What Is Just Culture

What Is Just Culture? Changing the way we think about errors to improve patient safety and staff satisfaction

Organizations are held accountable for the processes they have developed as well as for responding to the actions of their workers in a fair and just way, which is referred to as a “Just Culture.” Employers hold their employees accountable for the quality of their selections, as well as for reporting faults and weaknesses in the system. In the case of Brigham and Women’s Faulkner Hospital, leadership is dedicated to cultivating a Just Culture in which patient safety is enhanced and our employees feel more confident in the decisions they are making.

Peggy Duggan, states, “We know that providing a secure and open atmosphere encourages the reporting of mistakes and dangers, which ultimately enhances the care we deliver to our patients.” However, according to the findings of our latest Safety Culture Survey, personnel at BWFH do not always feel comfortable speaking up when they witness anything that concerns patient safety and/or when they feel blamed when errors occur when they work in the hospital.

According to Dr.

“We’re working on putting up an infrastructure to support this technique,” said the Director of Risk Management and Compliance of the company.

  • This is going to be a long process.
  • Our just culture advisory group and advisors will be formed in the near future.
  • So far, managers and supervisors have been asked to take part in the workshops.
  • As we learn to look at our job through a different lens, it becomes simpler and less difficult to do over time.
  • “Working in a Just Culture provides you with greater confidence in the judgments you make.
  • “For frontline employees, it boils down to more confidence in reporting and greater candor when it comes to mistakes.” Implementing Just Culture requires a shift in the way we think about our organizations, our processes, and our people.
  • LeSage, on the other hand, feels that BWFH will be successful.
  • As a result, I believe you are poised and ready,” he states.

Because of BWFH’s size, as a relatively small community hospital, it is in a unique position to complete the project more quickly than a truly large organization would. Staff members can find resources on our intranetBWFHconnect by visiting the Just Culture page.

Just culture – Wikipedia

When it comes to systems thinking, the notion of just culture is a concept that highlights that mistakes are often a consequence of defective organizational cultures rather than being primarily the responsibility of the individual or individuals directly involved. After an incident occurs in a just society, the inquiry posed is “What went wrong?” rather than “Who was responsible for the occurrence?” A fair society is diametrically opposed to a blame culture. Rather than being synonymous with no-blame cultures, a fair culture is defined as one in which individuals are held accountable for their purposeful misbehavior or gross carelessness.

  1. Alternatively, in a “blame culture,” individual employees are dismissed, penalized or otherwise punished for making mistakes, but the underlying reasons of the problem are not identified and rectified.
  2. Rather than injury, discipline in a just culture is tied to incorrect behavior rather than harming others.
  3. Honest human blunders are viewed as a learning opportunity for the company and its personnel in this method.
  4. Willful misbehavior, on the other hand, may result in disciplinary action, such as termination of employment, even if no harm has been done to the company.
  5. A fair culture was first articulated explicitly in James Reason’s 1997 book, Managing the Risks of Organizational Accidents, which was the first book to do so.
  6. It is necessary to create a fair culture in order to foster trust, which will allow for the development of a reporting culture.
  7. When David Marx published his 2001 paper, Patient Safety and the “Just Culture”: A Primer for Health Care Executives, he furthered the use of the notion of just culture in healthcare.


  1. Maurizio AbCatino is the author of this work (March 2008). “A Review of the Literature: Individual Blame vs. Organizational Function Logics in Accident Analysis” is a paper published in the journal Accident Analysis. Reason, James. “Journal of Contingencies and Crisis Management(Review).16(1): 53–62.” doi: 10.1111/j.1468-5973.2008.00533.x.S2CID56379831″ (1997). Preventing and Managing the Risks of Organizational Mishaps It is published by Ashgate Publishing under the ISBN 9781840141054. N. Khatri (October–December 2009). “In health care, we’ve gone from a blame culture to a fair society.” Health Care Management Review. Health Care Manage Rev.34(4): 312–22.doi: 10.1097/HMR.0b013e3181a3b709.PMID19858916.S2CID44623708
  2. Health Care Management Review. Health Care Manage Rev.34(4): 312–22.doi: 10.1097/HMR.0b013e3181a3b709. Just Culture essentials for the Emergency Medical Services (EMS), by Brian Behn, published on January 29, 2018. EMS Management Association of the United States
  3. “Just Culture System and Behaviors Response Guide” is an acronym for “Just Culture System and Behaviors Response Guide” (PDF). August 9, 2017, Los Angeles County Department of Mental Health
  4. J. Groeneweg’s “The Long and Winding Road to a Just Culture” was published in 2018. SPE stands for the Society of Petroleum Engineers. Harvey, H. Benjamin, and others (June 17, 2017). “The Framework for a Just Culture.” It is published in Journal of the American College of Radiology. Boysen, Philip A., ed (Fall 2013). Just Culture: A Foundation for Balanced Accountability and Patient Safety” is the title of this publication. The Ochsner Journal, vol. 13, no. 3, pp. 400–406, PMC3776518, PMID24052772
  5. Working Group E, Flight Operations/ATC Operations Safety Information Sharing, has been established (September 2004). A Roadmap to a Just Culture: Improving the Safety Environment is the title of this article (PDF). Aviation Information Network of the World (Global Aviation Information Network)
  6. Finding the correct balance between the aviation, legal, and political authorities is the goal of “Just Culture.” EUROCONTROL. retrieved on June 28th, 2019
  7. Sidney Dekker is a writer who lives in New York City (January 1, 2018). Just Culture: Striking a balance between safety and accountability It is published by Ashgate Publishing under the ISBN 9780754672678. David Marx’s etymology is Marxism (April 17, 2001). Patients’ Safety and the “Just Culture”: A Primer for Health Care Executives” (PDF)
  8. “Patient Safety and the “Just Culture”: A Primer for Health Care Executives”

Basic Concepts of a Just Culture

Federation Forum Magazine published an original version of this article in their Winter 2009 issue. When we talk about just culture, we’re talking about the process, the notion, of seeking to control human fallibility through system design and behavioral choices that we make inside our organizations. Just culture has been proven to be effective in a variety of different companies. One airline decreased its maintenance faults by half, and another airline reduced its ground damage by half, according to a study.

  1. It was one of the outcomes of the Medical Malpractice Insurance Company in Minnesota’s just culture implementation that one of the company’s employees recognized he or she could admit to a mistake and have the entire company profit from it.
  2. As a result, when someone does make a mistake, we are unable to learn from it because we lack the necessary skills.
  3. In accordance with the Federal Aviation Requirements – laws that guide all pilots and mechanics – no one should operate an aircraft in a negligent or irresponsible manner in order to risk the lives or property of another.
  4. The National Transportation Safety Board (NTSB), the aviation industry’s regulating body, describes it as the most fundamental kind of simple human mistake or omission.
  5. Will you raise your hand when you make a mistake if we tell you that you are not allowed to make a mistake and that we will hold you accountable for your mistakes and penalize you for doing so?
  6. That will not help to develop the culture of learning in any way.
  7. That does not rule out the possibility of holding individuals responsible for their actions.

Someone for making a mistake may not be the most effective strategy to help them learn from that error if they are being punished for it.

The importance of hand hygiene compliance cannot be overstated.

Nurses and physicians would be in high demand, and there would very likely be a scarcity of nurses and doctors!

Discover and penalize the individual who committed the error and you will have resolved the issue.

Problems will persist if people are not changed in conjunction with systemic changes.

Just culture is an attempt to determine the most efficient method of holding both individuals and institutions accountable.

No matter what happens, it’s going to be a disaster.

People do not go to work with the intent of doing a poor job or causing a negative incident to take place.

There are some things that we, as managers, executives, and regulators, have power over.

We must strike a balance between our input and output, and determine how we may be more proactive.

It is critical to investigate those events that were missed and to consider the system design and behavioral decisions that were made as a result.

To make a mistake is human.

We’re all going to make errors.

We veer between 9 and 3 a.m.

My wife is eight years old and wears cosmetics.

That’s a bit of a tangent.

and coffee as I do at 10 a.m.

However, in a blizzard, I am not up at eight o’clock and drinking coffee.

with the radio turned off and no distractions since I’m aware of the dangers.

Risk may be found everywhere.

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Physical treatment carries a certain amount of danger.

I believe this to be the case.

Is it really worth it?

When we manage and support our values, many of the things we do in healthcare can be incredibly hazardous, but they are well worth the risk when we manage and support our values.

It’s a gamble that we confront on a regular basis in the healthcare industry.

Safety is only one of the things that we hold dear.

As the CEO of a hospital system, you have limited resources, which means you must make choices on a regular basis.

No, there are other considerations to consider, such as privacy and comfort.

Human mistake, high-risk activity, and irresponsibility are all things for which we are all responsible. That is what makes a fair culture successful in the first place. Everyone, from the CEO on down, can see that we are all working together to promote these principles.


The design of the system is one of the things that we have influence over. Our system reliability may be managed by identifying and analyzing the factors that impact our system’s dependability or its rate of error. One of these areas is human factor design. For example, the usage of red and green lights on a car dashboard is the outcome of a long-ago military research on human behavior and perception. Because certain hues are easier to see in low light, they lower the danger factor for humans.

  • Five registered nurses worked together in Minneapolis to administer an adult dosage of a medicine to preterm newborns.
  • What caused them to make such a blunder?
  • The drug was in the same location as it had always been, and it was labeled with the same orange labels that it had always been labeled with The nurses, on the other hand, engaged in high-risk activity and failed to read the label.
  • However, they were unaware that the manufacturer had altered the color of the adult dosage prepackage and the infant dose prepackage, so that the items seemed to be the same.
  • The hospital replied by no longer administering a prepackaged dose but instead performing calculations, and two nurses are now required to check the calculations prior to administering the drug to patients.
  • In order to manage human dependability, one must look at the rate of human error within the operation, as well as skill and knowledge, perception of risk, and credentials of employees.
  • Are they only book smart, or can they put what they’ve learned into practice?


There are three types of behaviors: human mistake, at-risk conduct, and irresponsible activity.

Human error is when the mistake was not intended.

Keeping employees aware, teaching them on at-risk behaviors, holding individuals accountable, and taking disciplinary action against those who engage in risky conduct are all ways we may address these issues.


Events investigations are merely tools that assist us in discovering the truth about what occurred. Normally, this comprises a technique to identify why it happened, what caused it, what the reasons were, and what our system design was in effect at the time of the incident. Your inquiry will gain greater worth as a result of the questions you are asking. Identify and explain every human error, as well as at-risk behavior and procedural deviation. You may also discover the cause-and-effect link.

  • Create a risk model of your own.
  • Simply said, culture is a journey.
  • You evaluate your outcome, you evaluate your system, you evaluate your decisions, you evaluate your negative consequences, and you attempt to make adjustments.
  • In just culture, this is the most important instrument.
  • It is a collaborative effort with the regulatory agency, and it is about doing the right thing.

Work on human engineering design requirements and risk modeling for the NASA constellation project have been among John’s most recent responsibilities at NASA. His work in healthcare has focused on cultural implementation for healthcare systems and risk assessment, to name a few areas of expertise.

Just Culture and Its Critical Link to Patient Safety (Part I)

Believe your organization runs inside a Just Culture, or do you believe otherwise? In the course of our collaborative efforts with healthcare organizations and experts in pursuit of our common aim of minimizing drug mistakes, we have asked ourselves this question several times. Answering this issue is not straightforward, and it is mostly designed to stimulate fruitful discussion on the subject. Despite this, we frequently obtain fast affirmative replies, particularly from organizational executives, telling us that the organization has, in fact, built a Just Culture, despite the fact that our firsthand observations contradict such assurances.

Several components of an organization’s values, justice (equity to the workforce), and safety, as well as the design of safe systems and the establishment of a reporting and learning environment, are frequently examined in order to determine how far along the organization is on its journey toward a Just Culture.

Despite the fact that they are neither exhaustive or adequate in and of themselves to presuppose a Just Culture, the questions that follow might assist you in assessing your progress on this path.

Table 1 shows some of the findings from the AHRQ Hospital Culture Survey Report from 2012.

Organizational Values

What are the fundamental and secondary values held by the organization? The core (high) and secondary values of a company working under a Just Culture have been developed in order to guarantee that employees understand how to prioritize their job assignments. Safety should always take precedence over all other considerations. Values such as efficiency and productivity should be regarded as secondary considerations. Overzealous dedication to these and other secondary values can endanger worker safety and cause confusion, particularly if workers are not given clear instructions on which value takes precedence.

  1. Despite this, 26 percent of respondents from hospitals that took part in the AHRQ culture study stated that as pressure mounts, management want staff to work quicker, even if it means using shortcuts to accomplish their goals.
  2. Do managers’ actions and attitudes suggest that safety is a major (and high) priority?
  3. The open discussion of safety as a high value, as well as watching leaders and managers act in a manner that displays that safety comes first, promotes and supports staff decisions to do the same thing.
  4. Behaviors that communicate conflicting messages (e.g., safety against productivity) cause confusion and encourage people to engage in risky conduct.
  5. Patient safety has been elevated to the top of the priority list for many healthcare institutions, and it is deserving of their full focus right now.

Patient safety should be a long-term main value associated with every healthcare goal, rather than a secondary value that can be reordered in response to competing demands or other factors.

Justice and Safety

What actions does the company take in the event of a human error, at-risk conduct, or recklessness? Human error, at-risk behavior, and reckless conduct are the three categories of behavior that should be anticipated in an organization: human error, at-risk behavior, and reckless behavior. Because each form of conduct has a distinct source, each sort of response is distinct as well. Human error is defined as unplanned and unexpected conduct that results in or has the potential to result in an unfavorable consequence; it is not a decision on our part; we do not choose to create mistakes.

  • Due to the fact that the employee did not plan to engage in the behavior or to experience any negative consequences as a result, discipline is neither justified nor helpful.
  • Unfortunately, the AHRQ survey results reveal a different reality in many hospitals, as revealed by the results of the study.
  • In contrast to human mistakes, at-risk actions are distinct from them.
  • What is essential to us is often determined by the immediate desired outcomes, rather than by long-term or unknowable repercussions.

These potentially dangerous habits, which are frequently the standard among groups, are referred to be “the way we do things around here.” A Just Culture does not punish people who participate in at-risk activities; rather, it seeks to find and fix the system-based causes of their behavior while simultaneously decreasing staff tolerance for taking risks through coaching.

  1. They act on purpose and are unable to provide an explanation for their actions (i.e., do not mistakenly believe the risk is justified).
  2. The action reflects an intentional decision to disregard what they are well aware is a significant and unacceptable danger to their safety.
  3. Therefore, it should be dealt with in accordance with the organization’s human resources rules, either through remedial or disciplinary measures.
  4. The individual accountabilities of all employees in organizations that operate under a Just Culture have been developed and communicated to ensure that all employees understand what is expected of them.
  5. They are responsible for making safe behavioral choices and making judgments that promote safety in their environments.
  6. Identifying and managing everyday risks as well as coaching individuals who are engaging in at-risk behaviors are additional responsibilities for managers and administrators.
  7. In a Just Culture, all employees are aware that safety is a top priority in the firm, and they are always on the lookout for dangers that might pose a threat.
  8. When analyzing risk and mistakes, can the potential or actual severity of a consequence have a part in how personnel are handled in terms of how they are treated?
  9. In lieu of this, employees are evaluated based on the quality of their behavioral choices rather than the consequence or possible outcome of an incident or mistake.

If an error occurs, employees should be confident that they will be treated fairly when they disclose their errors, and that they will be held accountable for the quality of their choices rather than merely the consequence of their decisions.

Management of At-Risk Behaviors

Is the culture of the organization tolerant of at-risk behaviors? Human behavior is incompatible with safety because the benefits for taking risks are frequently immediate and positive (e.g., time saved), but the punishment (e.g., patient injury) is frequently delayed and distant. Therefore, even the most trained and cautious healthcare worker will learn to master potentially hazardous shortcuts, particularly when confronted with an unexpected system failure or emergency (e.g., technology glitches, time urgency).

  1. When these procedures are carried out over time, the risk connected with them diminishes, and the entire culture grows more tolerant of these dangers.
  2. Before placing prescription orders, you will no longer be able to review the patient’s complete drug profile, allergies, and weight.
  3. It is possible that as an experienced nurse, you would assume it is okay to keep unlawful stockpiles of pharmaceuticals on your unit, make IV admixtures rather than waiting for pharmacy to dispense them, and deliver medications to patients before pharmacy has evaluated the order.
  4. If you are only providing aprnmedication to the patient, you are no longer permitted to carry the patient’s medicine administration record to the bedside.
  5. Is there a tendency for the organization to penalise safe conduct while rewarding at-risk activity?
  6. Taking medication administration as an example, a nurse who takes longer to provide prescriptions may be criticized, even if the additional time may be ascribed to safe practice habits or patient education.
  7. Pharmacists who administer “missing” medications swiftly are more likely to receive positive reinforcement from the awaiting nurse than pharmacists who fully examine the basis for a request, causing the missing drug to be delayed in its delivery to the patient.
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These and many more shortcuts might even be considered efficient behavior, which is something that is not always the case.

It is difficult to modify habits because of the diminished perception of danger, the regular nature of the activities, and upside-down rewards that discourage safe actions while encouraging risky at-risk behaviors.

If coaching is being used to address at-risk behaviors, is there any apparent evidence of this?

Coaching is the process of assisting someone in seeing a danger that has previously gone unnoticed or has been misinterpreted as trivial or reasonable.

While “counseling,” as defined by the American Psychological Association, is often a boss-to-worker dialogue that includes notifying employees of prospective disciplinary action, coaching includes manager-to-staff, peer-to-peer, and staff-to-manager coaching.

However, according to the results of the AHRQ culture study, just about half of respondents feel free to criticize the decisions or actions of people in positions of more responsibility, and 37 percent said they are scared to speak out when something doesn’t seem right.

Part II

In one of our newsletters in June 2012, we will discuss the components of a Just Culture that are linked with system design, as well as the establishment of a reporting and learning environment. With the questions posed above and those in Part II, we hope that businesses would take a close look at their own organizational cultures and how they relate to what we call a “Just Culture” or “Just Culture-like environment.” It is far more than a fashionable metaphor for what was previously referred to as “non-punitive” or “blame-free” culture.

It is a comprehensive collection of principles, attitudes, and activities that give strong direction on how an organization may manage safety to the greatest extent possible.

(117-L05, 118-L05).

Just Culture in Healthcare

The question is, who is to blame when a therapeutic mistake occurs at the hospital or in an ambulance. When anything goes wrong in the healthcare setting, healthcare organizations, the legal system, and patients have typically held the caregiver liable. The premise is that the individual who has been taught and licensed to give care is ultimately accountable for the quality of care that is provided to the patient or client. Getty Images TEK IMAGE / TEK IMAGE When considered as a group, healthcare practitioners are inclined to agree with this idea.

This is not exclusive to the healthcare industry.

Pilots, for example, have extremely limited margin for mistake, as do soldiers, firemen, architects, police officers, and a slew of other professions and occupations.

What Is Just Culture?

Despite the expectation of perfection, it is a well-known reality that humans are prone to making mistakes. Anyone who has ever misplaced their vehicle keys or failed to include a paragraph in a mid-term essay can attest to the reality that mistakes happen no matter how much knowledge we have or how routine the activity is may attest to this. Everyone makes mistakes from time to time, but the repercussions of making a mistake may be devastating in some instances. There has to be a method to decrease and mitigate errors for people whose acts have such a great weight tied to them.


Instead of blame, the just culture approach suggests that errors should be treated as inevitable. There’s no way to make humans infallible. Instead, known failure points can be identified and processes can be engineered to help avoid those mistakes in the future. It’s called just culture as opposed to a culture of blame. It’s a change of how errors are perceived and acted upon by an organization. When an organization embraces a just culture, it is more likely to have fewer adverse incidents and caregivers in that organization are more likely to self-report errors or near misses.

Just culture treats errors as failures in the system rather than personal failures.

This idea is used every day in many areas.

For example, gas station nozzles and hoses have been ripped off because drivers forget to take them out of the tank filler opening. To combat this extremely expensive error, modern nozzles have a breakaway coupler that allows them to be pulled off of the hose without damaging the nozzle or the pump.


A fair culture is designed to prevent unfavorable patient outcomes by eliminating mistakes, although the term “just culture” is inadequate for describing the notion. It has been suggested that, because this concept is referred regarded as “just culture,” there is a tendency to focus solely on addressing persons who make mistakes in a fair and just manner, rather to concentrating on the system or the environment in which the mistake was produced. The majority of the time, there are contributing elements that can be recognized and, in some circumstances, eliminated.

  1. During a seizure, a paramedicis sedates a patient using sedatives.
  2. Inability to awaken the patient, the paramedic must administer rescue breaths to the patient throughout the remainder of the journey to the hospital.
  3. When a medication error occurs during an ambulance transfer, it is tempting to place the blame on the caregiver who made the mistake.
  4. Because there is no disciplinary action taken against the caregiver, the administration may view this method to be reasonable and an example of just culture.
  5. Then, what would be the underlying reason for anybody else in the organization to make the same type of drug error?

System vs. Individual Focus

The administrators want to limit the chance of a similar drug mistake occurring again in the future by implementing these measures. When reviewing a system, there are more options for improvement than when evaluating a person. In the instance of a medication error caused by administering the incorrect concentration of medication, standardizing all ambulances in the system to carry only one concentration of that medication will prevent any paramedic from making the same mistake in the future. Retraining merely the paramedic who made the mistake, on the other hand, simply reduces the likelihood of another caregiver making the same mistake.

Instead of publishing memoranda or regulations, giving training, or instituting discipline, leaders might ask themselves how they can support the behavior they desire without resorting to these methods.

In a robust just culture context, system design is centered on preventing mistakes from occurring in the first place. Not only should there be a response to problems as soon as they occur, but it is also critical to be proactive in preventing future occurrences.


You might be wondering when, if at all, the individual will be held responsible for his or her acts in this case. In a just culture, the person is held accountable not for faults in and of themselves, but for the choices they make. Take, for example, the paramedic who made the medicine error in our previous scenario. Were we ever going to hold him responsible for the overdose? Both yes and no. First and foremost, we would continue to repair the system flaws that created the chance for mistake.

  • However, it’s critical to consider all of the elements that might have played a role in the paramedic’s miscalculation.
  • Is it possible that he arrived at work exhausted?
  • All of these elements might have played a role in the error, and they are all decisions that the paramedic would have to make on the basis of their experience.
  • He’ll be able to tell if he didn’t get enough sleep before his shift started.

Outcome Bias

An incredibly crucial point to remember regarding accountability is that the outcome is irrelevant. It is not appropriate to hold a paramedic to a higher standard than he would be held to if the patient survived if the larger concentration of drugs was administered by mistake. In real-world scenarios, it is extremely difficult for regulators and administrators to overcome outcome bias. When reviewing instances, it’s highly probable that the patient’s health was what prompted the investigation in the first place.

  • It’s quite simple to slip into the trap of “no damage, no foul,” which means “no consequences.” However, if the goal of just culture is to reduce the number of episodes that might result in negative results, the outcome of any particular event should not be taken into consideration.
  • During an emergency room resuscitation, a respiratory therapist neglected to attach a sensor to the patient’s endotracheal tube, and the patient’s oxygen supply was interrupted.
  • She expresses gratitude to the nurse and connects the sensor, which alerts the rest of the team that the patient is not getting enough oxygen.
  • No one gives it a second thought because the patient turns out to be alright.
  • As an illustration of result bias, consider the following: The inaccuracy is the same in both versions, yet one is seen as a little blip on the radar while the other is regarded as a serious occurrence deserving of further investigation.
  • The objective of all caretakers would be to figure out how it is possible for the sensor to be accidentally turned off.
  • Perhaps the business would develop a checklist approach to assist identify faults that are readily ignored, such as this one.

Contributing behavioral decisions, on the other hand, would be taken into consideration. This may include holding the respiratory therapist accountable if she showed up to work weary or inebriated, for example.

Developing a Just Culture

When you hear the phrase “just culture,” what is the first thing that springs to mind? As an example, consider the following dilemmas:

  • Two nurses make the mistake of selecting the incorrect medicine from the dispensing device. One dosage is administered to a patient, causing him to fall into shock, while the other is intercepted at the patient’s bedside before it can do any harm. Do we treat these nurses in the same way that we treat our patients? A nurse loses control of a specimen that has not yet been tagged, but she chooses not to report the occurrence for fear of disciplinary action. Given the nurse’s apprehension, do we pardon the infraction? An complete surgical team argues disregarding the presurgical pause on the grounds that there was no adverse occurrence during the procedure. Do we condone this abuse of human rights?
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In this section, we will discuss a few examples of difficulties that may be handled using the idea of a just culture. Just culture refers to a form of shared accountability that is based on shared ideals. It is a culture that holds companies accountable for the processes they develop as well as for how they respond to employee actions in a fair and just manner, among other things. Additionally, employees are responsible for the quality of their decisions as well as for reporting both their own faults and system vulnerabilities to the appropriate authorities (Griffith, 2009).

The recognition that many individual or active mistakes are the result of predictable interactions between human operators and the system in which they operate is also part of a just society.


These are as follows:

  • We must shift away from viewing mistakes as individual failures and instead recognize that they are the result of system problems. A transition from a punishing atmosphere to a fair culture is required. We must make the transition from secrecy to transparency. Health care must shift from being provider-centered (i.e., doctor-centered) to being patient-focused. We must shift our care delivery models away from relying on autonomous, individual performance excellence and toward interdependent, collaborative, interprofessional cooperation instead. Accountability must be widespread and reciprocal, rather than imposed from the top.

Accidents occur as a result of mistakes made by individuals. Accidents result in the death of people. The conventional response is to point the finger at the individuals involved. But, if we track out the perpetrators of the errors and penalize them, are we actually correcting the problem? No. The problem is almost never the fault of a single individual; rather, it is the fault of the system as a whole. People must be changed, but the system must also be changed, or the issues will persist. How can we make systemic changes that will encourage people to disclose errors and learn from their missteps in the future?

Individually responsible practitioners should not be held liable for system failures over which they have no influence.

Rather than being problems to be rectified, events are opportunities to get a better knowledge of the system.

It is necessary to have an administration that supports the ideals of a fair culture and encourages employees to bring faults to their attention.

Highly dependable industries encourage its employees to be conscious of their surroundings. As stated by Weick and Sutcliffe (2001), mindfulness is comprised of the following 5 elements or components:

  • Even in the most successful enterprises, there is a persistent worry about the risk of failure. Respect for expertise, regardless of one’s position or standing
  • It is a dedication to resilience that allows you to adjust when the unexpected happens. The capacity to concentrate on a single activity while maintaining a sense of the larger picture (operational sensitivity)
  • The capacity to adjust and flatten hierarchy according to the needs of the scenario

Health groups are now drafting and advocating policies and papers that are solely focused on culture. The Joint Commission leadership standards (Schyve, 2009) address issues of leadership and safety that are special to the organization’s governing body and its members (the CEO and senior management and medical and clinical staff leaders). Instituting an organizationwide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where everyone feels comfortable discussing real and potential organizational vulnerabilities and supporting one another in an effort to report vulnerabilities and failures without fear of retaliation, according to the Joint Commission (formerly JCAHO).

Just/Accountable Culture

The question is, how do healthcare practitioners create a culture that supports open reporting of adverse occurrences and potentially dangerous circumstances while also holding people and organizations accountable in a fair and equitable manner? As a result, Just Culture reshapes our perspectives on responsibility, systemic role, and the role of human conduct. A framework for consistent management of operational systems and behaviors is provided by this document. The Department of Public Safety (DPS) supports culture improvement.

  • A culture of accountability encourages open reporting of faults in a non-punitive atmosphere (a “just” culture), which results in higher improvements in patient safety as a result.
  • We give teaching and coaching to ensure that it is used effectively throughout the continuum of care, as needed.
  • CPS assists in the implementation and long-term viability of programs.
  • CPS may assist you in achieving a successful and efficient deployment that is structured to work in your specific situation.
  • The CPS will:
  • Patient safety culture survey assessments to identify strengths and opportunities
  • Tracking improvement over time
  • Onsite identification and consultation support to determine your unique needs
  • Assistance in developing a realistic timeline for the implementation of Just/Accountable Culture at your organization
  • Ongoing virtual and onsite implementation and sustainability support for six months, a year, or longer

Every business is unique, but the fees of consulting and training are reasonable and tailored to meet your specific requirements. The success of now, tomorrow, and in the future is important to us! To receive more information on our implementation and sustainability program, please fill out the form at the bottom of this page, or email Kathy Wire at [email protected]. Download our summary of the Just Culture development process for a high-level understanding of the process.

The Department of Public Safety (CPS) provides Just/Accountable Culture Training. Are you merely interested in training, or would you want to take a refresher course? The training we provide may be tailored to complement your internal efforts. The CPS provides the following services:

  • First Steps Toward a Just and Accountable Culture: Would you and/or your team be interested in a general introduction of Just Culture? This is given in a succinct and instructive webinar style
  • Nonetheless, Manager Training in a Just and Accountable Culture: This one-day session will offer you with the hands-on training, skills, and resources you need to successfully adopt Just Culture in your workplace. It is possible for an organization to designate one or more persons to serve as program Champions. There is a 20-person minimum class size requirement, and the course can be given to an entire company or to a group of persons from various organizations within a similar geographic vicinity. This class will be scheduled according to demand
  • Culture of Justice and Accountability Re-educate yourself: Is your prior implementation at a standstill, or do you require assistance in reinvigorating a previous deployment? We may create a tailored approach depending on your specific requirements. This begins with a phone conversation and the formulation of a strategy that is tailored to your organization’s unique needs.

To receive more information on our implementation and sustainability program, please fill out the form at the bottom of this page or contact Kathy Wire at.Resources

  • See whether you qualify for Outcome Engenuity’s Just Culture online certification or if there are any forthcoming training opportunities. Changing Leadership Perceptions of Patient Safety Through Just Culture Training Written by: Scott Griffith, MS
  • Becky Miller, MHA, CPHQ, FACHE
  • Jill Scott-Cawiezell, PhD, RN, FAAN
  • And Amy Vogelsmeier, PhD, RN, BC-GCNS | October-December 2010, Volume 25, Issue 4, p288-294 | Journal of Nursing Care Quality
  • A Statewide Approach to a Just Culture for Patient Safety: The Missouri Story Writing for the Journal of Nursing Regulation
  • Walking the Tightrope of Punitive/Blame-Free Practice by Becky Miller, MHA, CPHQ, FACHE and Amy Vogelsmeier, PhD, RN, BC-GCNS By: Becky Miller, MHA, CPHQ, FACHE, Executive Director, Missouri Center for Patient Safety
  • Revee Booth, BJ, Communication Specialist, Primaris | Spring 2008 | Missouri Primary Physician
  • NAEMT Position Statement: Just Culture in EMS
  • National EMS Culture of Safety
  • “A Just Culture for EMS can improve safety”
  • Safety Culture in EMS
  • By: Becky Miller, MHA, CPHQ, FACHE, Executive Director, Missouri Center for Patient Safety
  • By Allison J. Bloom, Esq. | September 9, 2009 | EMS Insider | JEMS.com
  • By: Allison J. Bloom, Esq.

Fill out the form on the right to learn more about our consultation services or to organize a training session. We’ll create a strategy that is tailored to your company’s needs and goals.

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