Just What?

By Beth Besecker, MD, MBA, chief medical officer, Atrium Medical Center 

Just Culture is a framework that helps organizations respond in a consistent, just, and fair way when evaluating errors or safety events. Within this framework, both the caregiver and the system are evaluated for their contributions to the event.

Just Culture helps organizations support both psychological safety and caregiver accountability. When an organization uses Just Culture as part of its safety culture, caregivers know what to expect when reporting an error or safety concern. It also reinforces that individuals will not be punished for system-related issues. In addition, caregivers are encouraged to share concerns and help the system learn from mistakes, even before a negative outcome occurs. Together, these elements promote a culture of psychological safety and make sharing mistakes and concerns an expected, normalized practice.

Just Culture also improves accountability within an organization by establishing clear expectations for both leaders and caregivers in creating the safest possible environment for patients. Leaders are responsible for fostering a curious, learning-centered environment where risks are openly shared. They should seek to understand why at-risk behavior occurs and work to redesign systems and processes to reduce those behaviors, making it easy to do the right thing and difficult to do the wrong thing. Caregivers, in turn, are expected to speak up, promptly report concerns and contributing factors, and commit to safe practices and established policies.

Most organizations use an algorithm to support their Just Culture framework. This tool guides evaluators through a series of questions to assess the intent of the caregiver involved in a safety event. The algorithm helps determine where an action falls on a spectrum ranging from human error to reckless or intentional behavior. Based on the outcome, it then guides leaders toward an appropriate response, such as consoling, coaching, or disciplinary action. Applying a systematic approach helps prevent bias and avoids decisions based solely on outcomes. At each step, the system should also be evaluated for its contribution to the event, with improvements made where opportunities exist. Human accountability and system flaws are not mutually exclusive.

At Premier Health, Just Culture has been embedded in human resources policies for more than a decade. However, the current algorithm is complex and not always used to its full potential. At other organizations, I have seen the Just Culture algorithm successfully applied to human resources matters, patient safety events, and physician peer review.

If you are interested in participating in the revitalization of the Just Culture framework at Premier Health and the improved patient safety culture it supports, please email BBesecker@PremierHealth.com.

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