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Just Culture: Where Is the Justice?

By Topic: Safety Quality Culture of Safety Just Culture


Though many healthcare leaders believe just culture is essential to the success of an overall high-reliability safety strategy, some question whether the model can fulfill its potential. At the heart of their concerns is the belief that blame culture often continues to persist in healthcare environments that claim to be just. The lingering emphasis on who is at fault stifles the self-reporting that forms the bedrock of continuous improvement and high reliability, they say. 

A study of U.S. hospitals published in the April 2018 issue of the American Journal of Medical Quality (cited in the article on just culture in the March-April issue of Healthcare Executive) reports that 79% of respondents said their institutions have adopted a just culture process. More than half reported that this process has had a positive impact. 

However, the study showed no correlation between just culture adoption and hospital performance or increases in event reporting.  

Author Marc T. Edwards, MD, of QA to QI Consulting, Inc., Chapel Hill, NC, believes this is because the common use of an Incident Decision Tree or other algorithm to help managers determine the course of action for employees involved in an incident “mixes questions of accountability for performance into event analysis—where the default presumption should be staff innocence.”  

As a result, Edwards believes the approach has failed to eliminate the culture of blame and gross underreporting of opportunities for improvement that are necessary for the development of a high reliability safety environment, Edwards says. Just culture “is the wrong tool the for the job,” he argues. 

The data presented in his study indicate that “the results of exemplar institutions have not been replicated by most of the hospitals adopting just culture,” Edwards adds. “Moreover, the term is loosely used to describe organizational characteristics thought to be conducive to safety as well as an unproven process to improve patient safety. It has outlived its utility,” he says.

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