Just Culture – Fad or Future

In my last column, I reviewed the requirements for achieving high reliability in healthcare settings. Some might feel that my list should have included Just Culture. Count me among the skeptics. Here’s why.

Problems with Implementation

A few months ago (in The Role of Leadership in Shaping Culture), I highlighted Rotteau’s report of dysfunctional behaviors among senior leaders in patient safety walkrounds. I’ve seen similar issues with efforts to implement Just Culture models. The devil is always in the details and effective leaders must pay attention to such nuances. Fundamentally, the Just Culture model seeks to create accountability for behavior choices and no blame for human error. While the basic concepts underlying the model are widely accepted in quality and safety circles, there is danger in trying to address both no blame and accountability through the same program. I'm concerned that too many supervisors either get confused with the Just Culture algorithm or pervert it to justify continued punishment of staff. It's quicker and more emotionally satisfying to cast blame when something goes wrong than to do the harder work of getting to the root of the problem and fixing the related processes.

No Evidence of Effectiveness

For more than a decade, there has been much interest in Just Culture. My review of the medical literature has failed to surface any studies evaluating the impact of Just Culture on quality and safety. Moreover, the rise in popularity of Just Culture preceded the collection of Hospital Survey of Patient Safety Culture data. If Just Culture was effective, one would have expected some visible impact. As I showed in my mewsletter article on Patient Safety Culture, there has been no change in the tendency of hospitals to cast blame on their frontline staff during the past 6 years. Data recently released extends the trend to 7 years.

Focuses on the Wrong Problem

Looking at the experience in aviation, blame was a bigger barrier to progress than accountability. In healthcare, while we certainly have issues with accountability, those involving patient safety reside primarily at the organizational level. They include lack of transparency and systems that tolerate drift toward risky behaviors, such as lack of hand washing. At the individual level, disruptive behavior stands out as the one common issue that mandates intervention, but the Just Culture model is not needed to recognize or manage it.

Fails to Engage Staff

Just Culture is a legalistic framework. Even if it serves the desire of management to identify and punish blameworthy acts, it does not speak to the heart of healthcare workers. Although it might help to “private-label” the program using different terminology, the same goals could be targeted by deconstructing Just Culture into two separate programs, one involving processes for managing accountability and the other establishing processes for assuring no blame in the course of event evaluation. This split would create alignment with models of organizational learning from defects that mandate no blame for human error and those promoting learning from performance measurement via feedback and other interventions to drive accountability among individuals and groups (see Learning from Defects).

Coming Next: Barriers to High Reliability

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Marc T. Edwards, MD, MBA

President & CEO

QA to QI

An AHRQ Listed Patient Safety Organization