'Just culture' model called better, allows discipline for reckless behavior

No-punishment method can hamper error reduction

(Editor's note: This month's Healthcare Risk Management includes the first of a three-part series on the "just culture" approach to improving patient safety. This month's issue includes stories on how the just culture approach works and some potential problems with implementation. Next month, HRM will include tips for implementing a just culture, the types of behavior that can result in discipline, and the criteria for deciding when to punish an employee. The following issue will include a report on one hospital's experience in adopting a just culture.)

The popular belief that a nonpunitive approach will reduce errors and not get in the way of proper discipline of employees is being challenged by new research that suggests the tactic may not be entirely compatible with efforts to improve patient safety.

The surprising research results were presented at the recent annual meeting of the American Society for Healthcare Risk Management by Geri Amori, PhD, ARM, FASHRM, a consultant with The Risk Management & Patient Safety Institute (RM&PSI) in Lansing, MI, and past president of the American Society for Healthcare Risk Management (ASHRM), and Margaret Curtin, CPH, also a consultant with the institute. They reported the results of an RM&PSI survey of risk managers at 30 hospitals selected randomly nationwide, of which 80% have nonpunitive policies intended to promote greater reporting of potential safety issues.

One of the questions in the survey asked the participants to respond to this statement: "A nonpunitive culture has been described as blame-free by many. Has this complicated the overall error handling in regard to accountability determination and action?" Forty-five percent of the respondents said yes, 24% said they weren't sure, and 31% said no.

When asked how the nonpunitive approach has complicated error handling, the respondents cited several problems. The policy must still include accountability for carelessness, and there can be inconsistency in handling errors and disciplinary actions, they said. "They also reported that staff show disregard for rules and policies because they think they won't be disciplined for their actions," Amori says. "Plus, some respondents pointed out that the policy is still punitive in many instances, even when you call it nonpunitive."

Amori says the nonpunitive approach is rooted in the right philosophy, which is the idea that fixing the systemic errors that threaten patient safety is more important than punishing a single staff member, and that the fear of punishment can discourage people from coming forward with trouble reports. But in practice, she says, the nonpunitive approach brings its own problems, she says.

Follow-through can be a big problem with the nonpunitive approach, she says. Trust issues can develop if disciplinary action is taken when risk managers say it won't be used, she says, so you have to really commit yourself to a nonpunitive approach 100%, or the concept falls apart. Unfortunately, many organizations have difficulty with that when they are faced with a difficult situation in which it seems punishment is justified, she says.

"With nonpunitive, people think they can get away with anything, that there are no ramifications for any behavior," Amori says. "With 'just culture,' you are held accountable for things that you can control, but not for things that are rightly the responsibility of the system."

Blame game not good either

Curtin and Amori advocate a just culture approach as a sort of middle ground between the nonpunitive approach, which the survey results suggest isn't all it has been touted to be, and the old "blame and shame" management style that nearly everyone agrees discouraged the reporting of errors and patient safety concerns.

A just culture model is based on some of the same ideas as a nonpunitive approach, but it allows for situations in which a staff member recklessly or willfully disregarded policies intended to protect the patient, Curtin explains. In that way, it can be a more realistic way to encourage open reporting, one that won't put the manager in a frustrating position when an employee is clearly in the wrong, she says.

Like a nonpunitive approach, a just culture is based on the idea of transparency and encouraging the free and open communication and reporting of errors and patient safety issues. Rather than immediately blaming the staffer who is caught with the wrong drug syringe, for instance, the hospital with the just culture would investigate the systemic failures that allowed her to inject the patient with the wrong medication.

The just culture also views near-misses and events as opportunities and it acknowledges that punishment — the old-fashioned way of punishing whoever happened to be the person who committed the error, no matter what systemic problems encouraged it — can drive reporting underground. "The just culture still encourages managers to look further upstream in an organization for the origin of the error," Curtin says. "But it is not a no-blame culture, because that is not feasible or desirable. A blanket amnesty on all unsafe acts would lack credibility."

That is the key difference between a nonpunitive approach and a just culture, Amori and Curtin maintain. Employees want to know that they will not be punished for reporting an error, but they lose respect for a management style that is so reluctant to blame anyone that a reckless or willfully negligent co-worker is not held accountable. A just culture creates a line between acceptable and unacceptable behavior and draws a distinction between an honest mistake and a more willful act of disobedience, Curtin explains.

Reckless behavior is over the line

So if the basic idea of a just culture is that you encourage employees to report concerns without fear of punishment, yet you still reserve the ability to punish those who truly require discipline, how do you know where to draw the line? Amori says there are some rules of thumb to follow.

First, you don't discipline all employees who disregard safety policies or threaten patient safety. That's too broad a category without drilling down further into what prompted the employee to act that way. The just culture requires a recognition that professionals will make mistakes and that even professionals will develop unhealthy habits and standards that can threaten patient safety. "Those are the things you don't punish, but you do take the steps to correct the problems," Amori says. "But at the same time, a just culture requires a fierce intolerance for reckless conduct."

To encourage a just culture, the risk manager must distinguish between negligence and reckless behavior, Amori says. Risk management and human resources policies must make that distinction clear, she says. Be sure to include language in the policy's purpose statement that describes the organization's support of a just culture and the employee's responsibility for recognition, reporting, and participation in the improvement of patient safety related issues. The policies also should include definitions of near miss or good catch, an event or variance, sentinel event, and other possible scenarios.


For more information on adopting a just culture approach to patient safety improvement, contact:

  • Geri Amori and Margaret Curtin, The Risk Management and Patient Safety Institute, 6215 W. St. Joseph Highway, Lansing, MI 48917. Telephone: (517) 703-8464.