Quality & Safety Scoop: Patient Safety and Just Culture

By Bridget Norton, M.D., MBA, Children’s Chief Quality & Safety Officer

Dr. Lucian Leape, professor from the Harvard School of Public Health, said, “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” As an organization, we have committed to moving away from the punitive, reactive type of culture described by Dr. Leape, and toward being proactive, focusing on prevention by embracing what is known as Just Culture.

What is a Just Culture? The term Just Culture refers to a values-supportive system of shared accountability where organizations are accountable for the systems they have designed and for responding to the behaviors of their employees in a fair and just manner. Employees, in turn, are accountable for the quality of their choices and for reporting both errors and system vulnerabilities.

— Outcome Engenuity, LLC. 2013

In a Just Culture:

  • Organizational leaders ensure the design of safe systems (equipment, policies, software, etc.). If the system is flawed or broken it is leadership’s responsibility to fix it.
  • Providers & employees make behavioral choices, determining how they act and react within these systems. They are held accountable for the quality of their choices.
  • At the core of Just Culture is a process for allocating responsibility for events – that is, what is caused by the system, and what is caused by the human component.
  • When events occur, leaders will be asking what, why, and how it happened and there will be an investigation to determine any areas where the system may have broken down, and assess the risk of future events.

As physicians, we must be empowered both as leaders and members of the organization to report events that have already occurred, as well as areas of risk for future events. We must also be supportive of our Just Culture and the other leaders in the organization by focusing on the what, why and how of adverse events, helping to identify opportunities to improve the safety of the system and learn from these events to prevent them from happening in the future.

All providers should have received an email from Chris Maloney, M.D., Ph.D., with instructions on how to sign up in Cornerstone to take the Just Culture class. Physician and APP courses will be offered in November. This course is required for all hospital and Children’s Specialty Physicians staff, but we highly recommend that all members of the medical staff participate, as you are part of the culture of Children’s Hospital & Medical Center. If you have any questions please feel free to reach out to Dr. Maloney, Kim Peterson or me, Bridget Norton, M.D.