justified.”

“That’s called Reckless Behavior. In this case, the employee consciously disregarded a known substantial and unjustified risk. So if an investigation has established that there has been reckless behavior, punishment can occur in a just culture.”

“Well, it’s a relief to learn that there is a system out there in which the organization’s response is not totally dependent on how serious the error was.”

“There is a similar but less complex algorithm available from IHI; it’s called the Decision Tree for Determining Culpability of Unsafe Acts.(3) A critical element of this algorithm is the substitution test: ‘Would three other individuals with similar experience and in a similar situation and environment act in the same manner as the person being evaluated?’ It should be very helpful to an organization working toward a non-punitive approach to errors and patient safety.”

“Curmudge, I’ve had enough ‘raisin debt’ for one day. Will we continue the discussion next week?”

“We sure will, Julie. And bring your French dictionary.”

Affinity’s Kaizen Curmudgeon

(1)http://www.jutculture.org/faq.aspx

(2)http://www.mocps.org/resources/Marx%20Presentation%20Handouts%201.JC%201Day%20Training%20Slides%20PrintV2.pdf

(3)http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Decision+Tree+for+Unsafe+Acts+Culpability.htm