Building a “just” culture
by April Frawley Birdwell
On Monday, a floor nurse attends a training session and is told to significantly change a common nursing procedure for safety reasons, due to recently reported serious harm events. The following day, out of habit, the nurse performs the procedure as she always has. The patient dies. What happens next?
In a health care environment that espouses to the ideas of Just Culture, how to handle an employee error is less about what happened to the patient and more about the staff member’s intent. UF&Shands began introducing the values of Just Culture in September.
“Just Culture is about recognizing that we are working with fallible human beings,” said Susan Keating, director of clinical risk management for UF&Shands. “In the past, it was common for hospitals to react to an adverse outcome and look for someone to blame. We need to erase the outcome and look at intent. If it was a human error, we need to change the system so human beings can work within it and not make those errors.”
Although the focus is on making system changes to prevent errors, this doesn’t mean that risky behavior among employees is acceptable. Employees who engage in risk behavior, like taking shortcuts they perceive as safe, receive coaching. The system is changed to make it easier to do the right thing, and harder to do the wrong thing. Disciplinary action, on the other hand, is reserved for the rare occasions when employees act recklessly without regard for the patient, or in instances when employees take the same risks after being coached to stick to hospital policy.
The goal in Just Culture is for employees to feel safe discussing medical errors, because it is the only way to address them and prevent them from happening again.
“People are more comfortable when they feel like they are in a learning environment,” Keating said. “Culture change takes a long time. It will take years before we see the full benefits, but we are already on the journey.”