Patient Safety / Quality

Just culture promotes a partnership for patient safety

Editor’s note: This is first in a series of articles exploring the human side of patient safety.

Historically, hospitals have operated under the assumption that health care involves the isolated work of a sole expert clinician with an individual patient. So when an error occurred, the clinician was blamed and faced punitive action. As long ago as 2100 BC, the Code of Hammurabi called for amputation of a surgeon’s hands if he committed a surgical error.

In 1999, the Institute of Medicine (IOM) report “To Err Is Human: Building a Safer Health System” challenged the healthcare industry to recognize how systemic problems in a healthcare organization can contribute to errors and to migrate away from blaming individual clinicians. Moving away from a culture of blame will empower us to look at events comprehensively, identify the true causes of an error, and take appropriate corrective action.

So how do we transform our systems and work environments? By understanding how the “blame culture” emerged, acknowledging it isn’t working, and moving toward just culture, which encourages open reporting of errors, recognizes errors may be systemic rather than personal failures, and focuses on determining the root of the problem when events such as errors and near-misses occur.

How the blame culture emerged

In 1917, the American College of Surgeons (ACS) developed the Hospital Standardization Program (HSP) in an attempt to standardize medical education and physician competency. Peer review was used to assess physician quality. Accounts from this time suggest this method initially succeeded in improving hospital standards. But in the 1950s, the peer-review model morphed into a punitive, fear-based model that led to sanctions and even imprisonment for physicians. This change didn’t improve the quality of care. In essence, HSP enforced minimal practice standards but did nothing to promote or inspire excellence.

Hospitals haven’t deliberately chosen a blame culture. Compliance-driven, bureaucratic management styles that demand personal accountability for systemic problems have enabled the blame culture to flourish. The traditional process for conducting root-cause analyses (RCA) also contributes. When a sentinel event occurs, regulatory agencies require an RCA to be performed and an action plan to be submitted promptly for review. (A sentinel event is an unexpected event involving death or serious physical or psychological injury or the risk of death or serious injury).


Imagine you’re a nurse manager attending an RCA meeting for a medication error involving one of your staff nurses. It’s clear that problems with the electronic medical record contributed significantly to the error. Yet you’re told repeatedly there’s no easy fix for the problem. In fact, it could take up to 9 months to resolve because the hospital has to wait for a vendor’s software upgrade. You’ve learned that if you acknowledge the true systemic issue, you’ll be held accountable for the timely action plan, which you can’t control. You feel responsible that your staff nurse is deemed at fault when you knew she was operating in an unsafe system. In the end, your personal accountability for the action plan leads you to fix the error on paper by reeducating your staff nurses on the five rights of medication administration and counseling the specific nurse in the context of progressive discipline. With progressive discipline, an employee receives feedback regarding work performance; the first occurrence of an error results in verbal counseling, the second leads to written counseling, and the third may progress to suspension. Meanwhile, the systemic problem persists, continuing to put patients at risk for harm and staff nurses at risk for blame.

Recognizing the blame culture isn’t working

Hospitals are accountable for improving the safety and quality of patient care. But to improve care, we need to have a clear understanding of the problems that affect safety and quality. Most likely, hospital administrators are aware of some of the problems, but frontline staff know about every problem. How likely are they to share this information with managers and administrators if they face retribution?

Evidence suggests staff may feel more uncomfortable with the blame culture than we realize. The Hospital Survey on Patient Safety Culture conducted by the Agency for Healthcare Research and Quality is a valid, reliable survey used to assess patient safety-culture perceptions among healthcare leaders and staff. Research on this tool shows frontline staff perceptions of safety most accurately reflect the organization’s actual safety performance. In the 2009 survey, results for the item staff feel free to question the decision or actions of those with more authority revealed 68% of leaders agreed or strongly agreed with this statement, compared to only 45% of staff.

Moving toward just culture

The IOM report underscores the need to move away from a blame culture to better understand the complex causes of errors. Quality and safety leaders endorse just culture adoption as a way to analyze the actions of clinicians involved in errors and to recognize the contribution of systemic factors. Just culture has a simple model for accountability for errors, which asks four questions:

  1. Was the clinician knowingly impaired?
  2. Did the clinician consciously engage in an unsafe act?
  3. Did the clinician make a mistake that three other clinicians with similar experience are likely to make under the same circumstances? (substitution test)
  4. Does the clinician have a history of committing unsafe acts?

This model doesn’t absolve the clinician of personal responsibility for the error. Just culture isn’t blame-free; for example, it would hold accountable and call for
discipline of a nurse who repeatedly and consciously disregarded a policy calling for independent double verification of blood products. But if a nurse makes a medication error that three other nurses with similar experience could make, systemic factors clearly contributed to the error. Perhaps the hospital’s barcoding system is unreliable. Maybe a medication protocol is unclear and hard to follow or the medication comes in different concentrations not clearly differentiated on the vials.

Performing the substitution test forces recognition and analysis of these issues. In a mature just culture where just-culture values have become entrenched, the question isn’t “Who did it?” but “How could it happen?” If an RCA stops at “Who did it?” and blames the individual, systemic contributions go unrecognized, the error will likely recur, and more patients will be placed at risk.

Partnership of accountability

In a just culture, leadership and frontline staff share accountability for safety. Staff are responsible for recognizing and reporting errors and error-prone systems and openly discussing them with managers and peers. Leaders are charged with creating an environment where staff are comfortable disclosing actual and potential errors. Leaders promote organizational learning from these events and take actions to ensure that nurses practice in a safe environment. To promote upward reporting of events, leaders ensure that reporting won’t place the reporter at risk for punishment. What’s more, staff believe their concerns are heard and real action is taken when necessary, making their disclosures worthwhile.

The partnership for patient safety is interdependent. Staff need their leaders to ensure a safe practice environment, and leaders depend on staff to tell them about systemic problems so they can address these. (See Promoting just culture in your practice environment by clicking the PDf icon above.)

In many hospitals, shared leadership in nursing already is embedded as an integral component of the model for the Magnet Recognition Program®. This model was introduced largely to promote exemplary nursing-sensitive outcomes. Implementing a just culture furthers this partnership. In the new paradigm, patient safety becomes a powerful new nursing-sensitive outcome.

Click here for a complete list of references.

Selected references

Bashaw ES. Fusing Magnet® and just culture. Am Nurs Today. 2011;
6(9):42-5.

Berhans LD. Just culture and nursing regulation: learning to improve patient safety. J Nurs Reg. 2012;2(4):43-9.

Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.

Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Health Care Manage Rev. 2009;34(4):312-22.

Lazarus I. On the road to find out…transparency and just culture offer significant return on investment. J Healthc Manag. 2011;56(4):223-7.

The authors work at Orlando Health in Orlando, Florida. Susan Tocco is the director of Patient Safety and Transformation. Allison Blum is an administrative fellow.

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