Just Culture–What Is It and Can It Minimize Patient Harm and Promote a Positive Workplace Culture?
Healthcare employers, along with other high-risk industries, continually look for ways to minimize risk and to promote a positive work culture for employees. One approach is the implementation of a “just culture” framework.
In essence, “just culture” is a shared accountability methodology. In a “just culture” framework, both employers and employees are responsible for their respective roles when patient harm occurs and, ideally, for preventing it. Under this theory, employers are responsible for creating system design and enforcement tools that eliminate factors that place employees in a position whereby harm is likely to occur if there is human error, which is inevitable. Employees are also responsible for their conduct; however, this methodology places less emphasis on punitive action when employees make mistakes if the system design (as opposed to the employee’s reckless conduct) led to the ultimate patient harm. This theory differs from the traditional labor law theory of “just cause” but the principles of “just culture” are rooted in legal theories underlying both labor and tort law.
Classic examples of systems designed by healthcare employers to minimize the effects of human error are processes such as: the six rights “6 Rs” of medication administration, pre-surgery “time outs” or bar code scanning of patients’ wrist bands and medications before administration. There are various approaches to the “just culture” concept, but they all seek to create precisely what the name entails–a culture whereby accountability (and resulting employee discipline) is just.
Many “just culture” proponents (including practitioners) appreciate the, almost scientific, algorithm utilized in determining whether a specific patient harm was caused by failures in system design, as opposed to reckless employee conduct. Generally, when implementing “just culture”, managers follow a formulaic analysis tool to determine whether the resulting patient harm was caused by system design failure (something that should be fixed and for which employee discipline may not be appropriate), as opposed to reckless conduct by the employee in disregard of the system’s preventative measures.
Medical practitioners are often familiar with the concept of “just culture” but counsel, human resources and other risk management professionals may not be, resulting in opportunity for increased partnership between these groups to better manage risk and create a positive work environment. When implemented correctly, “just culture” can: (1) create consistency in determining whether employee discipline is appropriate; (2) minimize patient harm; and (3) create a workplace culture of self-reporting (since employees understand that mistakes won’t necessarily result in punitive action when the system design failed, as opposed to their reckless conduct causing the harm). However, “just culture” does not dictate what discipline level is appropriate. Similarly, it does not take into account other practical or legal considerations often at play in determining whether employee discipline may be appropriate.
Whether or not an employer deems “just culture” methodology right for its organization, human resources professionals, in-house counsel and other risk management professionals should review how, and to what extent, “just culture” is implemented in their organization as part of ongoing risk management efforts.