Have you heard of the "Just Culture"?

Patient Safety Quality Monthly

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May 24, 2007

Creating a positive culture for patient safety is a goal of many hospitals today. One method currently being explored is the concept of the Just Culture created by David Marx. This concept was originally developed for healthcare to create a fair approach to define culpability for potential or actual harm due to medication errors.

The Just Culture is based on a combination of the legal concepts of negligence and corporate approaches to culpability or fault relating to safety in high risk industries, such as aviation, that have an impact on employee morale and function. The goal of the Just Culture is to assign the consequences for an unsafe act in a fair way based on an understanding of an individual's accountability and responsibilities within the context of the systems and circumstances that the individual was operating.

The four key categories of the Just Culture for assigning fault are:

• Human Error: Unintended slips, lapses, and mistakes
• Negligence Conduct: Failure to exercise care expected of a prudent worker
• Reckless Conduct: Conscious disregard for a known risk
• Knowing Violations: Conscious disregard for known rules

The Just Culture is not a blame-free culture. It merely tries to provide a consistent guide to determine: 1) when a person is truly at fault for a specific act and 2) reasonable consequences to that individual that will best serve the individual's and organization's interests in the long run.

To guide managers and organizations in making fair decisions, decision algorithms have been developed using these concepts. These algorithms typically ask a series of questions:

• Were the actions intended?
• Was the person under the influence of unauthorized substances?
• Did the person knowingly violate existing policies, procedures, or expectations?
• Would another person in the same situation perform in the same manner?
• Does this person have a history of unsafe acts?

Based on the answers to those questions, the actions taken may involve consoling, coaching, counseling, progressive discipline, termination, or system changes.

While not universally accepted, many hospitals and healthcare systems are beginning to adopt this approach for their employees. If you haven't heard of it before, an article entitled, Patient Safety and the "Just Culture": A Primer for Health Care Executives can be obtained from the website http://www.mers-tm.net/support/marx_primer.pdf. You can also find more information by web searching "Just Culture by David Marx."

Interestingly, the efforts to implement the Just Culture for employees have recently raised questions from some hospital medical staffs as to whether this model should also be applied to peer review. Creating a positive approach to peer review has been a fundamental principle of The Greeley Company. To achieve this, we have used an approach we call the Physician Performance Pyramid. This model is based on the mutual accountability of physicians in physician performance evaluation and improvement.

I have had some questions recently asking whether the Just Culture and the Physician Performance Pyramid are similar or compatible. Next month, I will provide some initial thoughts for your consideration.

Sincerely,
Robert Marder, M.D.
Vice President, The Greeley Company

For more information on our Patient Safety and Quality consulting services, click here or contact Sharon Courage, Practice Director of Quality and Patient Safety, by e-mail, scourage@greeley.com, or by phone at 888/749-3054, ext. 3501.

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