Just culture

Just culture is a concept related to systems thinking which emphasizes that mistakes are generally a product of faulty organizational cultures, rather than solely brought about by the person or persons directly involved. In a just culture, after an incident, the question asked is, "What went wrong?" rather than "Who caused the problem?".[1] A just culture is the opposite of a blame culture.[1] A just culture is not the same as a no-blame culture but is a culture where individuals are accountable for their willful misconduct or gross negligence.[2]

A just culture helps create an environment where individuals feel free to report errors and help the organization to learn from mistakes. This is in contrast to a "blame culture"[3] where individual persons are fired, fined, or otherwise punished for making mistakes, but where the root causes leading to the error are not investigated and corrected. In a blame culture mistakes may be not reported but rather hidden, leading ultimately to diminished organizational outcomes.

In a system of just culture, discipline is linked to inappropriate behavior, rather than harm.[4] This allows for individual accountability and promotes a learning organization culture.

In this system, honest human mistakes are seen as a learning opportunity for the organization and its employees. The individual who made the mistake may be offered additional training and coaching.[5] However, willful misconduct may result in disciplinary action such as termination of employment—even if no harm was caused.

Work on just culture has been applied to industrial,[6] healthcare,[7][8] aviation[9][10] and other[11] settings.

The first fully developed theory of a just culture was in James Reason's 1997 book, Managing the Risks of Organizational Accidents.[2] In Reason's theory, a just culture is postulated to be one of the components of a safety culture. A just culture is required to build trust so that a reporting culture will occur. A reporting culture is where all safety incidents are reported so that learning can occur and safety improvements can be made. David Marx expanded the concept of just culture into healthcare in his 2001 report, Patient Safety and the "Just Culture": A Primer for Health Care Executives.[12]

References
  1. Catino, Maurizio (March 2008). "A Review of Literature: Individual Blame vs. Organizational Function Logics in Accident Analysis". Journal of Contingencies and Crisis Management (Review). 16 (1): 53–62. doi:10.1111/j.1468-5973.2008.00533.x. S2CID 56379831.
  2. Reason, James (1997). Managing the Risks of Organizational Accidents. Ashgate Publishing. ISBN 9781840141054.
  3. Khatri, N. (October–December 2009). "From a Blame Culture to a Just Culture in Health Care". Health Care Management Review. Health Care Manage Rev. 34 (4): 312–22. doi:10.1097/HMR.0b013e3181a3b709. PMID 19858916. S2CID 44623708.
  4. Behn, Brian (January 29, 2018). "Just Culture basics for EMS". National EMS Management Association.
  5. "Just Culture System and Behaviors Response Guide" (PDF). Los Angeles County Department of Mental Health. August 9, 2017. Archived from the original (PDF) on June 28, 2019. Retrieved June 28, 2019.
  6. Groeneweg, J. (2018). "The Long and Winding Road to a Just Culture". Society of Petroleum Engineers.
  7. Harvey, H. Benjamin (June 17, 2017). "The Just Culture Framework". Journal of the American College of Radiology.
  8. Boysen, Philip (Fall 2013). "Just Culture: A Foundation for Balanced Accountability and Patient Safety". The Ochsner Journal. 13 (3): 400–406. PMC 3776518. PMID 24052772.
  9. Gain Working Group E, Flight Ops/ATC Ops Safety Information Sharing (September 2004). "A Roadmap To A Just Culture: Enhancing the Safety Environment" (PDF). Global Aviation Information Network.
  10. "Just culture Finding the right balance between the aviation, judicial and political authorities". EuroControl. Retrieved June 28, 2019.
  11. Dekker, Sidney (January 1, 2018). Just Culture: Balancing Safety and Accountability. Ashgate Publishing. ISBN 9780754672678.
  12. Marx, David (April 17, 2001). "Patient Safety and the "Just Culture": A Primer for Health Care Executives" (PDF).
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