Just culture

To create and support accountability, leaders must first clearly articulate their organization’s mission and values. Having a clear understanding of their organization’s values allows healthcare providers to embody and protect those values through their behavioural choices. Clarity on values also enables organizational leaders to coach staff towards alignment of individual behavioural choices and institutional values.

A just culture results from the consistent application of a just system of investigation and performance management in support of a set of values. It reflects what is known about system design, human free will, and human fallibility.²

In healthcare, a just culture is first and foremost a culture focused on the prevention of harm. A just culture is about relationships between team members, the creation of psychological safety, and building systems to continuously learn and improve in a supportive environment.³

Psychological safety is a shared belief that anyone on the care team can speak up and share their opinion respectfully without fear of retribution.⁴ In a psychologically safe environment, all individuals feel safe to:

• ask questions without fear of being labelled ignorant
• ask for feedback without fear of being considered incompetent
• be respectfully critical of a plan without fear of being regarded as disruptive
• offer suggestions for improvement without being branded as negative

A number of evidence-based models have been devised to explain the genesis of patient safety incidents.⁵ Many models such as those by Dekker, and Reason’s algorithm have adopted a rule-based approach to accountability after a patient safety incident (accident, in Québec), The just culture model is a values-supportive system of shared accountability where organizations are accountable for the systems they have designed and for responding to the behavioural choices of their employees in a fair and just manner. Employees (and others in the workplace, including physicians), in turn, are accountable for the quality of their behavioural choices and for reporting both patient safety incidents and system vulnerabilities.⁶

Defining organizational missions, values, and duties

A mission is an organization’s reason for being (e.g. provision of safe medical care, educating healthcare providers of tomorrow).

An organization’s vision represents the path to achieve its mission.

An organization’s values are the guiding principles that help it achieve its mission (e.g. compassion, teamwork, accountability).

Values tell healthcare providers what is important to an organization. To operationalize a vision, leaders must interpret and deconstruct it into a set of values that staff can use to guide their decisions. Whether it be to provide cost effective care, to act in the patient’s best interests, or to maximize patient turnover, clearly articulated values are the foundation on which a workplace culture is built. In short, values are a guide to expected staff behaviours. The leader/manager’s role is to ensure staff act in ways that protect and promote the organization’s values.

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In a just culture of accountability, three types of human behaviour are recognized as affecting a provider’s ability to fulfill their duties in support of their organization’s mission:

1. human error
2. at-risk behaviour
3. reckless behaviour

Leaders/managers must use appropriate interventions to promote behavioural choices that support the organization’s values.

Human error

Human error is an unintended action which is, by definition, inevitable and unintentional. Consequently, the appropriate response from leaders when human errors occur is to recognize and learn from the episode and to console the healthcare provider who made the mistake. The organization then has a responsibility to identify how it may improve the systems in place in order to reduce the risk of unintentional human error.

At-risk behaviour

Healthcare providers typically receive training on their organization’s rules and procedures. But over time, as they acquire competence and learn to cope with increasing demands and pressures of clinical practice, individuals inevitably develop shortcuts, workarounds, and heuristics.⁷ Thus, the provider drifts from accepted behaviours into more dangerous patterns of behaviour that they may regard as being more efficient, but still within the spectrum of what may be considered safe. Behavioural drift is a normal aspect of human behaviour. It is an unconscious choice to deviate from training, policies, and rules stemming from:

• a lack of perception of risk
• a mistaken belief that the risk is insignificant or justifiable
• competing priorities that motivate modified behaviour

As providers become more comfortable with their work, drift is further reinforced by the fact that any resulting harm is relatively rare, thus obscuring the link between drift and potential harm.

The impact of drift or normalization of deviance in healthcare

Deviating or drifting away from recognized standards of practice for patient care can become normalized or routine over time. Some common examples include:

• not washing or sanitizing hands every time before and after examining patients
• not gowning with the appropriate infection control measures
• not using two-step patient identification before administering medication
• not using two-step identification of ambulatory clinic patients
• ignoring or turning off alerts in an electronic medical record (EMR)

Drift is considered to be at-risk behaviour. Within a culture of accountability, it is generally recognized that behavioural drift is the single greatest threat to patient safety, owing to its unconscious nature and to its pervasiveness in everyday practice.

For healthcare leaders who have identified occasional, at-risk behaviour, an appropriate intervention is to coach the healthcare provider back toward safe practice. Coaching is a values-supportive positive discussion that may include:

• pointing out the drift
• reminding the provider of the risks
• clarifying how the drift is not aligned with the organization’s values
• redirecting the provider’s choices toward accepted policies and procedures that are aligned with the organization’s values

Repeated at-risk behaviour can be managed by evaluating performance-shaping factors at both the provider and system levels.

One of the biggest challenges in managing at-risk behaviour occurs when drift is identified, but no patient safety incident or near miss has resulted. To not coach the behaviour in such instances would represent a missed opportunity for learning that can ultimately imperil the establishment of a culture of accountability by tacitly reinforcing drift. Leaders/managers should instead strive to coach as many episodes of drift as reasonably possible, whether or not these incidents result in adverse outcomes.

The management of at-risk behaviour should include a search for factors that contributed to shaping the provider’s at-risk behaviour:

1. system performance shaping factors
   These include issues like competing values (e.g. timeliness versus safety), lack of appropriate equipment or supplies, ineffective orientation, or training and team culture.
2. provider performance modifying factors
   These include issues such as hunger, fatigue, illness, stress, or anxiety.

Coaching brings value by enabling the reframing of the risk, and addressing the modifiable system and performance shaping factors. Disciplining at-risk behaviour may create a disincentive to self-reporting of patient safety incidents, near-misses or flaws in the system; and will inhibit cross-monitoring and team psychological safety. Disciplinary action may be appropriate when repeated at-risk behaviour is evident, despite coaching and efforts to address the personal and system contributing factors.⁸

Reckless behaviour

Reckless behaviour represents intentional risk-taking. It is a conscious decision to act without regard to a known, substantial, and unjustifiable risk. While often egregious, this type of behaviour is rare.

Generally, the appropriate management response to confirmed reckless behaviour is to take disciplinary action with the individual care provider.

Before determining a course of action, leaders should first consider all the facts and circumstances of the case. Factors such as insight, cooperation, and commitment to change are often relevant to the severity of the chosen intervention, There may be situations where the social benefit of a conscious choice to deviate from a policy would justify an otherwise reckless behaviour. The correct response in such cases is not to punish or discipline, but rather to support the provider’s choice to deviate from a policy in the moment.

Addressing recurring undesirable behaviours

When an individual repeatedly makes errors or exhibits recurring at-risk or reckless behaviours, these may be symptoms of broader system or provider issues. Leaders in these circumstances may want to identify and help address these performance-shaping factors that may be compromising the delivery of safe medical care.

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Biases challenge the creation and maintenance of a just culture of accountability.

• severity bias
• hindsight bias
• confirmation bias
• fundamental attribution error
• self-serving bias

Severity bias: overreacting to singular events and underreacting to risk.⁹ It occurs when an organization reacts to a harmful outcome by punishing the person involved, yet ignoring the same behaviour when the outcomes are good. Severity bias is difficult to avoid because we are taught to believe a stronger punishment is warranted if there is a poor outcome. However when we espouse a “no harm, no foul approach,” we let risky behaviour continue unchecked. If we only punish when there is a poor outcome, we may punish someone who doesn’t deserve to be punished.

Hindsight bias: knowing the outcome significantly affects our perception of an event. Hindsight is 20/20. Knowing an undesirable and unexpected clinical outcome has occurred increases the belief that it was predictable, therefore preventable and related to carelessness or poor clinical care. The red flags in the clinical decision-making appear more obvious to others after the outcome is known.

Confirmation bias: the tendency to interpret new evidence as confirmation of one’s existing beliefs or theories.

Fundamental attribution error: tending to interpret the actions and behaviours of others based on their characteristics and personality (e.g. laziness, lacking in clinical knowledge), but explaining our own actions and behaviours based on situational factors (e.g. interrupted, too busy). In a just culture, the reasons for clinical outcomes and events are not prejudged, and any rush to blame individuals is avoided.

Self-serving bias: seeing our successes as a result of our own strengths or personal factors, but denying responsibility for our failures, attributing such failures to situational factors beyond our control.

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A just culture of accountability seizes opportunities for learning from undesirable behaviours and system flaws. When leaders and health providers identify the causes of human error, at-risk, and reckless behavioural choices, then use appropriate system and performance enhancing interventions and modify processes as needed, it can result in strengthening the organization’s learning system, more engaged team members, and a more reliable healthcare system that supports safe medical care.

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