JUST CULTURE

To recognize that the principles of just culture promote an environment in health care organizations in which safety is valued, reporting of safety risks is encouraged, and a fair process is used to hold staff and leaders accountable; further,

To encourage hospitals and health systems to include just culture as a component in organizational safety culture surveys and quality improvement initiatives.

Rationale

The Council, Board, and House agreed that a specific ASHP policy supporting just culture principles should be developed, and that education on the topic should be an important focus for ASHP. In developing the policy, the Council reviewed principles and methods established by David Marx, a systems safety engineer and just culture educator, and noted the following (Marx, D. Whack-a-Mole: The Price We Pay for Expecting Perfection. Plano, TX: By Your Side Studios; 2009):

• The notion that humans can perform perfectly if they are well trained and continuously vigilant is unrealistic. Humans will never be perfect.
• Safe environments anticipate human error and systems are designed accordingly. However, systems will never be perfect.
• Individuals are accountable for behavioral choices that lead to error and leaders are accountable for establishing environments that encourage reporting of unsafe conditions and adverse events. 
• Behaviors that cause or may cause errors are addressed regardless of whether harm occurs.
• Individual culpability for adverse events is assessed using a decision algorithm that defines attributes of behaviors and systems and can be summarized as follows:

1. Human error: inadvertent; a mistake; doing other than what should have been done. 
   Origin: System design, processes, procedures, training.
   Manage by: correcting system, supporting employee.
2. At-risk behavior: behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified.
   Origin: System inefficiencies, such as steps that create rework, are burdensome, or seem irrelevant to outcome. The system incentivizes workarounds and shortcuts that are unsafe.
   Manage by: Improving procedures or processes to remove incentives and reward safe behaviors.
3. Reckless behavior: choosing to behave in a manner that places others at substantial and unjustifiable risk knowing that harmful outcome is likely but indifferent to it.
   Origin: the individual.
   Manage by: remedial action, punitive action.
4. Negligence: determined by using the substitution test, i.e., would another individual in the same work area with comparable experience and qualifications have behaved any differently?

The Council identified significant advantages to this approach, one of the most important being that it encourages reporting of adverse events and provides essential information for improving systems and processes of care. In addition, holding individuals accountable by using criteria to distinguish between behaviors that do or do not merit punishment was perceived to be the fairer approach than a strictly punitive or strictly blame-free approach. Another positive attribute of just culture is that behaviors associated with error are handled with the appropriate responses regardless of whether harm resulted. By focusing on behaviors rather than outcomes, potential errors are averted, safe behaviors are encouraged, and at-risk or reckless behavior is not tolerated. 

The Council recognized that while the just culture approach has been accepted by safety leaders, implementation is challenging for a number of reasons. The goals of just culture--to sustain a nonpunitive reporting and learning environment, yet hold individuals accountable for their behavior--seem contradictory. Methods for differentiating behaviors for which to hold an individual accountable tend to use subjective, rather than objective, criteria, and may lead to misinterpretation. Maintaining the just culture approach is particularly challenging under the pressure of media coverage and legal liability when a patient is harmed or dies from an error. The belief that individual practitioners are solely responsible for their errors continues to predominate in the health care professions. 

The Council noted that decision-making tools and education are available to support implementation of a just culture. They suggested that ASHP consider providing education and practical tools for implementing fair processes for holding individuals and leadership accountable for medication safety. Council members also characterized just culture as a component of the larger issue of culture of safety and proposed that assessment of just culture as part of assessing general safety culture should be included in ASHP’s national survey.