Making Just Culture a Reality: One Organization's Approach

Alison H. Page

Making Just Culture a Reality: One Organization's Approach

Alison H. Page, MS, MHA | October 1, 2007

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Perspective

We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.

At Fairview Health Services, a large integrated delivery system in Minnesota, we identified addressing our culture as the primary opportunity to improve patient safety in 2001. We focused on two key areas of cultural concern: the leadership culture that sets the tone and judges the behavior of others, and the culture at the point of care, or team culture. In 2003, we worked with the Minnesota Alliance for Patient Safety (MAPS), a multi-stakeholder group founded by the Minnesota Hospital Association, the Minnesota Department of Health, and the Minnesota Medical Association, to establish a state-wide initiative to create a culture of justice and accountability. This effort includes hospitals, the professional boards, and the department of health.

Establishing a just culture within an organization requires action on three fronts: building awareness, implementing policies that support just culture, and building just culture principles into the practices and processes of daily work. Based on our experience over the past 6 years, let me give you examples of how you might do this.

Raising Awareness

Building awareness is the first step in any movement. To raise awareness we did two things.

First, with the assistance of David Marx, JD, president of Outcome Engineering, we conducted a survey of staff, medical leaders, managers, and administrators asking them various questions about how they thought the organization would respond to a given behavior by a clinician (e.g., bringing unauthorized equipment into the operating room [OR] for use in a surgery) if that behavior resulted in harm. We then asked the same question, except this time the behavior resulted in no harm. The survey results were clear. Members of the organization had no clear sense of how people would be judged, or how they should be judged when their behavioral choice was the wrong choice. And respondents consistently judged people more harshly if the behavior resulted in harm (Figure). The survey results were a wake-up call for the organization's leaders.

Our second step to raise awareness was education. First, a small group of 10 key clinical and operational leaders attended a day-long session with David Marx to evaluate the just culture concepts and learn how we should proceed inside our organization and as a state. Following this, 60 Minnesota health care leaders attended a 2-day summit sponsored by MAPS, which included the professional boards and the department of health, to deepen understanding of just culture and to better understand the perspective of the professional boards and public agencies. The leaders who attended enthusiastically embraced the just culture concept, finding that it provides practical and useful principles and tools anyone can use.

We then conducted a "big bang" educational session for all operational and clinical leaders across the system. Our message: "anyone who finds himself/herself in the position of judging the behavioral choices of other human beings" should attend the session. Three hundred and fifty people were educated in an 8-hour training session with David Marx. The education included an overview of the concepts, education on the use of a set of algorithms that guide people through the process of classifying behavioral choices as "error," "at-risk behavior," or "reckless behavior." Participants also practiced applying the algorithms to real-life scenarios. In hindsight, conducting this mass education was very effective. It caused the organizational perspective on justice and accountability to shift almost overnight. We did not conduct education sessions for front-line staff on just culture, but instead we have woven the expectations for staff behavior, along with the concepts of error, at-risk behavior, and reckless behavior, into orientation and unit education sessions.

The behaviors we can expect:

Human errorinadvertent action; inadvertently doing other than what should have been done; slip, lapse, mistake.
At-risk behaviorbehavior that increases risk where risk is not recognized, or is mistakenly believed to be justified.
Reckless behaviorbehavioral choice to consciously disregard a substantial and unjustifiable risk.

Implementing Policies that Support Just Culture

This might better be termed, "eliminate the policies that don't allow you to incorporate just culture." Policies that require punishment for errors, for example, won't work. Sentinel event investigation policies that say, "We will only look at systems and not human behavior" won't work. Ideally, the organizational policies related to employee behavior expectations, consequences for behavior, and event investigation would incorporate the language of just culture. Job descriptions, medical staff bylaws, and codes of conduct should incorporate the principles. This will take time, so start by removing the policies that are barriers to just culture and work incrementally to build the philosophy in as you go. Our organization is still in the process of incorporating just culture principles into policies, but we have eliminated the policy barriers to using the principles. For example, if you have policies that authorize punishment (e.g., written reprimand or dismissal) after a certain number of errors, or that predicate punishment on the severity of the outcome, get rid of them.

Building Just Culture into Organizational Practices and Processes

Once the leadership group of the organization has grasped the concept and leaders buy in to the philosophy, you can begin to incorporate it into the work you do every day. I recommend not introducing just culture as a new initiative or it could become the "flavor of the month." Instead, leaders should look at the challenges they face and ask, "How would I apply just culture principles to this situation?"

If your organization's priority is reducing harm related to misidentification of patients, for example, how would you work with the staff to understand and categorize behavioral choices as "error," "at-risk," or "reckless"? How would you clarify what the organizational response will be to each type of behavior? If a person makes an error, he/she knew the right thing to do, intended to do the right thing, and followed the right process, but made a mistake (e.g., misreads a label); he/she should be consoled and we should figure out a system that will prevent future errors. If a person engages in at-risk behavior, he/she knows the right thing to do, but does otherwise because he/she does not see the risk or feels that the benefit of the chosen behavior outweighs the risk (e.g., does not wake a patient to check a name band), management must understand why people are engaging in this risky behavior. Leaders must ask hard questions like, "How prevalent is this behavior? Why are people doing this? How can we put systems in place that will encourage or force the correct behavior? How can we help people perceive the risk that exists so they will make the right behavioral choice?" Lastly, the organization and clinical leadership should identify which behaviors will be considered reckless and are, therefore, punishable. Reckless behavior is punishable regardless of the outcome of the behavior. Leaders must establish processes to know when someone is engaging in reckless behavior and be willing to punish those who engage in it. A given behavior may be considered "at risk" in one situation or organization and be considered "reckless" in another.

Consider this scenario. In hospital "A," a nurse, not wanting to disturb a sleeping patient, does not check a patient's name band and administers an IV antibiotic to the wrong patient, who was allergic to that drug. The patient has an anaphylactic reaction and ends up in the ICU on a respirator. How do we judge this nurse's behavioral choice not to check the name band before administering the medication? Do we punish her? Some organizations would punish the nurse (i.e., retrain, reprimand, or dismiss) because she violated the patient identification policy. A just culture would want to know:

Was the nurse aware of the policy to check name bands?
Was it possible to check the name band?
Do all the nurses on the unit check name bands prior to administering medications?
Why didn't the nurse check the name band? Did she mistakenly believe it was better not to? Why?

The error in this scenario is administering the medication to the wrong patient. We determined the nurse's behavior to be "at-risk" (and not "reckless") because the nurse violated the policy for what she believed to be a good reasonallowing the patient to sleep. It turns out that customer satisfaction scores had recently been reviewed at a staff meeting, and sleep interruption was identified as the number one concern of patients. In addition, the other nurses on the unit agreed that they have not awakened patients to check name bands many times.

Now consider another scenario. In hospital "B," a patient checks in. A name band is applied, and the patient is told that all staff will be asking patients to spell their names and give birth dates before providing care or treatment. The patient notes that all care providers and transport personnel follow the procedure. Now, let's say a nurse does exactly the same thing as the nurse in the first scenario. She enters the room, observes the patient sleeping, and decides not to wake the patient to check the name band. A just culture would classify the nurse's behavior as "reckless." The policy was known, the policy was doable, and others were following the policy.

Within Fairview, we have incorporated just culture into our performance improvement initiatives, such as hand washing and patient identification. We identify what types of errors are made, what types of at-risk behaviors we see, and whether or not anyone is engaging in reckless behavior. As we make improvements in the process, we make sure we design it to prevent error, make risk apparent, and discourage at-risk behavior. We also clarify what behavior will be considered reckless. Currently, we are incorporating just culture principles into team training.

Just culture principles will help you change your organizational culture. In 2001, an accident occurred in our interventional MRI room when a piece of equipment flew across the room and attached to the outside of the MRI while a patient was in the tunnel. The event investigation that followed focused on system solutions and staff behavior. The department established safe processes and expectations for staff training and behavior. All staff are screened for MRI safety themselves, participate in MRI safety training, follow check-in procedures, and wear pocketless scrubs to minimize the opportunity to forget something in a pocket. Six years later, in 2007, a physician entered the room wearing scrubs with pockets, disregarding the prompt from colleagues to stop. Administration was notified. The conversation that ensued among operational and medical leaders focused on categorizing the behavior as error, at-risk, or reckless and, from that, determining whether the physician should be consoled, coached, or punished. Since Fairview has implemented clear policies and behavior expectations, and others are able to follow the policies, the behavior was found to be reckless. The physician apologized for her behavior and was warned that future behavior of this type would impact her clinical privileges. Just culture principles and tools provide a useful and necessary construct to aid organizations in dealing with difficult cultural issues, particularly to determine when the generally appropriate focus on systems needs to give way to a focus on individual accountability.

Alison H. Page, MS, MHAChief Safety OfficerFairview Health Services

Figure

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Figure. Survey question: How would our organization respond to a surgeon who uses an unauthorized piece of equipment in the operating room?(Go to figure citation in perspective)

Percent of respondents who believed Fairview would discipline the surgeon if...

In Conversation with...David Marx, JD

October 1, 2007

Editor's Note: An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. After a career focused on safety assessment and improvement in aviation, he has spent the last decade focusing on the interface between systems engineering, human factors, and the law. In 2001, he wrote a seminal paper describing the concept of just culture, which became a focal point for efforts to reconcile notions of "no blame" and "accountability." He has gone on to form the "Just Culture Community" to address these issues at health care institutions around the country.

Dr. Robert Wachter, Editor, AHRQ WebM&M: Is "just culture" a concept that you brought into health care, or was it a known concept in other industries?

David Marx: It was known in other industries. The civil aviation authority in New Zealand has been doing this for 10 years. Still, aviation has been on a slightly different pathearly on, its entire effort was focused on how to create a safe haven to allow the reporter to come forward. But aviation has been relatively slow to embrace keeping people accountable on a day-to-day basis. Health care has always recognized the tension between holding the system accountable and holding the individual accountable. Health care was ripe to find this middle ground: how do we create a safe haven around reporting, but secondly, after knowing the risks, how do we hold people accountable to what the best practice is? For example, when hand hygiene compliance rates are just 60%, how do we get people to be compliant? There's a lot of system contribution, but there's also the issue of the individual's choices. Just culture provides some of the answers by controlling the system design and making it safe. But individuals have to come in and engage in safe practices and be accountable for their choices as they proceed through the workday.

RW: For people who aren't familiar with the just culture concept, can you briefly describe the tension between the early thrust in patient safety toward no blame with the belief that sometimes blame is appropriate? How does the just culture concept reconcile or deal with that tension?

DM: Early on, those who wore the safety hats in the patient safety or the aviation safety movement thought that people should come forward so that the precursors to errors could be better understood, in order to fix the system issues. But the tension was ultimately that individuals played a role. Even before the event occurred, they contributed through the quality of the choices that they made. So early on, it was all about getting the report. But ultimately, errors are going to occur. There are two things managers can control: the system they design around their employees, and the behavioral choices they make in that system. In the just culture model, you identify three classes of human fallibility. The human error is inadvertentfor example, inadvertently going faster than the speed limit. Once in a while, we catch ourselves going faster than we want to. That's human error. The second category is at-risk behaviorthat is, taking shortcuts that ultimately lead to increased risk. It might be doing a task by memory, not confirming two patient identifiers, or not doing hand hygiene because of time constraints. People convince themselves that this is the right path to take. Can this corner be cut to get the job done? In some cases the corner is not the right one to be cut, so it's called at-risk behavior. The third behavior is reckless behavior, and that is where someone chooses to put others in harm's way. It's that notion of the drunk driver on the road who thinks he is not choosing to harm people in the minivan next to him, but who is putting them at risk by being intoxicated on the road. That's reckless behavior. While recklessness in health care is rare, it does occur. But is a punitive response appropriate for reckless behavior? Our answer is yes. If you go into any hospital and ask which of these three classes of human fallibility is the biggest contributor to harm or potential harm in the clinical area, staff and hospitals will not say it is reckless behavior. Although the IOM Report implied that error was the major contributor to harm, nurse managers and charge nurses will say that at-risk behavior is the biggest contributor. It's nurses who think they don't need two patient identifiers because they know who their patient is. And it's that at-risk behavior where it's not only about the systemit's also about our propensity as humans to drift. We have to help individuals through good coaching and mentoring, and also through system design. But ultimately, there must be an accountability system that doesn't allow someone to stay in that system if they choose to put patients in an unsafe place.

RW: So, these are subtle distinctions. Let's take a couple of examples of what might be at-risk behavior and what might be reckless behavior. For instance, if I don't wash my hands before seeing a patient because I'm too busybut then I keep failing to do it, even though I've read the literature and know it's putting my patients at risk. Or, if I, as a surgeon, don't believe in doing a time out because I've never had a wrong site surgery, and then something bad happens. Or if a nurse doesn't do a two patient identifier once or twice because he or she is too busy, but then keeps omitting it despite counseling. How do we draw these lines?

DM: That's a great question because they are subtle distinctions. The easy way to make them not subtle is to make it clear that if someone knowingly violates the rule, there will be repercussions. But the reality is that some policy violations are going to be the right thing to do. There has to be that exception to say that the rules were not meant for every circumstance. You have to support noncompliance in some cases. Health care is more complex than any industry I've worked in, from nuclear power to shuttle systems to aviation. In this complexity, there are overlapping demands and choices that have to be made. So there's that nurse or pharmacist or physician making choices that they perceive to be in the best interest of the patient. Some of those choices are going to be knowing violations of policy. But they're going to perceive that this is the right path to take. Let's go back to hand hygiene. If a physician walks into the OR and chooses not to scrub in, or breaks the sterile field, everybody would universally say that's reckless behavior. You just don't tolerate that. But the physician who is going patient to patient doing rounds after surgery probably has a compliance rate close to 50% when it comes to CDC hand hygiene standards. Hand hygiene noncompliance is accepted because the culture has accepted it. The privileges of the physician won't be pulled. The nurse won't even be coached around the behavior. And all of a sudden you have this embedded norm that, to people on the outside, looks like reckless behavior. The same thing is happening with time outs. Initially, we said time outs are really important. Everyone has to comply, and not to do so would be considered reckless behavior. What has happened, I believe, is that we're seeing some drift on time outs. Compliance with time outs is going down. The issue is, does the organization take a stand and say that this is an unacceptable and reckless breach, or does the organization begin to tolerate it, which ultimately makes it at risk because it turns a blind eye to noncompliance? It's not easy. What we say is that you cannot proclaim what reckless behavior is. Organizations must educate the professionals in the workforce to understand the risks, and ultimately that local culture deems an activity to be reckless. You see the same thing on the road, where speeding turns into reckless driving. And societies to some extent define these boundaries.

RW: You seem to be implying that an individual hospital could make the decision that the failure to do a time out will or will not be deemed reckless. Yet, there's a role of larger units, whether it's the state or the federal government or the Joint Commission. Just on that example, where do you draw the line?

DM: I think a hospitalor even a state or a collection of hospitalscould say that not doing a time out is in fact a reckless choice. Now, the issue with that is they have to follow up. They cannot just say it's reckless and then turn a blind eye. That hospital needs to come back and stand behind that because they cannot tolerate a reckless group or a reckless individual working on patients. So I think it can be done, but the hospital has to stand behind it because the employees will call their bluff. If the hospital comes out with a letter saying that this is really important but then doesn't take action, it will drift right back to at-risk behavior.

RW: In terms of enforcing these rules against reckless behaviors, when do you draw a line and say there will be action? How have you seen that play out in terms of uniform versus disparate enforcement for doctors versus nurses?

DM: The doctor versus nurse issuewe have a gap analysis tool that looks at perceptions of staff. One of those scenarios is hand hygiene noncompliance. In one case it's a nurse, and in the other it's a doctor. And we find radically different views in the hospital about what accountability looks like. In health care, there's a very strong physician versus nurse biaswith a different sense of accountability, and a very strong severity biasa feeling that if there has been no harm, then there will be no action taken with the doctor. In contrast, in our just culture model, if a person is reckless, whether they caused harm or not, the action should be the same. Because what we're doing is holding people accountable for the risks that they choose to take, not the outcome. That is the substantial shift in culture that we're talking about. You'll even hear from some of the Minnesota hospitals that the culture has been really "no harm, no foul." If a patient has been harmed, we're looking for the person last to touch the patient. We're going to go after that person. If a person caused no harm, there may be a tendency to turn a blind eye. But in the just culture model, reckless behavior is reckless behavior whether it caused harm or not. And that's the big shift an organization goes through: to not look at how bad it was and who was to blame, but to judge people on the quality of their choices.

RW: That, of course, is incredibly important because many of the harms are relatively rare, and you can do a lot of surgeries without a time out and not do a wrong site surgery.

DM: You'll meet a surgeon who will argue that he or she has never had an event. But a person's choices dictate the likelihood of the future event. And it's these choices that we're going to hold people accountable for. Nobody is suggesting that the surgeon is accountable for the harm to the patient. That's an organizational accountability. But the surgeon is accountable for the quality of choices he or she makes, irrespective of any future event.

RW: We began in patient safety with this no blame concept. And then over the first few years we began to recognize that it left out this critical notion of accountability. It seems to me that we're flipping very strongly toward accountability and, like most complex issues, there's a pendulum there and it tends to go back and forth until it settles somewhere in the middle. Where do you think the pendulum will settle out?

DM: For a long time, we've had perceptions of the culture being overly punitive. And you're rightit did swing to this notion of blame free. I think we're seeing from health care regulators and hospitals a pretty rapid movement to find that center ground, because we know where some of the risks are. It's about really dealing with the system issues, but individuals have to be accountable for their choices. Now, that being said, states that have gone down this path always worry that if they have a big event, like a wrong site surgery, the tendency of media, the prosecutors, and perhaps even governmental leaders is to find somebody to blame. And the issue is how are we going to resist that? The good news is that the Joint Commission is supportive of this path around just culture. AHRQ is supportive. State departments of health and credentialing boards are supportive of it. So we're gaining enough momentum that it hopefully won't be derailed by a big event where the press and parts of society are clamoring to, as James Reason says, put a carcass up on the wall to show that we've done something. It's tenuous, though, because we really need to get more and more people in the system supporting just culture so that it doesn't get derailed by the after effects of a big event.

RW: Could you comment on the malpractice system and how its way of judging errors and bad outcomes plays into efforts to create a just culture?

DM: If you participate in sports, which is a high-risk system, if you make a mistake and break the ankle of the second baseman sliding into second base, the person who gets harmed has to deal with it. It's the cost of doing business to participate in the high-risk endeavor of sport, and it's a reason that most of us carry first-party insurance to protect us from unanticipated injury. But if the player is reckless, the sport says that you have a cause of action against that person; that is, you should pay for my broken ankle because you were reckless. Health care has an analogy to sport, in the sense that it is filled with fallible human beings and is a very high-risk endeavor. Physicians are going to make mistakes; they are fallible human beings. But it hasn't changed the tort system, which says, if you get harmed by the medical system, you sue. I think the underlying logic is flawed. There are high-risk industries and, to a certain extent, there's an assumption of risk. When I come into that system, I know there's a risk of a mistake. Another example is workers' compensation systemsyou don't sue your employer, but there is a system to deal with the remedy if you're hurt on the job. Some physician leaders, in particular, believe that the just culture model will ultimately lead to tort reform. I think the answer is that we have to believe that health care institutions are going to produce bad outcomes. They're going to be fallible, and we need a social insurance system that doesn't rely on having to sue your physician. In New Zealand today, you don't sue your physicianyou go to the Accident Compensation Scheme if there's a medical error. But if you believe the doctor was reckless, you go to the regulator, and say, there's a reckless doctor, deal with him. But if the doctor was merely fallible, that doesn't lead to a lawsuit.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers