Hospital shows just culture can work

(Editor's note: This month's Healthcare Risk Management includes the third a three-part series on the "just-culture" approach to improving patient safety. Previous issues included stories on how the just-culture approach works, potential problems with implementing it, and tips for implementing a just culture. This month's final installment is a report on one hospital's experience in adopting a just culture.)

Adopting a "just culture" approach can be an effective way to improve patient safety in a hospital, judging from the experience of one large hospital that made the move in recent years to a just culture instead of the more common "blame-free" approach used by many health care providers.

As part of a nationwide effort by the parent company, Kaiser Foundation Hospital in San Francisco began shifting to a just culture five years ago, says Helen Archer-Dusté, RN, MSN, CHC, assistant administrator for quality at the hospital. To make the move, Kaiser established key steps to achieve each year, such as requiring in the first year that executive leaders must be trained in patient safety and just culture, then mandatory training for physician leaders and managers, and training in human factors for other leaders and staff. Part of the education process for staff was explaining the hospital's new approach to discipline for willful violation of safety procedures.

Leadership must be fully involved in introducing the just culture approach, or the effort will fail, says Linda Groah, RN, MSN, FAAN, chief operating officer of Kaiser Foundation Hospital San Francisco and recently the risk manager. She says it is not enough for leaders to merely approve the idea; they must be active participants.

"Just culture can't just be frosting on the cake," she says. "It has to be a fundamental part of who you are as a health care provider, and that can only come when the top leadership makes it so."

The just culture approach is different from the "blame-free" or "nonpunitive" philosophy in that it allows for individuals to be held personally accountable for their unsafe actions and in some cases punished. (Accountability, and even punishment, can be found in the nonpunitive approach as well, but they are more of an option under a just culture.)

Staff are aware, appreciative

Dusté says surveys have shown that staff awareness of patient safety issues have improved significantly over the past five years, and also the staff's appreciation of how important safety measures are. Groah and other senior leaders also do monthly patient safety "walk-arounds" to talk with staff about patient safety issues, and she says the staff have adopted the culture well. Most staff report that they appreciate a system that will hold someone responsible for willful violations of safety rules rather than claiming a totally blame-free culture, she says.

"When you are working hard to keep patients safe, you don't want to think that the other guy who disregards all the rules is going to be treated the same way," she says. "That's only natural."

Groah says the switch to a just culture approach was prompted by a belief that safety could be improved if people were more accountable for their actions. "If you say 'blame-free' to some people, it means no accountability, and we thought that was the wrong message," she says. "We want people to be accountable for their actions, but we're here to support them and help them do the right thing."

Paul Preston, MD, an anesthesiologist and associate chief of quality, says most health care professionals have a hard time respecting a blame-free approach.

"I don't know that anyone can really have a blame-free environment because if you don't do something you knew you absolutely had to do, there's blame there whether the organization says so or not," he says. "When I say it's our responsibility not to egregiously violate the bright-line things, everyone smiles and nods because that's what they want for themselves when they're patients."

Zero tolerance on some items

Groah gives the example of how the hospital uses a just-culture approach when enforcing the Universal Protocol that is intended to prevent wrong-site surgeries. The protocol requires a timeout to confirm identity and other details, and the anesthesiologist is primarily responsible for calling the timeout.

If the anesthesiologist does not take the lead for some reason, the circulating nurse or the surgeon must call the timeout, Groah says. Ultimately every person in the operating room is expected to speak up if the procedure is about to begin and no one has called a timeout. And once a timeout is called, it is mandatory that each person participate.

If all of the team members do not take part in this timeout or they do not implement the timeout at all, the privileges for the surgeon are suspended and the entire team is suspended. That is a tough stance, but Groah says it is consistent with the just-culture approach. Employees know that discipline is an option when their behavior is willful, she says. So far, compliance with the Universal Protocol has been consistent, and no surgical personnel have been disciplined.

"Other failures to follow safety protocols have resulted in discipline," Groah says. "It's not our desire to discipline employees for systems problems or simple mistakes, but everyone in this organization knows that discipline is an option when you willfully put patients at risk."


For more information on Kaiser Foundation Hospital's experience with a just-culture approach, contact:

  • Linda Groah, Chief Operating Officer; Helen Archer-Dusté, Assistant Administrator for Quality; Paul Preston, Associate Chief of Quality, Kaiser Foundation Hospital, 2425 Geary Blvd., San Francisco, CA 94115-3358. Telephone: (415) 202-2000.