Guest Columns

Creating a 'Just Culture'

Kathleen Mace
Kathleen Mace

Defined by the Office of Inspector General as “harm resulting from medical care,” adverse events are imperative for skilled nursing facilities to avoid — by adopting a Culture of Patient Safety that operationalizes risk management systems.

This can be achieved by implementing a “Just Culture.”

A Just Culture embraces risk management by acknowledging that choices are managed, and includes coaching to keep staff on track.

At a skilled nursing facility with a Just Culture, it is recognized that human error is inevitable. However, errors and adverse events are not assumed to result from recklessness or disgruntled employees. Rather, they typically result from faulty systems/processes, miscommunication, and confusing conditions.

The important aspect of Just Culture in long-term care is holding individuals accountable for their actions and choices with a constant effort to improve performance. When errors or adverse events occur, the focus is on identifying a root cause to prevent the same event from recurring rather than finding someone to blame.

It's important to recognize that employees are not the only sources of error in a facility. Errors are also made by facilities with state and federal regulations governing the skilled nursing environment mandating voluntary or self-reporting. The nature of this mandate is frequently uncomfortable because when we report, we know that an official from the regulatory agency will probably visit the facility and we will face a citation of non-compliance.

By holding us accountable for our actions and choices, and through the plan of correction process, the regulatory agency's citation should result in finding the root cause of the error and preventing its recurrence. This becomes an easier process when we embrace the paradigm of Just Culture. 

Rather than seeking to blame and punish, we put our efforts into fixing broken systems and processes, clarifying communication, and removing confusion through education and process improvement.

A barrier to the successful implementation of a Just Culture is that long-term care workers oftentimes are afraid to speak up when they identify safety issues or adverse events. They fear retaliation and do not want to make others angry or put working relationships in jeopardy.

Or, they believe that it is not their job to speak up and that doing so will not do any good. In a Just Culture, employees are taught how to navigate through uncomfortable conversations. Policies are implemented reflecting a zero-tolerance for retaliation and that speaking up is expected. A facility's leadership must demonstrate its commitment to a Just Culture by personally conducting training sessions.

The benefits a Just Culture brings to a skilled nursing facility include the identification of adverse issues in a timely manner, with a course of action for immediate remediation. Then, even when self-reporting is required, the remediation is completed, frequently before a regulatory agency pays a visit.

Having clear evidence of the remediation frequently mitigates consequences of non-compliance.

In summary, a Just Culture embraces values and expectations that are reasonable and achievable. Facility leadership is fully-engaged in guiding and training staff.

A skilled nursing facility with a Just Culture is a learning organization. Systems of gathering data make it safe to admit mistakes and improve systems.

A Just Culture holds individuals accountable for their choices. Poor choices are coached, reckless behavior is remediated and consequences are fair and consistent. A Just Culture is a healthy culture.

Kathleen Mace, RN, is a clinical compliance consultant at Compliagent in Los Angeles.

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