What is a “Just Culture” and Why It’s Important to Improve Healthcare

A foundation of the patient safety movement is non-judgmental recognition of the ubiquity of human and system error. This appreciation of human imperfection creates a shift from a “culture of blame” toward a “culture of safety”.  The Veteran’s Administration (VA) summarizes this philosophy as follows: “We’ll never eliminate all individual errors. The goal is to design systems that are ‘fault tolerant,’ so that when an individual error occurs, it does not result in harm to a patient. That’s why we’ve based VA’s patient safety program…on prevention, not punishment”(2009). This paradigm became known as a “no blame” patient safety model.

This “no blame” culture has been questioned with the introduction of the concept of “just culture”(Marx 2001, Wachter and Pronovost 2009). The Agency for Healthcare Research and Quality (AHRQ) describes just culture as one that identifies and addresses systems issues that lead individuals to engage in unsafe behaviors while maintaining accountability.  Marx and AHRQ are careful to distinguish between “human error (e.g., slips), at-risk behavior (e.g., taking shortcuts), and reckless behavior (e.g., ignoring required safety steps), in contrast to an overarching ‘no-blame’ approach.” For example, an egregious form of recklessness is willful refusal to follow widely accepted and efficacious policies, akin to a pilot refusing to use checklists, or a physician consistently refusing to wash his or her hands.  

What should form the basis of a “just culture” in healthcare?  When preventable error results in an adverse outcome, should one focus on punishment or making amends?  Should one do anything at all if there is no harm? A similar tension is found in legal theory, which uses principles of retributive and restorative justice (Wenzel, Okimoto et al. 2008). Retributive justice, based on the principle of lex talionis (“an eye for an eye”), describes the “culture of blame”, where fault is decried and punishment is proportionate to harm.  Alternatively, restorative justice encourages responsibility, reparations, and rehabilitation. For example, a physician who ignores “time-outs” in the operating room would lose operating privileges for two weeks in the retributive model; in the restorative model they would receive advanced instruction on checklists and “never events” and be required to co-lead a training module on “time-outs” for new staff. Loss of privileges would remain a last resort, used only when prior remedies are ignored or ineffective.

 

Where does the individual physician fit into a just culture that must balance “no blame” and accountability?  While restorative disciplinary measures are appropriate in cases of misconduct involving willful disregard for safety or standards, as James Reason points out in the case of a “slip”, there is little benefit from simply “putting a carcass on the wall” to show you have done something (Marx 2007).

 

Without losing sight of the serious consequences to the patient, it is crucial to be cognizant of the fact that adverse outcomes can leave a devastating impact on the caregiver as well, who will often have many years, and thousands of patients, to care for over the rest of their career.  Even before an event is reviewed, usually at the first instance of recognition, the emotional and psychological consequences to the caregiver begin. The “sickening realization” of making the mistake turns into dread and agony, then defensiveness and anger. In many ways the physician becomes a “second victim” and is subject to the phenomenon of “secondary trauma”, which occurs when one witnesses a traumatic event (Wu 2000). Scott and colleagues outline the trajectory of recovery for the physician after an adverse event, noting six stages:  1) chaos and accident response, 2) intrusive reflections, 3) restoring personal integrity, 4) enduring the inquisition, 5) obtaining emotional first aid, and 6) moving on (Scott, Hirschinger et al. 2009). The last stage encompasses three pathways—dropping out, surviving, or thriving.

In the wake of an error-related adverse event, great care is needed to avoid giving the physician the sense that they are “on trial” for a crime.  If not, there is the potential of losing good doctors—literally by “dropping out” or figuratively by merely “surviving”—whose only fault is being human. One strategy to consider in evaluating a physician following an error, especially one that causes harm, is to focus on three crucial questions:

  1. Was the standard of care met, including adherence to crucial policies and guidelines?
  2. Is the physician willing to incorporate lessons learned into future practice?
  3. Is the physician committed to maintaining their relationship with the patient and participating in a full disclosure of events?

At all times, but particularly when these answers are obviously “yes”, physicians deserve maximal support (Pettker and Funai 2010). It may be especially powerful if the physician can maintain a role as an advocate for the patient’s best interests throughout the process, including deliberations regarding potential compensation. Ultimately in the wake of an adverse event, both the patient and the entire team of caregivers, will need additional support and monitoring.

 

Further reading:

 

“Patient Safety Primer:  Safety Culture.” Retrieved December 7, 2009, from http://www.psnet.ahrq.gov/primer.aspx?primerID=5.

Affairs, U. S. D. o. V. (2009). “VA’s Approach to Patient Safety.” Retrieved December 7, 2009, 2009, from http://www4.va.gov/ncps/vision.html.

Marx, D. (2001). Patient Safety and the “Just Culture”:  A Primer for Health Care Executives. New York, Columbia University.

Marx, D. (2007). “In Conversation with…David Marx, JD.” from http://webmm.ahrq.gov/perspective.aspx?perspectiveID=49.

Pettker, C. M. and E. F. Funai (2010). “Getting it right when things go wrong.” Jama 303(10): 977-978.

Scott, S. D., et al. (2009). “The natural history of recovery for the healthcare provider “second victim” after adverse patient events.” Qual Saf Health Care 18(5): 325-330.

Wachter, R. M. and P. J. Pronovost (2009). “Balancing “no blame” with accountability in patient safety.” N Engl J Med 361(14): 1401-1406.

Wenzel, M., et al. (2008). “Retributive and restorative justice.” Law Hum Behav 32(5): 375-389.

Wu, A. W. (2000). “Medical error: the second victim. The doctor who makes the mistake needs help too.” Bmj 320(7237): 726-727.