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Just Culture and its critical link to patient safety (Part I)
May 17, 2012

Do you believe your organization operates within a Just Culture? We have asked this question many times while working collaboratively with healthcare organizations and professionals in pursuit of our shared goal of preventing medication errors. It’s not an easy question to answer; it’s mostly intended to trigger valuable dialogue on the topic. Yet, we often receive hasty affirmative responses, particularly from organizational leaders, assuring us that the organization has, indeed, established a Just Culture, when our direct observations belie such attestations. As a result, we worry that “Just Culture” has simply become a popular catchphrase used by many, without fully understanding its tenets and nuances, and its crucial link to patient safety.

To assess how far along an organization is on their journey to a Just Culture, we often look for certain components regarding the organization’s values, justice (fairness to the workforce) and safety, reduction of at-risk behaviors, design of safe systems, and establishment of a reporting and learning environment. We thought it might be helpful to organizations that have embarked on a Just Culture journey if we shared some aspects of these components. Although not inclusive or sufficient alone to presume a Just Culture, the questions that follow can help you assess your progress on this journey. In addition, when applicable, we have included results from the 2012 report on the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (see Table 1 in the PDF version of the newsletter) to provide a national snapshot of where hospitals stand regarding certain aspects of a Just Culture.

In Part I, we cover components associated with values, justice and safety, and reduction of at-risk behaviors.

Organizational Values

What are the organization’s primary and secondary values? An organization operating within a Just Culture has defined its primary (high) and secondary values to ensure that workers know how to prioritize their work. Safety should always be a primary value. Values such as efficiency and productivity should be considered secondary values. Overzealous commitment to these and other secondary values can threaten safety and confuse workers, particularly if they are not provided with direction regarding which value takes precedence. In general, it should be clear to workers that safety should not be sacrificed to achieve secondary goals such as productivity. Yet, 26% of respondents from hospitals that participated in the AHRQ culture survey said that, whenever pressure builds up, managers want staff to work faster, even if it means taking shortcuts. Fifty percent said they work in crisis mode, trying to do too much too quickly, and 36% reported that safety is sacrificed to get more work done.

Do managers’ behaviors demonstrate that safety is a primary (high) value? The best way to influence the day-to-day decisions that staff make—which, in turn, affects patient safety—is through employee observations of leaders’ and managers’ practices and behaviors. Open discussion of safety as a high value, and seeing leaders and man-agers behave in a manner that demonstrates that safety comes first, encourages and supports staff decisions to do the same. But, about a quarter of respondents to the AHRQ survey reported that managers overlook repetitive safety problems and do not act in a way that demonstrates to staff that safety is a top priority. Behaviors that send mixed messages (e.g., safety vs. productivity) create confusion and promote unsafe behavioral choices.

Is safety a value or a priority? Many healthcare organizations have made patient safety a priority that deserves their utmost attention right now. But priorities can easily shift, and once again, patient safety could take a back seat to other dimensions of quality, leaving tragic patient injuries in its wake. Patient safety should be a sustained primary value associated with every healthcare priority, not a priority that can be reordered based on competing demands.

Justice and Safety

How does the organization respond to human error, at-risk behavior, and reckless behavior? Three types of behavior should be anticipated in an organization: human error, at-risk behavior, and reckless behavior. Each type of behavior has a different cause, so a different response is required.

Human error involves unintentional and unpredictable behavior that causes or could cause an undesirable outcome; it is not a behavioral choice—we don’t choose to make errors. Since most human errors arise from weaknesses in the system, they are managed within a Just Culture through system redesigns that reduce the risk of errors. Discipline is not warranted or productive because the worker did not intend the action or any undesirable outcome that resulted. In a Just Culture, the only just option is to console the worker who made the error and to redesign systems to prevent further errors. Unfortunately, the AHRQ survey results uncover a different reality in many hospitals. Half of respondents feel like mistakes are held against them; 65% worry that their mistakes are kept in their personnel file; and 54% feel like the person is being written up, not the problem, when events are reported.

At-risk behaviors are different than human errors. Behavioral research shows that we are programmed to drift into unsafe habits, to lose perception of the risk attached to everyday behaviors, or mistakenly believe the risk to be justified. Our decisions about what is important are typically based on the immediate desired outcomes, not delayed and uncertain consequences. Over time, as perceptions of risk fade away and workers try to do more with less, they take shortcuts, violate policies, and drift away from behaviors they once knew were safer. These at-risk behaviors, often the norm among groups, are considered to be “the way we do things around here.” In a Just Culture, the solution is not to punish those who engage in at-risk behaviors, but to uncover and remedy the system-based reasons for their behavior and decrease staff tolerance for taking these risks through coaching. 

In comparison to at-risk behaviors, workers who behave recklessly always perceive the risk they are taking and understand that it is substantial. They behave intentionally and are unable to justify the behavior (i.e., do not mistakenly believe the risk is justified). They know others are not engaging in the behavior (i.e., it is not the norm). The behavior represents a conscious choice to disregard what they know to be a substantial and unjustifiable risk. In a Just Culture, reckless behavior is blameworthy behavior. As such, it should be managed through remedial or disciplinary actions according to the organization’s human resources policies.

Are individual accountabilities documented in job descriptions, performance evaluations, and/or policies, and communicated to staff? Organizations that operate within a Just Culture have defined and communicated individual accountabilities so all staff understand what is expected of them. In a Just Culture, staff at all levels are held accountable to perform at the highest level of personal reliability while conscious of human limitations. They are accountable for making safe behavioral choices and decisions that promote safety. They are responsible for identifying patient safety and other organizational risks, including system vulnerabilities, human errors, at-risk behaviors, and reckless behaviors. They must work with others to identify and manage everyday risks and coach individuals who are engaging in at-risk behaviors.

Managers and administrators have additional responsibilities to continually assess the behavioral choices of staff, monitor systems and processes, design and redesign systems to improve safety, investigate the causes of risk and errors, and to respond fairly and consistently to staff who make human errors or engage in at-risk or reckless behavior. In a Just Culture, all workers know that safety is a primary value in the organization, and they continually look for risks that pose a threat. They are thoughtful about their behavioral choices and always thinking about the most reliable ways to get the job done right.

Does the potential or actual severity of an outcome play a role in how staff are treated when evaluating risk and errors? An organization operating within a Just Culture does not employ an outcome-based model of accountability, meaning there is no severity bias—the potential or actual severity of the outcome plays no role in determining how staff are treated. Instead, staff are judged on the quality of their behavioral choices, not the outcome or potential outcome of a hazard or mishap. When patients are harmed, this is a difficult but worthwhile stance, as an outcome-based accountability model often results in a “no harm, no foul” approach to staff, with missed opportunities to console employees for human error, coach individuals regarding at-risk behaviors, or to redesign systems to prevent human errors from reaching patients. If an error happens, employees should know that they will be treated fairly when they report their mistakes, and that they will be accountable for the quality of their choices, and not simply the outcome.

Management of At-Risk Behaviors

Is the culture tolerant of at-risk behaviors? Human behavior runs counter to safety because the rewards for risk taking are often immediate and positive (e.g., saved time), while the punishment (e.g., patient harm) is often delayed and remote. As a result, even the most educated and careful healthcare professional will learn to master dangerous shortcuts, particularly when faced with an unanticipated system problem (e.g., technology glitches, time urgency). Staff will drift from safe and controlled processes, as first learned, to unsafe and automatic processes. Over time, the risk associated with these processes fades and the entire culture becomes tolerant to these risks.

For example, if you’re an experienced pharmacist, you might not think twice about answering the phone and managing special requests at the pharmacy window while entering complex medication orders. You may no longer check the patient’s full drug profile, allergies, and weight before entering medication orders. You may now rush past drug interaction messages with barely a notice, and fill medication orders using the label, not the order. If you’re an experienced nurse, you may believe it’s acceptable to maintain unauthorized stashes of medications on your unit, prepare IV admixtures instead of waiting for pharmacy to dispense them, and administer medications to patients before pharmacy has reviewed the order. You may borrow another patient’s medications for quick administration to your patient and leave medications at the bedside. You may no longer bring the patient’s medication administration record to the bedside if you are just administering a prn medication. Successful outcomes foster continuance and tolerance to the risks, particularly when others ‘look the other way’ or begin imitating the at-risk behavior. 

Does the organization tend to punish safe behavior and/or reward at-risk behavior? When organizational tolerance to risk is high, safe behavioral choices may actually invoke criticism, and at-risk behaviors may invoke rewards. For example, a nurse who takes longer to administer medications may be criticized, even if the additional time is attributed to safe practice habits and patient education. But a nurse who is able to handle four new admissions in the course of a shift may be admired, and others may follow her example, even if dangerous shortcuts must have been taken to accomplish the work. A pharmacist who dispenses a “missing” medication quickly is more likely to receive positive reinforcement from the awaiting nurse than a pharmacist who fully investigates the reason for the request, thus delaying receipt of the missing medication. The pharmacist who typically ignores those “nuisance” alerts and is able to enter a large volume of orders without a backlog may receive a better performance evaluation than a pharmacist who takes longer because he evaluates the significance of all alerts. In fact, shortcuts like these and many others could even be labeled as efficient behavior.

At-risk behaviors represent the greatest risk to patients given that reckless behaviors are rare and human errors usually present as single isolated failures. The faded perception of risk, the habitual nature of the behaviors, and upside-down rewards that discourage safe behaviors and encourage unsafe at-risk behaviors make it difficult to change the behaviors. In a Just Culture, the solution is not to punish those who engage in at-risk behaviors, but to identify and report these behaviors, determine the scope of the behavior, uncover and remedy any upside-down rewards and the system-based causes for the behaviors, and decrease staff tolerance to risk-taking.

Is there visible evidence of coaching around at-risk behaviors? Within a Just Culture, at-risk behaviors are reduced by removing the barriers to safe behavioral choices, removing the rewards for at-risk behaviors, and coaching staff to reduce their tolerance to risk and encourage a decision-making process that results in the desired safe behavioral choices. Coaching involves helping another see risk that was not seen or misread as being insignificant or justifiable. It entails a productive discussion between individuals about the risks vs. rewards of certain behaviors and the decision-making process for behaviors under the control of the worker. Unlike “counseling,” which is typically a boss-to-employee discussion that entails putting the employee on notice regarding potential disciplinary action, coaching involves manager-to-staff, peer-to-peer, and staff-to-manager coaching. Staff willingness to coach peers and managers and to be coached by others can be a strong indicator of a Just Culture. Yet, the AHRQ culture survey results suggest that only about half of respondents feel free to question the decisions or actions of those with more authority, and 37% reported that they are afraid to speak up when something doesn’t look right.

Part II

In one of our June 2012 newsletters, we will cover the components of a Just Culture associated with designing systems and establishing a reporting and learning environment. We hope organizations will consider the questions above and those we pose in Part II, and take a hard look at the culture in which they operate and how it really compares to a Just Culture. “Just Culture” is so much more than a trendy metaphor for what was previously called a “non-punitive” or “blame-free” culture. It’s a robust set of values, beliefs, and actions that provide solid guidance on how an organization can best manage safety. For pharmacists attending the ASHP 2012 Summer Meeting on June 9-13 in Baltimore, two sessions on Just Culture will be offered (117-L05, 118-L05). We will suggest additional resources for organizations to learn more about Just Culture in Part II of this article.
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