Strategies for Moving to a Fair and Just Culture

Complex systems, such as hospitals, are inherently unsafe and culture is the key to getting and keeping patients safer. A Just Culture is defined as an environment of trust and fairness where it is safe to report and learn from mistakes and system flaws. It is where we are clear about the difference between human error in complex systems and intentional unsafe acts.

A Fair and Just Culture is where reporting and learning are valued, people are encouraged and rewarded for providing essential safety-related information and leaders and human resource systems assure we achieve it.

Lessons for Leaders

Know who is accountable and in what respect. Employees, leaders including human resource leaders and physicians are accountable for a creating a Fair and Just Culture.

Employees are accountable to act in ways that avoids harm to patients; to report critical events and good catches-our own our others; to identify and stop unsafe systems or accidents waiting to happen; and to participate fully when adverse events happen to learn what went wrong and how to prevent in the future.

Leaders are accountable to be a role model for all employee accountabilities by holding themselves to the same standards; to promote a fair and just culture; to assure respectful behavior for all; to set high performance standards, enable employees to achieve the standards, and coach employees to improve performance; and to provide equipment and resources so that each person can work safely and reliably.

In addition, leaders are accountable to develop teamwork skills; to note when behaviors drift from safe to at-risk; to actively seek and listen to employee’s concerns with unsafe systems that may harm patients or staff; to take action to address the concerns; to develop reliable systems in partnership with staff, patients, and families; to role model leadership behaviors when things go wrong — both immediate response and patient disclosure; and to fully review and learn from all critical events and good catches with those involved — get to a deeper understanding of how the system failed or the ‘second story’.

Human Resource Leaders are accountable to design systems that support leaders and employees in achieving a Just Culture; for systems that include: leadership development based on Just Culture principles; performance management systems that assure skilled application of Just Culture principles; and respectful work environment systems and consequences for all.

Physicians are accountable to develop reliable systems in partnership with and work with staff, patients, and families; to role model leadership behaviors when things go wrong — both immediate response and disclosure to patient/family; to fully review and learn from all adverse events and good catches with those involved — to get to a deeper understanding of how the system failed.

Know the Basic Requirements: identify safety content experts — staff and executive; display teamwork and respectful communication skills, enhance performance improvement skills and share stories. Know what to do when things go wrong: implement immediate response systems, ensure transparency — disclosure and apology, conduct event reporting and analysis and provide support for patients, families, and caregivers after an event.

Know the Action Items for Leaders: First Steps: describe Fair and Just culture to colleagues — talk with senior team about the fundamentals of a Fair & Just Culture; and identify what actions you will take with an adverse event.

Be Courageous: join a causal analysis review as a learner; talk to a caregiver involved in an event; meet with a family to apologize after an event; teach Fair and Just Culture to the Board; and talk with your healthcare media contact.

Celebrate the Milestones: tell two stories of patient harm and what happened afterwards in the next two weeks; tell a story of learning from an error — your own and others; thank someone for speaking up: for telling the truth; and share stories of harm and impact on the patient, family, and caregivers at the Board.

Permission granted by B. Balik to use content in this article. Barbara Balik

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