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Just Culture 1

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Just Culture

Effective Date: January 28, 2010

Status: New Position Statement

Originated By: Congress on Nursing Practice and Economics

Adopted By: ANA Board of Directors

Related Past Action: 1. ANA Position Statement (2007): Safety Issues Related to Tubing and Catheter Misconnections

2. ANA Position Statement (2006): Assuring Patient Safety: The Employers’ Role in Promoting Healthy Nursing Work Hours for Registered Nurses in All Roles and Settings

3. ANA Position Statement (2006): Assuring Patient Safety: Registered Nurses’ Responsibility in All Roles and Settings to Guard Against Working When Fatigued

4. 2000 ANA House of Delegates Report Adopted: Building Safe Health Care Systems for Informed Patients

Purpose: The purpose of this position paper is to interpret the Just Culture concept and

its application for nursing and health care in a variety of settings.

Statement of ANA Position: The American Nurses Association (ANA) supports the

Just Culture concept and its use in health care to improve patient safety. The ANA

supports the collaboration of state boards of nursing, professional nursing associations,

hospital associations, patient safety centers and individual health care organizations in

developing regional and state-wide Just Culture initiatives.

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History/Previous Position Statements: This is the first ANA position on the Just

Culture concept. In regard to patient safety, ANA has published the positions Safety

Issues Related to Tubing and Catheter Misconnections (2007), Assuring Patient Safety:

The Employers’ Role In Promoting Healthy Nursing Work Hours for Registered Nurses

in All Roles and Settings (2006), and Assuring Patient Safety: Registered Nurses’

Responsibility in All Roles and Settings to Guard Against Working When Fatigued

(2006). ANA through its National Center for Nursing Quality has long been working with

patient safety initiatives, including the National Database for Nursing Quality Indicators,

Handle With Care Campaign, Safe Staffing Saves Lives Campaign, and its work with

the National Quality Forum, the Joint Commission, and the National Priorities

Partnership. The 2000 ANA House of Delegates adopted the report “Building Safe

Health Care Systems for Informed Patients”.

Supportive Material: In testimony before congress, Lucian Leape, MD, member of the

Quality of Health Care in America Committee at the Institute of Medicine and adjunct

professor of the Harvard School of Public Health, noted that “Approaches that focus on

punishing individuals instead of changing systems provide strong incentives for people

to report only those errors they cannot hide. Thus, a punitive approach shuts off the

information that is needed to identify faulty systems and create safer ones. In a punitive

system, no one learns from their mistakes” (Leape, 2000).

As an alternative to a punitive system, application of the Just Culture model, which has

been widely used in the aviation industry, seeks to create an environment that

encourages individuals to report mistakes so that the precursors to errors can be better

understood in order to fix the system issues. The term “Just Culture” was first used in a

2001 report by David Marx (Marx, 2001), a report which popularized the term in the

patient safety lexicon (Agency for Healthcare Research and Quality, n.d.).

Traditionally, healthcare’s culture has held individuals accountable for all errors or

mishaps that befall patients under their care. By contrast, a Just Culture recognizes that

individual practitioners should not be held accountable for system failings over which

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they have no control. A Just Culture also recognizes many individual or “active” errors

represent predictable interactions between human operators and the systems in which

they work. However, in contrast to a culture that touts “no blame” as its governing

principle, a Just Culture does not tolerate conscious disregard of clear risks to patients

or gross misconduct (e.g., falsifying a record, performing professional duties while

intoxicated).

Development of the Just Culture Concept

In 1997, John Reason wrote that a Just Culture creates an atmosphere of trust,

encouraging and rewarding people for providing essential safety-related information. A

Just Culture is also explicit about what constitutes acceptable and unacceptable

behavior. Therefore a Just Culture is the middle component between patient safety and

a safety culture (Reason, 1997). Marx argues that discipline needs to be tied to the

behavior of individuals and the potential risks their behavior presents more than the

actual outcome of their actions (Marx, 2001).

The Just Culture model addresses two questions: 1) What is the role of punitive

sanction in the safety of our health care system and 2) Does the threat and/or

application of punitive sanction as a remedy for human error help or hurt our system

safety efforts? The model acknowledges that humans are destined to make mistakes

and because of this no system can be designed to produce perfect results. Given that

premise, human error and adverse events should be considered outcomes to be

measured and monitored with the goal being error reduction (rather than error

concealment) and improved system design (Marx, 2001).

In addition, the model describes three classes of human behavior that create

predictability in error occurrence. The first is simple human error - inadvertently doing

other than what should have been done. The second, at-risk behavior occurs when a

behavioral choice is made that increases risk where risk is not recognized or is

mistakenly believed to be justified. Finally, reckless behavior is action taken with

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conscious disregard for a substantial and unjustifiable risk.

Under the Just Culture model, creating an open, fair and Just Culture relies on

developing managerial competencies that appropriately hold individuals accountable for

their behaviors, and investigates the behavior that led to the error. With regard to

human error, managers console the individual, then consider changes in processes,

procedures, training and design. At-risk behavior suggests the need for coaching and

managing through removing incentives for at-risk behavior; creating incentives for

healthy behaviors; and increasing situational awareness. With reckless behavior, it is

necessary to manage through remedial action and/or punitive action (Marx, 2001).

Ultimately, the Just Culture model is about creating an open, fair and Just Culture,

creating a learning culture, designing safe systems, and managing behavioral choices.

The model sees events not as things to be fixed, but as opportunities to improve

understanding of both system risk and behavioral risk. It is also about changing staff

expectations and behaviors to ones such as looking for the risks in the environment;

reporting errors and hazards; helping to design safe systems; and making safe choices,

including following procedure; making choices that align with organizational values; and

never signing for something that was not done.

To mitigate errors, Marx created the Just Culture Algorithm, a methodology for

considering what a manager should do when a breach occurs and suggests actions to

address the breach from both the system and employee perspective (Marx, 2008).

Application to Nursing

The American Nurses Credentialing Center (ANCC) has developed the Five Model

Components for the Magnet Recognition Program® that reflect the focus of the

healthcare organization on achieving superior performance as evidenced by outcomes.

The components stress that outcomes of an infrastructure developed for excellence are

essential to a culture of excellence and innovation, of which safety is a prime

component. The components include Transformational Leadership; Structural

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Empowerment; Exemplary Professional Practice; New Knowledge, Innovations and

Improvements; and Empirical Outcomes (ANCC, 2008). Although not referred to as

such, Just Culture is congruent with this model. Transformational Leadership conveys a

strong sense of advocacy and support on behalf of staff and patients by all nursing

leaders. Professional Engagement, one of the Sources of Evidence for this component,

promotes structure and processes that enable nurses to actively participate in

organizational decision making groups. This would allow staff to be integral in

promoting a Just Culture environment. Exemplary Professional Practice promotes

nurse control over staffing and scheduling processes and encourages that the nursing

staff work in collaboration with their interdisciplinary partners to achieve high quality

patient outcomes. The New Knowledge, Innovations and Improvements component

establishes and implements effective, efficient care, which would include a culture of

safety. A Magnet ® organization continually assesses and monitors the empirical

measurements relative to nursing leadership and clinical practice.

The Just Culture concept correlates with nurses’ critical thinking skills and the nursing

process in determining the root cause of an error. Since nursing relies heavily on

assessing a situation, diagnosing a problem, and creating a plan to improve or avoid

that problem, the Just Culture concept is a natural fit for any environment where nursing

care is delivered.

For staff nurses and students, the concept gives the opportunity to feel more at ease

reporting problems, and a sense of accountability for system improvement. For nurse

administrators and educators, the Just Culture concept represents an opportunity to

improve care delivery systems for patients/individuals, and to improve the environment

for those that work in that system, including nurses but extending to all others that work

within it.

Intimidation and disruptive behaviors can foster medical errors, contribute to poor

patient satisfaction and to preventable adverse outcomes, increase the cost of care, and

cause qualified clinicians, administrators and managers to seek new positions in more

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professional environments. Safety and quality of patient care is dependent on

teamwork, communication and a collaborative work environment. To ensure quality and

promote a culture of safety, healthcare organizations must address the problem of

behaviors that threaten the performance of the health care team. (Joint Commission,

2008).

All healthcare organizations should implement a zero tolerance policy related to

disruptive behavior, including a professional code of conduct and educational and

behavioral interventions to assist nurses in addressing disruptive behavior (Center for

American Nurses, 2008).

The Just Culture concept establishes an organization-wide mindset that positively

impacts the work environment and work outcomes in several ways. The concept

promotes a process where mistakes or errors do not result in automatic punishment, but

rather a process to uncover the source of the error. Errors that are not deliberate or

malicious result in coaching, counseling, and education around the error, ultimately

decreasing likelihood of a repeated error. Increased error reporting can lead to

revisions in care delivery systems, creating safer environments for patients and

individuals to receive services, and giving the nurses and other workers a sense of

ownership in the process. The work environment improves as nurses and workers

deliver services in safer, better functioning systems, and that the culture of the

workplace is one that encourages quality and safety over immediate punishment and

blame.

Recommendations:

1. That the ANA officially endorse the Just Culture concept as a strategy to reduce

errors and promote patient safety in health care.

2. That the ANA promote and disseminate information about the Just Culture

concept in ANA publications, through constituent member associations, and ANA

affiliated organizations.

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3. That the ANA promote the collaboration of state government, boards of nursing,

all healthcare professional associations, and hospital and long term care

associations in the development and implementation of Just Culture initiatives in

each state.

4. That the ANA encourage continued research into the effectiveness of the Just

Culture concept in improving patient safety and employee performance

outcomes.

5. That nurse administrators in any level of oversight act on their dual role as

representatives of nursing and stewards of the organization to promote safe

systems in the spirit of Just Culture to promote safe patient outcomes and protect

employees from failure.

6. That direct-care registered nurses advocate for the use of the Just Culture

concept in their practice settings.

7. That educators incorporate Just Culture concepts into nursing curricula at every

level, and adhere to the Just Culture concepts in the academic setting.

8. That ANA collaborate with other health care professionals to develop Just

Culture joint statements.

9. That the ANA encourage all healthcare organizations to implement a zero

tolerance policy related to disruptive behavior, including a professional code of

conduct and educational and behavioral interventions to assist nurses in

addressing disruptive behavior

Summary: For many years, the Just Culture concept has proved effective in error

reduction and improvement in safety in aviation and other industries where errors have

dire and sometimes catastrophic repercussions. The Just Culture concept is an ideal fit

for health care systems, where errors have just as serious consequences. By

promoting system improvements over individual punishment, a Just Culture in

healthcare does much to improve patient safety, reduce errors, and give nurses and

other health care workers a major stake in the improvement process.

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Examples of Just Culture Initiatives in Health Care

Federal and state initiatives

The following are examples of efforts to incorporate and promote the Just Culture

concepts into healthcare at the federal and state levels.

Veterans Affairs

The National Center for Patient Safety (NCPS) exists to improve the safe delivery of

healthcare to America's veterans. The Department of Veterans Affairs National Center

for Patient Safety was established to lead Veteran’s Affairs (VA) patient safety efforts

and to develop and nurture a culture of safety throughout the Veterans Health

Administration. Its multi-disciplinary team is located in Washington, DC, Ann Arbor, MI,

and White River Junction, VT. It offers expertise on an array of patient safety and

related health care issues. Patient safety managers in all 154 VA hospitals actively

participate in the program, as well as do patient safety officers in all 23 network

headquarters. Internally, the NCPS provides employees with agency guidelines,

directives, education, training, tools, products, initiatives, studies, publications, dialogue

and conferences.

Minnesota

The Minnesota Alliance for Patient Safety (MAPS) provides a comprehensive active

partnership among the Minnesota Hospital Association, the Minnesota Medical

Association, the Minnesota Department of Health and more than 50 public-private

health care organizations working together to improve patient safety. MAPS is

governed by an executive committee, a steering committee, and subcommittees/task

forces operating under a set of governing principles. MAPS published a statement of

guidance and toolkit for health care organizations under the banner of Just Culture. It

has also developed a statewide informed consent form and policy envisioning this form

as Minnesota's universal documentation of informed consent, and that health care

organizations statewide will use the informed consent form with no variation. MAPS

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produced a My Medicine List wallet card, published in six languages, to enable

consumers/individuals to carry clear notes on the medications they take (Minnesota

Alliance for Patient Safety, n.d.).

North Carolina

The North Carolina Center for Hospital Quality and Patient Safety facilitates a

collaborative of several state hospitals implementing the Just Culture in their facilities.

The North Carolina Board of Nursing supports the “Just Culture” collaborative, and has

a pilot project to partner with participating hospitals to promote consultation and

discussion of events in a positive manner. The pilot will serve to assist employers in

identifying events that can be addressed in the practice setting versus those that would

benefit from board consultation. The purpose of the pilot project is to provide a

mechanism for employers of nurses and the regulatory board to come together to

promote a culture that promotes learning from practice errors while properly assigning

accountability for behaviors, consistently evaluating events, and complying with

mandatory reporting requirements (George, Chastain, & Burhans, 2008).

Missouri

A grant from the National Council of State Nursing Boards brought together Missouri

regulators and health care providers to improve patient safety in September, 2007. The

grant funds the Just Culture Collaborative, an effort led by the Missouri Center for

Patient Safety (MOCPS) to establish an understanding of why medical errors happen

and establish a common understanding of aspects of culture to improve methods for

preventing them. Statewide, the following health care leaders have signed statements of

support for the project: Healthcare Services Group, Missouri Hospital Association,

Missouri Nurses Association, Missouri Organization of Nurse Leaders, Missouri State

Board of Healing Arts, Missouri State Board of Nursing, Missouri State Medical

Association, Missouri Association for Healthcare Quality, Missouri Department of Health

& Senior Services and 33 hospitals, agencies, and health care systems in the state as

participating organizations (MOCPS, n.d.).

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California

In a state where strict laws mandate medical error reporting, the California Patient

Safety Action Coalition (CAPSAC) is attempting to ensure errors are dealt with using the

Just Culture concepts. CAPSAC conducts trainings and promotions striving to influence

healthcare leaders to incorporate a concept called “Fair and Just Culture” as part of the

environment of patient safety, and to create a system where prevention and learning are

stressed, regardless of the severity of the incident (CAPSAC, 2008). At the local level,

the Los Angeles County Department of Health Services, which serves more than 10

million people and is the second largest health department in the U.S., adopted and

abides by the Just Culture, and was one of the earliest health care entities in California

to do so (CAPSAC, 2008).

Professional Associations

The following are examples of attempts by professional associations to promote and

incorporate the Just Culture concepts.

American Organization of Nurse Executives

The American Organization of Nurse Executives (AONE) states in the document

Guiding Principles: The Role of the Nurse Executive in Patient Safety that “the role of

the nurse executive in patient safety is to help lead best practices and establish the right

culture across multiple disciplines within the organization” (AONE, 2006a). AONE goes

on to state that one of the principles for the nurse executive is to lead cultural change

(AONE, 2006b). A major part of this role is to transform the culture from one of a silent,

hierarchical structure of blame to an open team-oriented culture to improve patient

safety. Reason argues that an informed culture requires a reporting culture, Just

Culture, flexible culture, and learning culture. Together these subcultures form a

blameless culture that encourages and rewards reporting (Reason, 1997).

Another role of the nurse executive is to develop leadership competencies which

include culture of safety competencies. The competencies most related to Just Culture

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are: “Timely, fair, appropriate actions that are carried out equitably when blameworthy

behaviors have occurred”; and “Assign accountability, determine goals, avoid blame,

thank those that share concerns and perceived patient safety risks” (AONE, 2007).

Association of periOperative Registered Nurses

The Association of periOperative Registered Nurses (AORN) issued a position

statement which stated that “all health care organizations must strive to create a culture

of safety. Such a culture will provide an atmosphere where the perioperative team

members can openly discuss errors, process improvements, or systems issues without

fear of reprisals.” (AORN, 2006). Further, AORN recommends that health care

organizations adopt a disciplinary system theory approach in promoting a Just Culture

that freely reports errors. These disciplinary policies must balance the benefits of a

learning culture with the need to retain personal accountability and discipline (AORN,

2007).

Illinois Nurses Association

The Illinois Nurses Association (INA) has recommended that “professional nursing

organizations and the State Board of Nursing investigate the adoption of the Just

Culture Algorithm” in a recent position paper on patient safety (INA, 2008).

References Agency for Healthcare Research and Quality. Patient safety network glossary.

Retrieved July 27, 2009, from http://www.psnet.ahrq.gov/glossary.aspx#J

American Nurses Credentialing Center. (2008). Magnet Recognition Program ® manual

- Recognizing nurse excellence. Silver Spring, MD: Author.

Just Culture 12

American Organization of Nurse Executives. (2007a). Guiding principles: The role of the

nurse executive in patient safety. Retrieved February 22, 2009, from

http://www.aone.org/aone/resource/PDF/AONE_GP_Role_Nurse_Exec_Patient_

Safety.pdf

American Organization of Nurse Executives. (2007b). Role of the nurse executive

guiding principles toolkit. Retrieved February 22, 2009, from

http://www.aone.org/aone/pdf/Role%20of%20the%20Nurse%20Executive%20in

%20Patient%20Safety%20Toolkit_July2007.pdf

Association of periOperative Registered Nurses. (2007). AORN position statement on

patient safety. Retrieved February 22, 2009, from

http://www.aorn.org/PracticeResources/AORNPositionStatements/Position_Patie

ntSafety/

Association of periOperative Registered Nurses. (2006). AORN Just Culture tool kit.

Retrieved February 22, 2009, from

http://www.aorn.org/PracticeResources/ToolKits/JustCultureToolKit/DownloadTh

eJustCultureToolKit/

California Patient Safety Action Coalition. (August 20, 2008). Press release: California

Patient Safety Action Coalition (CAPSAC) charts new path in preventing medical

errors.

Center for American Nurses. (n.d.). Lateral violence and bullying in the workplace.

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BULLYINGFACTSHEET.pdf

George, J., Chastain, K., & Burhans, L. (2008). The North Carolina

Board of Nursing Just Culture pilot project toolbox. (Unpublished work).

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Illinois Nurses Association. (2008). Position paper on patient safety and medication

errors. Retrieved May 21, 2009 from http://www.illinoisnurses.com/

Joint Commission. (2008). Sentinel event alert. Retrieved October 3, 2009 from

http:/ /www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm

Leape, L. (January 25, 2000). Testimony, United States Congress, United States

Senate Subcommittee on Labor, Health and Human Services, and Education.

Marx, D. (2001). Patient Safety and the “Just Culture”: A Primer for Health Care

Executives. New York, NY: Columbia University.

Marx, D. (2008). The Just Culture Algorithm. Outcome Engineering, LLC.

Minnesota Alliance for Patient Safety. (n.d.). Minnesota statement of support for a

statewide culture of learning, justice, and accountability. Retrieved February 22,

2009 from www.mnpatientsafety.org

Missouri Center for Patient Safety. (n.d.). Missouri Just Culture Collaborative.

Retrieved February 22, 2009 from http://www.mocps.org/initiatives/index.asp

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© 2010 American Nurses Association