A consultant from SG Collaborative Solutions leads a Just Culture training session at BWH.

One of the key outcomes resulting from employee responses to BWH’s 2012 Patient Safety Culture Survey was the hospital’s commitment to enhancing a “just culture” within our institution.

Just Culture refers to organization-wide efforts to be “just” and fair with all of our employees when errors occur. Creating a safe and transparent environment encourages reporting mistakes and hazards when they arise, ultimately improving the safety of care we provide. Just Culture seeks to understand and address in a fair and consistent manner the risks, behaviors and choices which lead to errors affecting patients, families and staff. In the Just Culture model, three general categories of behavior receive attention: human error, at-risk behavior and reckless behavior.

Human error refers to unintentional mistakes that anyone can make. Human error can be traced to personal performance factors (e.g., stress, time pressure or not being fully focused on a task due to a lack of rest), or defects within the systems within which we work. The Just Culture response to human error is to console those involved and to identify the personal performance and system issues which may have contributed to the error so that they can be corrected.

At-risk behavior involves decisions made or actions taken in which we think we are justified and/or safe, but actually are not. Because we face difficult-to-balance pressures or competing priorities, like safety and productivity, we may make a choice believing a risk is insignificant. We’re trying to do the right thing, but we “drift” away from the established safety protocol making at-risk choices. At-risk behavior choices increase the risk of harm to people or property, but the individual does not recognize this, consequently placing themselves, other people or the hospital at an increased level of risk. According to the Just Culture model, at-risk behavior is addressed through coaching—assisting an individual in seeing and understanding the risks inherent in certain choices and guiding them toward different choices in the future. Often coaching is needed for a group as well as an individual, because everyone is likely balancing the same competing priorities and making similar choices that increase risk.

Reckless behavior, while uncommon, is the choice to knowingly take a substantial and unjustifiable risk. For those engaged in such decisions and actions, given their deliberate disregard for identifiable risks, current policies associated with corrective action are followed in addressing the behavior.    

All members of the BWH community have both an opportunity and a responsibility to contribute to a Just Culture environment.  Leaders can use rounding and other strategies for identifying and correcting patient safety risks found within the systems, protocols and physical environments in their areas. Recognizing  the risks and hazards present within our work environment and being more conscious of the behavioral choices we make contribute to a culture of safety. We can also be more vigilant in reporting safety issues to department leaders or by using the safety reporting system.

By responding to adverse events in a fair and consistent manner, educating each other through transparent dialogue about risks and safety expectations, and proactively managing risks and behavioral choices, we co-create a culture of shared accountability that will make BWH a safer environment for our patients, their families and each other.

Just Culture training