A Just Culture speaks up for patient safety

A culture of change is arriving at UPMC. It is an approach to patient safety unlike any other, and it’s called “A Just Culture.” A Just Culture will empower our physicians, nurses, and other health care providers to voice concerns about patient safety without fear of retaliation, and will ensure confidence that leaders will listen and take action in a fair and consistent manner. A Just Culture helps to create a culture of safety — for patients, and for physicians and staff to speak up and identify opportunities to improve patient safety every step of the way.

“Adoption of A Just Culture will be a journey leading to a significant change in the way we identify, treat, and learn from errors and near misses at UPMC. We will be opening lines of communication and understanding that were previously unavailable,” says Paul Phrampus, MD, who is leading the physician component of A Just Culture.

Introducing new accountability

Research has shown that the single greatest impediment to error prevention in health care is that caregivers typically are punished for making mistakes. A punitive culture instills fear, destroys creativity, erects barriers to safety, and drives errors and near misses underground, making it very difficult for a system and care providers to learn from them. A Just Culture changes the old way of thinking by introducing a new accountability for patient safety, one that is balanced and empowers everyone to take part.

A Just Culture fosters a work environment in which both patients and staff are safe and treated with dignity and respect. It provides guidelines for calling attention to and addressing mistakes before they happen and for dealing openly with mistakes when they do occur. A Just Culture creates a learning environment in which potential error is thwarted and future error prevented.

“The essence of A Just Culture is transparency,” says Thomas Worrall, MD, medical director, Donald D. Wolff Jr. Center for Quality, Safety, and Innovation at UPMC. “We need to be constantly evaluating our working environments, because more times than not, people are being set up for failure by errors in process, not by negligence.” 

A Just Culture therefore protects those who speak up and ensures those who were involved in the error are treated fairly and steered away from a purely punitive process. It is an open, fair, and learning-oriented culture.

How do we build A Just Culture?

How do we create a culture in which front-line physicians and staff feel comfortable disclosing errors, including their own?

First, by recognizing that individual practitioners should not be held responsible for system failings over which they have no control. Also, by realizing that competent professionals sometimes make errors, and by understanding that when errors are not routinely addressed, they create unhealthy norms, bad habits, shortcuts, and routine violations that compromise safety.

A Just Culture provides and establishes a structure for fair, consistent, and predictable organizational responses to errors; encourages us to be open and transparent, to address and fix system issues and issues of process; and directs us to share our learning to prevent future errors.

A Just Culture sets up a framework so we can understand that no one comes to work wanting to do wrong. It also directs us to address risky behavior, human error, and those who may be impaired or careless.

A Just Culture provides direction for listening, identifying error and risk, and consoling. It is based on the real-world input and concerns of clinical staff on the front lines of care. “No one caring for patients wants to feel like their job is in jeopardy every day that they come to work. A Just Culture instills the faith that if an error occurs, the care provider will be treated fairly and consistently across UPMC,” explains Dr. Phrampus, who also serves as director of the Peter M. Winter Institute for Simulation, Education and Research (WISER) in the Department of Anesthesiology at the University of Pittsburgh School of Medicine.

“We conducted the Culture of Safety Survey in the spring of 2010 with our employees. The results showed that employees felt that there was a punitive approach in use,” says Susan Christie Martin, RN, MSN, director, Donald D. Wolff Jr. Center for Quality, Safety, and Innovation at UPMC. “To address this, a structured set of responses was developed to be followed when issues are identified.”

Training for managers and physician leaders

In a special educational program for clinical managers called “A Just Culture: Accountability for Patient Safety,” managers and leaders attend a one-hour training session that introduces a culture of openness and engagement. Managers are bringing these tools into the clinical workplace to educate staff in managing their own behavioral choices. Physician leaders at each UPMC hospital have been identified. These leaders will disseminate information about A Just Culture to physicians throughout the health system.

A Just Culture provides specific structure and guidelines for analyzing errors, near misses, adverse events, and risky behaviors. It establishes “rules to play by,” in which staff members are accountable, but not inhibited, and fosters a constructive environment that strives to eliminate the impediments to preventing error.

“What is key to whether or not we’ll be successful,” says Dr. Worrall, “is the human element.” Clinical staff will need to have transparent conversations and feel comfortable talking about how error happens. It’s a circle that goes around and connects to itself. The only way it will work is for that circle to be unbroken.”

Watch UPMC Presbyterian Shadyside Physician eNews for updates on A Just Culture.