Put simply a safe culture is one in which those in charge are willing to hear bad news and act appropriately. Developing such a culture is a central element of efforts to improve both the safety and the quality of care provided to patients.
Just Culture:
A Just Culture is one in which the line between acceptable and unacceptable behavior is clearly stated. It recognizes that individuals make mistakes and acknowledges that even the most committed professionals will develop unhealthy norms (short cuts, rule violations, etc), but has no tolerance for behaviors that are repeatedly or purposefully harmful.
When an error or adverse event occurs, rather than asking “who is at fault”, a Just Culture asks “why did this happen”. Human error can be viewed in one of two ways: (1) it is the fault of the people working in the system (violations of procedure or policy, loss of situational awareness, careless or poorly trained individuals) or (2) it is a symptom of a system that has latent vulnerabilities dispersed throughout. Latent failures are faults created by policies, directive, or decisions that have been made remote from immediate patient care setting. These latent failures typically occur at higher levels in the organization and they may be difficult to see until such time that they combine with other active failures and triggering factors that together combine to overwhelm barriers put in place to protect a patient. This results in a near miss or actual harm. Examples of latent failures specific to the healthcare settings include hospital policies that impact the flow of patients through health systems, high patient volumes resulting in cognitive overload, multiple interruptions, limited patient information available at critical times, inadequate staffing, frequent overtime or long shifts, complex medical equipment, limited standardization of medical equipment or processes, challenging computer interfaces, the list goes on.
If the assumption is made that an individuals do not come to work with the intent to cause harm, then it is important to move beyond blaming the individual (who works at the “sharp end”) and instead look for the system vulnerabilities (latent errors) that have contributed to the adverse event. Highly Reliable Organizations (HROs) do not look for the simple or first answer found when considering adverse events and errors, they dig below the obvious to find and correct the latent problems within the system that if uncorrected will likely cause a recurrent or similar adverse event in the future. If the individual involved is blamed and punished for the error it is unlikely that underlying contributing factors will be found. Further, others who witness the punitive action will be unlikely to disclose their own errors or near misses. Opportunities to focus on, and deeply understand, failures and near misses, core concepts of HROs, will be lost. We cannot continue to blame people who find themselves at the end of a series of events, environmental and design, and occasionally policy that make it very easy to do the wrong thing.
It is important to note that a Just Culture does expect accountability for those acts that are blameworthy. Individuals who purposefully violate policies that are intended to protect patients should be counseled and disciplined appropriately. Further, accountability in a Just Culture expects managers and supervisors to address problem employees before they make an error that harms a patient, rather than waiting to act until the problem employee makes the predictable error that harms a patient.
It is worth a short discussion to question whether we can fully understand the intention of an individual when an adverse event has occurred. When reviewing an error that has harmed a patient it is almost impossible to avoid “hindsight bias” and it can seem as though some events rise to the level of a willful disregard for patient safety. But such confident leaps should be approached cautiously. The harms that occur with complex health care systems are not necessarily caused by the random collision of independent failures, human error and behaviors that might seem intentional. Rather, it often results from a slow but steady systematic migration of organizational behavior caused by the stress of operating in an under-resourced and cost conscious environments where cutting corners to improve efficiency is not only valued, but openly celebrated. The more success that is attained (or perceived) at these limits of appropriate operating capacity, the more accepted (and even expected/demanded) it will become until a tragedy occurs. This is called the normalization of deviance, and is very difficult to detect as it is happening. Only in hindsight do all the missteps clearly align and it becomes clear that limits were being pushed well beyond what was safe or reasonable. At that point, the person working at the bedside all too often becomes the scapegoat for all that the larger system demanded and expected of them.
References:
Reason J. Achieving a safe culture: Theory and practice. Work & Stress: An International Journal of Work, Health & Organisations. 1998;12: 293-306.
Weaver SJ, Lubomski LH, WIlson RF, e tal Ann Intern Med. 2013;158(5_Part_2):369-374.