Just Culture
A couple of weeks ago I had the privilege of attending a presentation on Just Culture. The presentation was given by Dr. Ward Flemons, a member of the Health Quality Council of Alberta and a key thought leader in this area. It is important to note that Just Culture is something that Bethany will be working on over the coming year so this presentation was very helpful.
Just Culture is a concept that has longstanding origins in the Aviation industry but is relatively new to healthcare. In the healthcare context, a Just Culture is a learning culture that is constantly improving and oriented toward patient/resident safety. It is a culture where healthcare workers and residents or family members feel comfortable to report errors and threats to patient/resident safety. This information is then used to learn and make changes to the system to improve resident safety. A Just Culture fosters an atmosphere of trust where people feel safe discussing quality and safety concerns without fear of blame. When something does go wrong with patient/resident care, healthcare workers will be supported and treated fairly. Other features of a Just Culture include creating a learning culture, designing safe systems and managing behavioral choices. It is important to note that a Just Culture is not a blame-free culture, as everyone is still held accountable for following policies and procedures, but it is through reporting and event analysis that the organization learns what is wrong, how it went wrong and how it can be prevented from happening again.
Don Norman, a leading researcher and author of “The Design of Everyday Things” says that when accidents happen we often blame the people involved and punish them with the idea that punishment will solve the problem. As he notes, “the problem is seldom the fault of an individual; it is the fault of the system. If we change people without changing the system, the problems will continue”. Creating a Just Culture requires a change in focus from blaming for errors and bad outcomes to the enhancement of system design and supporting the management of the choices of employees.
A Just Culture improves patient/resident safety by empowering employees to proactively monitor the workplace and participate in safety efforts in the work environment. Improving patient/resident safety reduces risk by its focus on managing human behaviors and redesigning systems. In a Just Culture, both the organization and its employees are held accountable while focusing on risk, systems design, human behavior and patient/resident safety. I look forward to working with all of you as we embark on this important work over the next year.
As always, I welcome any ideas or suggestions you may have. Please send them to me at nancy.hughes@bethanyseniors.com.
Regards,
— Nancy
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