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The Promise and Practice of a Just Culture

Focus on Consistency of Purpose

By Topic: Safety Quality Culture of Safety Just Culture High Reliability By Collection: Safety

Leaders whose organizations have made big safety gains will tell you that a high-reliability safety culture is one of shared learning characterized by an atmosphere of trust. Members of the workforce feel safe speaking up when they make an error or encounter circumstances that could lead to harm. And, since these high-performing organizations recognize that most errors are due to flawed systems, not individual negligence, they’re listened to and supported.

It’s a cornerstone of high-reliability industries that’s now widely referred to in healthcare as “just culture.” In the guide, Leading a Culture of Safety: A Blueprint for Success, ACHE and the IHI Lucian Leape Institute include just culture as one of six core domains for driving to zero harm. 

A just culture holds people accountable for following procedures and protocols (when they’re in the patient’s best interest) but unites teams in working for the common good. The ethos: Forget finger-pointing. Let’s learn from this error and improve this system. Let’s correct this process before someone gets hurt. See a problem? Call it out.

Evidence suggests it’s an environment many healthcare organizations still struggle to embrace.

Since launching in 2004, the Agency for Healthcare Research and Quality’s Surveys on Patient Safety Culture have found nonpunitive responses to errors to be the top area for improvement. The 2018 survey found that more than half of staff respondents believe event reports are held against them and kept in their personnel files.

A study of U.S. hospitals published in the April 2018 issue of the American Journal of Medical Quality sheds further light on blame culture’s persistence in healthcare. Seventy-nine percent of respondents reported that their institutions have adopted a just-culture process, and more than half believe it has had a positive impact. But the study found no correlation between just-culture adoption and hospital performance or event reporting.

The core of what we do is make sure that patients feel safe that the care they receive will be reliable, consistent and deliver the outcomes they and their families expect.

- Robert A. Cherry, MD, FACHE, FACS, UCLA Health

Though some experts say the reasons vary, including that just culture errs in its emphasis on distinguishing blameworthy from blame-free events, leaders whose institutions have succeeded in developing a learning climate of openness around error reporting have a different take.

Just culture is only one aspect of a larger safety strategy, but it’s an essential one, and it needs ongoing work, they say. Healthcare Executive spoke with three leaders about their experiences and what organizations can do to bring just culture to fruition.

UCLA Health: Flattening the Hierarchy to Encourage Safety Reporting  
“The core of what we do is make sure that patients feel safe that the care they receive will be reliable, consistent and deliver the outcomes they and their families expect,” says Robert A. Cherry, MD, FACHE, FACS, chief medical and quality officer at UCLA Health.
Where does just culture fit in with that? “Just culture is not the complete solution, but it’s a tool that complements our efforts to be a high-reliability organization and enhance the patient experience,” he says. 

To be able to learn every day from events and near misses, you need an environment in which raising concerns is not only normal but expected. That’s not something you accomplish by running through a couple of initiatives. It needs to be relentless. We’re never satisfied.

- Stephen E. Muething, MD, Cincinnati Children’s Hospital

At UCLA Health, just culture means shared accountability and an intentional effort to flatten the vertical, hierarchical structure under which hospitals have traditionally operated. 

“It’s important to have high-functioning teams working toward the same goals, but to do that, you have to have safe, transparent conversations in which people feel like they’re talking with their peers rather than feeling they’re in a command-control situation,” Cherry says.

Because of UCLA Health’s size, the organization used a phased approach that began with a formal assessment of cultural perceptions followed by the development of a cadre of 40 culture champions “chosen for their skill in facilitating change and introducing just-culture principles in their units,” explains Anet Sinanyan, patient safety director.

In 2016, UCLA Health introduced a reporting system for documenting near-miss and actual harm events called Safety Opportunities for Improvement, built to overcome the limitations of the previous homegrown system. “We encourage everyone to memorialize their understanding of an event in SOFI,” says Cherry.

Most harm events are addressed locally, with appropriate subject matter experts and department leaders informed in near real time via automatic notifications. Incident review committees look more closely at events and trends that might offer opportunities for learning and improvement across broader swaths of the system.

As in many organizations, events that look like judgment errors at first often turn out to be systems and process issues. These cases undergo a root-cause analysis and corrective action planning. Root-cause analyses and significant trends are shared with the clinical excellence committee and the system board.

Last year, UCLA Health introduced a dashboard that lets teams access data in SOFI at hospital and departmental levels and use that data for continuous improvement. The dashboard gives users easy access to reporting data for their own department and for all of UCLA Health. Users can easily drill down into specific areas with a few clicks, says Sinanyan. 

The health system also holds monthly patient experience rounds in which clinical and nonclinical leaders talk with patients, families and staff, and then share findings and improvements. Findings that need to be addressed are logged in a tracker and saved on a website specific to the rounds, where they’re followed to make sure they’re resolved in a timely manner.

UCLA Health also presents “good catch” awards for incident reporting, with a personal note from CEO John C. Mazziotta, MD, PhD, to individuals whose clinical skills and judgment have prevented harm.

“Teams and individuals go back to their units and talk about how supported they felt in articulating their concerns, and that good feeling gets around,” Cherry reports. “When we deal with issues in a transparent, constructive way, people see we have a culture that values their opinions, and they begin speaking up.” 

Just culture is about accountability for underlying systemic problems to improve safety and prevent harm. It’s also about people feeling safe saying, ‘I made this mistake. Let’s find out why.’

- Anthony J. Warmuth, FACHE, Cleveland Clinic

Cincinnati Children’s Hospital: A Focus on “Psychological Safety”
Just culture doesn’t work in isolation, but it’s a critical part of the continuous learning system that is the bedrock of high-reliability organizations, says Stephen E. Muething, MD, chief quality officer at Cincinnati Children’s Hospital. “It allows you to create the learning cycle that’s necessary to make real progress in patient safety,” he says. 

Cincinnati Children’s Hospital has been committed to high reliability  for 15 years, Muething says, and though it is still far from where it wants to be, “when people visit to learn from us, they’re struck by how openly and actively we learn from events every day. Everybody’s talking about what they can do better and what they learned. They don’t take joy in not finding problems; they take joy in finding them.” 

The hospital embarked in 2019 on a culture refresh focused on psychological safety. This initiative included training for all 15,000 leaders and staff on empowering front-line employees to voice safety concerns during active events. “Some of our front-line people said that they still feel that their concerns won’t be listened to or appreciated. There’s still some fear they’ll be told they’re wrong, so they may wait for someone else to speak up,” says Muething. All leaders underwent four hours of training and then led training for their teams on the importance of sustaining an environment in which team members feel confident they will be supported if they identify a potential concern during the delivery of care. 

“Our clinicians have done great work without just culture, so it can be hard for some to accept the fact that culture change is necessary,” Muething observes.

The hospital uses the power of individual stories to guard against complacency, a danger in any organization. “If someone is harmed in our organization, whether it’s an employee or a patient, we talk about it openly. You have to make this real for people so they can connect it with the work they do,” he says. The hospital also holds open sessions to help employees extrapolate lessons learned and improvements made based on safety events to their part of the organization.

“To be able to learn every day from events and near misses, you need an environment in which raising concerns is not only normal but expected,” Muething says. That’s not something you accomplish by running through a couple of initiatives. It needs to be relentless. We’re never satisfied.” 

Cleveland Clinic: Consistency and Commitment Deliver Superior Results
“There are limitations to just culture, but I think those limitations are usually self-imposed when we’re not being effective change agents or when we’re unclear about what just culture is,” says Anthony J. Warmuth, FACHE, executive director of enterprise quality and safety at Cleveland Clinic. “Just culture is about a cultural transformation. If you practice what you preach, you will see results.”

Organizations that buy into the misperception that just culture means lack of accountability will run into trouble, Warmuth believes. “Just culture is about accountability for underlying systemic problems to improve safety and prevent harm. It’s also about people feeling safe saying, ‘I made this mistake. Let’s find out why.’” 

Though the seeds were planted about 10 years ago, Cleveland Clinic has been intentionally focused on high reliability for the past five years, and just culture is an integral part of the transformation. “We think actively about what could go wrong, speak up when we see conditions that could cause harm, and work together to drive improvement every day,” he says. “Are we there yet? No. It’s a journey.”  

That journey has included the realization that harm can happen in a variety of ways, in nonclinical as well as clinical settings. “We usually think of harm in terms of medical errors, but lack of empathy can harm a patient, too,” he says. Similarly, a billing specialist working on a claim that a patient is having difficulty understanding should be thinking and speaking up about ways to improve billing to enhance clarity and accuracy. 

“Our commitment as a learning organization involves listening actively, learning from each other and leading together,” says Warmuth. Toward that end, senior leaders regularly go on rounds to talk with patients about their experience and what the health system and care team could be doing better. 

The commitment to learning also involves fostering a learning environment by giving employees multiple avenues through which their voices can be heard. Last year, CEO Tomislav Mihaljevic, MD, introduced a “speak up” award to recognize individuals whose safety error reporting has led to significant improvements or prevented harm.  

Cleveland Clinic has also developed a good-catch reporting system that allows a staff member to submit a concern by answering a few quick questions. 

Timely feedback and follow-up when errors are reported are essential. “If someone presents a safety issue and it goes into a black hole, they’ll probably never report another one again,” Warmuth says.  

In addition, Mihaljevic and his leadership team hold daily huddles to discuss indicators from across the organization, including safety events, “so we’re not reacting to an event a month after it’s happened,” says Warmuth. “Leadership’s timely, clean line of sight into safety is really important.” 

Susan Birk is a Chicago-based freelance writer specializing in healthcare. 

Cincinnati Children’s Hospital: Fostering Workforce Trust

To reduce harm to employees by increasing reporting on potential concerns and threats, the hospital converted the previous reporting system to a 24/7 call line through which employees can both report and receive help. The change included a new process for transparently sharing learning across the organization and led to a 300 percent increase in reporting. The system receives an average of 1,800 calls per year and plays a key role in fostering trust among the workforce in the hospital’s commitment to employee as well as patient safety.

Abington-Jefferson Health: A Just Culture Algorithm

Abington-Jefferson Health, Abington, Pa., a two-hospital system that became part of 14-hospital system Jefferson Health in 2015, began its patient safety journey 20 years ago. But it was seven years ago that the organization realized it needed to incorporate just culture practices into its overarching high-reliability strategy in a much more robust manner in order to continue making progress.