Just Culture

Theory and practice

 Just Culture - Theory and practice | The Patient Safety Company

Just Culture
Theory and practice

Who?
This e-book is written for quality control managers and head nurses.

What?
This e-book describes the theoretical assumptions of Just Culture as they relate to a fictional yet
recognisable practical case.

Importance
Just Culture contributes to a culture of proactive safety and a positive company atmosphere in
which people are consistently comfortable sharing their thoughts on what works and what does
not. It aims to create an environment where people hold others and themselves accountable
for their actions.

What will you learn?

By means of a practical example, this e-book attempts to describe and clarify the pitfalls that can
occur when introducing and maintaining a Just Culture regimen.
 Just Culture - Theory and practice | The Patient Safety Company

Case
The elderly Mrs. Peters ends up in the hospital with a broken hip. She has been brought in from
a nursing home. During her admission to the hospital, it becomes apparent that she suffers
from balance disorders and has recently begun taking painkillers. Examinations indicate that
Mrs. Peters suffers from the side effects of her painkillers: decreased blood pressure, muscle
weakness, and drowsiness, which all do their part to aggravate her balance disorders. Mrs. Pe-
ters’ daughter must file a complaint with the nursing home. Her mother has received the wrong
medication.

At the nursing home, Mrs. Peters is cared for by an older, highly experienced nurse. He was not
surprised to find Mrs. Peters on the bathroom floor. Falling comes with the territory at this age.
And hips are easily broken. So really, it was nothing out of the ordinary.

The woman also complained about having pain. After consulting with the doctor, the nurse
began giving her painkillers. He had also noticed that the woman complained of increasing
dizziness. But Mrs. Peters rarely ever stops complaining about her balance disorders, so that
kind of complaint is par for the course. To be honest, she rarely ever stops complaining in
general. It hurts when she sits, it hurts when she stands, and it hurts when she walks. So, of
course she is always dizzy. Her limited movement often leaves her frustrated and upset as well.
Mrs. Peters is just a rather demanding patient.

The doctor does not notice the nurse’s remarks about dizziness during the extensive description
of Mrs. Peters’ complaints. He thinks that the nurse is just blowing off some steam after dealing
with a demanding patient and not without reason. So really, it was nothing out of the ordinary.
 Just Culture - Theory and practice | The Patient Safety Company

Neither the doctor nor the nurse takes the complaint from Mrs. Peters’ daughter seriously.
Apparently, complaining is a family trait. Like mother, like daughter. When it becomes
indisputably clear that her fall is the result of the painkillers, it is difficult to determine exactly
what went wrong.
The nurse takes his work quite seriously and has an excellent work ethic. Of course, he is going
to make mistakes. But that is a given—it is just as normal as an elderly woman breaking her hip.
Furthermore, he only began giving her the painkillers after consulting the doctor.

Now that the daughter’s complaint is considered valid, he remembers doubting the doctor
when the painkillers were prescribed. He was well aware of the risk of side effects. However, the
doctor, just like himself, is a first-class professional who gives 120 percent in order to offset the
declining number of doctors and health care workers as best he can. So it is inevitable that some
mistakes will be made. No one is really to blame here.

The doctor becomes defensive as well. Do you have any idea how many of these requests he
receives each week? Do you have any idea how heavy his workload is? Not to mention that this
particular nurse, in spite of being a highly capable and hard-working man, is clearly a little past
his prime.

He complains about patients a great deal and this is also related to increasing administrative
pressure. The latter happens to be another of the nurse’s pet peeves. This is a man who longs
for bygone times when every treatment did not have to be reviewed ‘four times’. This kind
of overstatement is not so much a reflection of the reality, but rather a strong expression of
personal feeling. And in the end, feelings are facts too.

However, this is how the doctor chooses to rationalise it—essential information can get lost in
such a long string of complaints. He does not really have time to listen to the complaints of the
health care workers anyway. That is not why he is here. A mistake was made. That much is clear.
But that cannot be avoided. No more than the elderly can avoid falling in their bathrooms.
 Just Culture - Theory and practice | The Patient Safety Company

Just Culture
At a convention in October 2015 about patient safety and the use of Just Culture, the practice was
described as follows: “Ideally, each team would begin the work day by asking things like: ‘What
are we going to do today?,’ ‘Who is doing what?,’ and ‘Are there things we need to consider?’
Unfortunately, hospitals and nursing homes are not this organised. Doctors and nurses do not
start their days at the same time.”

At the same convention, the Australian professor Sydney Dekker discussed Just Culture, a
positive company culture in which people consistently feel comfortable sharing their thoughts
on what works and what does not. An environment where people hold others and themselves
accountable for their actions. The cornerstone for all of this: telling your story.

This need is felt strongly, not only within organisations, but also in society. More and more, the
need for a new narrative is being expressed, for stories that clarify what exactly it is that we are
doing and where we should be headed. By definition, this connects to culture in the broadest
sense: culture as a vehicle for change.

That all sounds quite good in theory. However, this ultimately involves accountability for
mistakes that are sometimes serious and have consequences, not only for the victims, but also
for the culprits and (the image of) the organisation in which the error occurred.

James Reason, Professor of Psychology at the University of Manchester, has been researching,
educating, and publishing about human error for his whole life. He suggests that, “the degree to
which someone is held responsible for an undesired outcome should, in a just culture, be based
on the behaviour and not the gravity of the outcome”. A simple example: you are likely to be
angrier with a child who knocks over a full glass of milk than one who knocks over a glass that is
almost empty. It is more just and more sensible to point out the behaviour that caused the glass
to fall over to the child, i.e. flailing their arms about. In order to make complex care processes
safer, it also makes more sense to guide by behaviour than by outcome.
 Just Culture - Theory and practice | The Patient Safety Company

Conditions for a Just Culture

Sydney Dekker, a fervent advocate of Just Culture, distinguishes five conditions under which such
a culture (shift) can occur. In an interview with Leading Opinion Films, he says:

People have to know for certain that error reporting is handled in a just manner and that there
will not be disproportionate consequences. The dilemma, of course, is that people have to be
held accountable in certain situations and this poses the risk that others will stay silent in the
future. This is where Just Culture is important: for balancing accountability with learning. And
ultimately to make accountability and learning compatible.

However, this all falls apart the second that you consider introducing Just Culture and say: we
will handle all reported errors fairly, unless they involve gross negligence, intentional violations,
or improper behaviour. This still leaves people feeling uncertain, because there are no clear
definitions of these concepts.

Negligence is primarily a legal term and should not be readily used to describe human
performance. This all depends on the definitions of professionalism, adequate care, and the
degree to which you can see problems occurring. After this, discuss judgements. Who is going
to make the judgements? Who sets the boundaries? The concern of modern-day Just Culture is
that more and more people are setting the boundaries: managers, judges, and the like have a
limited scope of the sometimes raw reality of an operating organisation.
 Just Culture - Theory and practice | The Patient Safety Company

So how can you build a Just Culture?

Dekker indicates five conditions in his interview:

1 D
 o not assume that a clear line can be drawn between desirable and undesirable
behaviours. Consider who can and may draw such a boundary. If that is still unclear,
engage in discussion: these may have to occur outside of your organisation or at a political
level.

2 C
 onsider how your business deals with incidents. Do not stigmatise people. Ensure
that there is a sufficient amount of amicable support and definitely do not hand out
punishments.

3 E
 nsure that there is an independently operating division that handles errors and incidents,
so that notifications are not made to an individual manager.

D
 ekker does not name the contemporary variant in which the line bears responsibility for the
handling of errors and incidents. However, his recommendation emphasises that, at the very
least, supervisors must develop the skills to direct and guide there staff while wearing ‘a number
of different hats’.

4 D
 espite the fact that organisations have a societal obligation to be transparent and, if
necessary, to be accountable for their actions, be sure to protect your data from parties
with suspect motives.

5 E
 nsure that people are aware of their rights and obligations after an incident has occurred.
What can they expect, who can they talk to, and who should they not talk to. In short: limit
their concerns about who will soon be judging their behaviour.

This is not about running away from your responsibility. It is about taking responsibility for
your own actions and holding others accountable for theirs. That is where Just Culture starts
out: complete transparency in responsibility—and it ultimately ends at stories that enrich,
strengthen, and improve an organisation.

At a large oil company, they follow the credo: ‘Work safely or work somewhere else’. Despite the
aggressive tone of this mission statement, it is based on two supporting conditions for a Just
Culture: verifiability and vulnerability.
 Just Culture - Theory and practice | The Patient Safety Company

Just Culture relationship - Patient Safety

From a 2014 article about a culture of proactive safety from the VVAA (a Dutch association that
provides financial services to health care organisations): “In order to preserve patient safety,
hospitals have already established protocols, created work arrangements, and introduced safe
incident reporting and safety management systems. However, these only come to pass as a
result of good safety culture. In order to not run aground amidst bureaucratic solutions, more
involvement is necessary from health care employees and professionals. Further application of
a proactive safety culture contributes to Just Culture having more wiggle room and being better
appreciated”.

And: “In a good safety culture, errors are up for discussion throughout all hierarchical structures.
People who unconsciously or unintentionally make mistakes should not be punished. Errors are
made by individuals, but are often caused interactions within the entire organisation. Therefore,
stimulating communication about errors is beneficial, as the entire organisation can learn from
them”.

Just Culture - Communication

In a study from Joint Commission International, an American health organisation that provides
hospitals with quality and safety certifications, it was determined that 67 percent of medical
errors were the result of miscommunication. Communication between patients and doctors,
doctors and nurses, and between doctors, management, and directors is a far cry from perfect.
In his book, If They Had Only Listened..., about preventing medical errors, Matthijs Buikema
indicates that this is not terribly surprising. Good communication has to be a two-way street
and requires time. The latter is often in short supply for health care workers. Nurses have many
patients in their care— possibly too many. Many patients are sharply aware of the pressures
that face nurses and avoid asking too many questions as a result. However, even communication
between nurses and (assisting) physicians often takes place quickly and ineffectively.
 Just Culture - Theory and practice | The Patient Safety Company

Just Culture as applied to the fictional case

Now back to the fictional Mrs. Peters, who broke her hip while disoriented from painkillers.
Firstly, it is interesting to take a look at whether the assumptions made here are valid:

• Both the nurse and the treating physician view the accident as inevitable. Old people fall
and they break bones easily..
• Both the doctor and the nurse have a heavy workload.
• B
 oth the doctor and the nurse consider making errors to be a given. Each takes his work
quite seriously and has an excellent work ethic. They are proud of what they do and they
do it as best they can. That is their own perception of how they work
• In hindsight, the nurse appears to have had doubts about the prescription of painkillers,
but did not express them. Why not? Is he afraid of openly questioning the decision of the
doctor?
• T
 he doctor seems to have had enough of the ‘string of complaints’ from the nurse for quite
a while. Why has he not said anything about it? Is he afraid of discouraging a motivated
nurse? Or is it just not ‘his business’?
• The doctor acknowledges that, during the discussion of Mrs. Peters’ complaints, ‘essential
information’ was not clearly communicated. Or was the knowledge he had at hand about
his patient incomplete or outdated?
• There is also the matter of the ‘administrative pressure’ that irritates the nurse. He
experiences this reporting as something unnecessary that undermines his work.

Just Culture is based on verifiability and vulnerability. This means that a supervisor or official
who is in charge of handling this specific complaint must also employ these two properties. They
are also receptive and responsive to errors and misconceptions.
 Just Culture - Theory and practice | The Patient Safety Company

It is important that both the doctor and the nurse have their issues with workload and increasing
bureaucratic processes acknowledged. An acknowledgement does not necessarily contain a
solution. The person who examines a complaint or attempts to analyse an error is often not in a
position to make any bureaucratic or legal changes to administrative processes. By recognising
this honestly, a supervisor becomes vulnerable.

It is only then that an atmosphere can be created where the traditional method of blaming and
shaming, which entails determining who is at fault and taking disciplinary measures against them,
and often includes a loss of status, trust and motivation, can be banished from an organisation.

Within an organisation where Just Culture is not applied, the following issues can be observed:

• Errors are analysed in order to take disciplinary measures, rather than being used as an
educational tool.
• A company culture where the comments, contributions, and critiques of employees are
undervalued or outright ignored, which undermines the focus on safety.
• A lack of clear leadership. A culture in which supervisors do not behave as role models for
their staff. Verifiability and vulnerability.
• A culture in which professionals exhibit a sort of pride in their work which causes them to
feel like ‘do-gooders’ and that making mistakes is an inherent part of the job.
• A
 lack of team spirit which results in the comments and suggestions routinely being ignored
or considered of little use.
• A culture in which professionals protect each other and themselves out of fear of
‘accusations’.
• A
 culture in which the analysis of errors or the fear of it, poisons working relationships and
individual status can be affected.
• Fear of legal claims and their impact on individual professional reputation.
• An organisation in which determining errors is perceived as a waste of time.
• A
 lack of support for doctors and health care workers who are second victims. These are
people who suffer from sadness and feelings of guilt after having made an error.
• A lack of structural feedback during which error reports are shared and lead to change
throughout the organisation.
 Just Culture - Theory and practice | The Patient Safety Company

Always Events
Where Just Culture is oriented toward the organisation itself, Always Events instead puts the
patient first.

This approach is based on the opinions of the American doctor, Harvey Picker (1915-2008),
the founder of the eponymous institute, who felt that American health care institutions were
excellent from a scientific and technological perspective, but that they did not take the comfort
of the patient into consideration sufficiently.

Picker suggested that respecting the values, preferences, and expressed needs of the patient
was a pillar of patient care. This includes safety as well.

The term Always Events is the exact opposite of the term Never Events, which is often used regarding
patient safety. The latter is used by many organisations, including American institutions like the
National Quality Forum and the Centers for Medicare and Medicais Services to describe events
that should never occur during patient care.

Always Events, on the other hand, focus on patient care aspects which are considered important
enough by the patient and their family that care providers should always handle them well. The
power of Always Events lies in its focus on the positive. Studies indicate that this approach has
a positive effect on patient safety, subsequent hospital admission, and death figures. Picker
himself felt that, regardless of these results, without an effective relationship between care
providers, patients, and their families that was characterised by mutual respect and involvement
in the care process, true healing could not take place
.
 Just Culture - Theory and practice | The Patient Safety Company

Two important themes arise from this: communication and transfer.

• Communication in Always Events is oriented towards sharing and exchanging information

between the most important members of the care team and patients and their families—
the collective responsibility for the care of the patient is first and foremost. Communication
is considered the foundation of an effective collaboration during every interaction between
the patient and the care institution.

• Transfer refers to the experiences of patients and their families when being moved from
the care of a physician to a specialist, from the emergency room to the hospital division, or
from the hospital to the home. These transitions are viewed as critical, because it is right
at these moments that the risk of errors is high.

Of course, implementing Always Events requires a wholly unique approach. More on this can be
read in the online publications of the Picker Institute and possibly in a future e-book from the
Patient Safety Company.
 Just Culture - Theory and practice | The Patient Safety Company

Sources
Always events (2016, August 8). Retrieved from http://www.ihi.org/Engage/Initiatives/
PatientFamilyCenteredCare/Pages/ AlwaysEvents.aspx

Buikema, M. (2012). Hadden ze maar geluisterd… The Netherlands: Zin Publishing.

Dekker, S. [Modernisering Medische Vervolgopleidingen]. (2016, August 8). CanBetter-congres

Patiëntveiligheid – Sidney Dekker [YouTube].
Retrieved from https://www.youtube.com/watch?v=Dy2awkglnTE

Dekker, S. [Opinion Films]. (2016, August 8). Sidney Dekker on Just Culture [YouTube].
Retrieved from https://www.youtube.com/watch?v=t81sDiYjKUk

Diemen-Steenvoorde van, R., Leistikow, I., & Tuijn van der, Y., Onveilig gedrag aanpakken om
de zorg veiliger te maken, 2016 August 8, http://www.sin-nl.org/igz-promoot-just-culture-waar-
of-niet-waar/

Picker, H., Always Events, 2016 August 8, http://alwaysevents.pickerinstitute.org/

VvAA, Van checklist naar leiderschap, de volgende stop naar een proactieve veiligheidscultuur,
2016 August 8, https://www.vvaa.nl/voor-leden/artikelen/proactieve-veiligheidscultuur