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
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.