Just Culture is one of the foundations of building highly reliable systems. It’s an elegantly simple philosophy—hold systems accountable for how they are designed and people accountable for the choices they make. Underneath that simplicity, though, organizations face a host of challenges, from the difficulty of implementing large-scale culture change to the tug of deeply-rooted outcome bias that can cloud what is fair and just.
Health systems like Tidelands Health understand that implementing a truly “Just Culture” is a long road.
“Any time you talk about changing the culture, it's going to take a while,” says Chris Rees, vice president of clinical transformation for the health system. “But I think we've finally gotten to the place where we're starting to live it.”
Tidelands Health began its journey in 2012 when the organization became one of eight health systems that joined the South Carolina Safe Care Commitment, a collaborative effort designed to improve the safety and quality of care by embracing high reliability practices which has evolved over time into the Zero Harm Network.
Rees began his tenure with Tidelands Health in 2015 when the organization made a firm commitment to Just Culture training. He, along with Risk Manager Laura Sousa and Patient Safety Officer Gregory Nobles, worked to develop a comprehensive plan to integrate the principles of Just Culture into the day-to-day management of the health system.
“We started talking about Just Culture in 2012, but we didn’t really have it hard-wired into the system,” Nobles recalls. “In 2014, we set a goal. We wanted a team of staff members to be certified in Just Culture first, then we wanted all of our managers to be trained. Now every manager in our health system has been trained in three-hour training sessions. We also have human resources and clinical policies that support it.”
“It’s definitely been a bit of a whirlwind,” says Rees of the process. Still, the trio was methodical in its implementation, looking to other health systems for guidance on how to integrate Just Culture principles. One of the organizations that provided support was Roper St. Francis in Charleston, another health system in the Safe Care cohort that had a similar goal.
“They did a fantastic job of running it through their leadership team and even integrating it with their frontline staff, which can be particularly difficult to do effectively,” says Rees. Roper was open about the challenges it was facing fully engaging its medical staff with Just Culture, which was also a potential hurdle for Tidelands Health.
“We realized we couldn’t hold our staff accountable for their behavioral choices using these tools without asking our physicians to do so as well,” Rees remembers saying as they left Roper. The team at Tidelands Health recognized the complexities of integrating an administrative cultural initiative into a well-entrenched line of thinking instilled through years of medical training.
Fortunately, the health system developed effective strategies to help with implementation, including embedding Just Culture terminology into its event reporting system. The approach made integrating Just Culture principles into day-to-day operations more seamless.
"We did this to make sure managers, as they are doing their investigations of events, are also considering the behavioral choice and what breach of duty the individual(s) are falling into,” explains Sousa. “It also leads them to seek out assistance from other people who are certified—their peers or even HR—to figure out action plans based on the determination of whether the behavior was at risk, deliberate misconduct, human error or a system issue. It helps us focus on risk, systems and managing the behavioral choice, not just the event. This also helps us remove bias from assessing individual events.”
When it came to addressing physician engagement, the health system worked closely with its doctors to help ensure the reforms had support from staff. The physicians adopted the Just Culture algorithms as part of their peer review process.
“They liked it right away,” says Sousa. “The new scoring system based on Just Culture allows more flexibility for management of care issues instead of only a choice between appropriate or inappropriate. It’s also more educational for the providers who are being scored.”
Rees agrees, noting there was a hunger among the health system’s physicians for a more complex and nuanced approach to assessing performance.
“They wanted the structure, they wanted some kind of guidance on how to assess things and some specific language to use,” he points out. “It’s not completely rigid, but at the same time it provides good principles and guidelines to follow.”
The health system is already seeing the fruits of its efforts, with a nearly two-fold increase in the number of employee partners who feel comfortable speaking up about an error, placing Tidelands Health in the 90th percentile nationally for transparency. Yet, despite the improvement, four out of 10 staff members still fear repercussions.
“It's definitely hard work. You have to remind yourself over and over,” Rees acknowledges. “But I'm starting to hear, ‘oh, that's human error’ or ‘that was truly at risk.’ Not as many reactions of 'what the heck are you doing?' It's 'do you understand why this is our policy, why we have to gown and glove every time, even if you aren't going to touch the patient?’”
To combat mission drift, Nobles says leadership works to reinforce the instant reporting process and the investment in Just Culture to continue the positive trends they’ve seen in transparency numbers and serious safety event rates.
“Going forward, if we do Just Culture right, we will be increasing accountability on the part of the staff and really looking out for each other, which will lead to better disclosure when something does happen,” Sousa says. “We want transparency, to share our triumphs and challenges with everyone in the organization.”