Implementing a Just Culture

Long-term care too often embraces a blame culture-when a mistake is made, someone or something is punished. The Institute of Medicine notes that this kind of culture is a major factor in medical errors. Employees are not going to report errors if the consequence will be punitive or if they are going to be blamed for system-level failures.1

When Reporting Goes Wrong

One element that contributes to a blame culture in LTC is the mandatory reporting of significant events, and the annual survey process by the Department of Health and Human Services. If a surveyor deems an error was made, DHHS issues a deficiency, which reduces a facility’s Star Rating on the CMS website for 3 years. The facility also faces a monetary penalty that ranges from hundreds to thousands of dollars per day. The legal system uses the copious standards in the federal tags to determine standards of care and liability. One error can open the door to a poor rating, a high legal settlement or both. The punitive nature of these factors fosters the underreporting of errors.

Encouraging Safety

If we truly want to implement a safety culture in LTC, we must transition to a just culture. Open communication about errors and near misses that are analyzed with industry-wide changes will create a safer environment for residents to live in and staff to work in. We must replace our code of silence with a culture that embraces learning, information, reporting, flexibility, justice and safety.2,3

A just culture is an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.4 To decrease medical errors, first an organization or industry must know about the errors.


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Being Human

One of the challenges of implementing a just culture is analyzing whether an adverse event was the result of human error, at-risk behavior or reckless behavior. A human error is when something is inadvertently done, a lapse, slip or mistake. At-risk behavior is when an employee knowingly bypasses processes and mistakenly believes that his behavior is justified. Reckless behavior is when someone consciously disregards a substantial and unjustified risk.5


Building a just safety culture is not new to healthcare. The Veteran’s Administration developed the National Center for Patient Safety in 1999. In 2009 The Joint Commission, in a Sentinel Event Alert, required that healthcare organizations implement a just culture into the leadership decision-making processes. This meant avoiding two actions that erode leadership credibility and undermine a safety culture. The first is terminating, or failing to support, an employee who committed a blameless act during an adverse event. The second is exempting individuals from complying with safety standards, such as intimidating and disruptive behaviors.7 So where do we go from here?

Moving Forward

To implement a true just culture in LTC, the government must change its position on handling of adverse events. In the meanwhile, here’s a plan for individual facilities to make progress.

1. Identify the current safety culture of your organization. The Agency for Healthcare Research and Quality offers a survey (there is a fee) and tool kit on its website. The results and resources available will provide facility leadership with extensive information on how to begin implementing a just culture.8

2. Communicate with line staff about the leadership’s change in philosophy on addressing errors. Transparent communication about past mishandling of errors will begin the healing that must occur in most organizations.

3. Explain how accountability will be determined moving forward. An ongoing discussion and implementation of accountability criteria for error, at-risk and reckless behavior needs to be part of the organization’s human resource manual. The staff needs to understand the purpose of disclosing near misses and errors so that they can be analyzed, and the environment can be made safer for all concerned.

Worth the Effort

It is hard to build a just culture. Government agencies, criminal and civil legal systems, the lack of protection of internal investigation reports, and society’s need to blame someone are all impediments to creating a just culture.2 In an industry that is already struggling to use its limited resources, why should we put all this effort into creating a just culture? Most importantly, it will decrease medical errors and improve the quality of care to the residents we serve.

But the benefits go farther. A just culture will improve the work environment for our staff. This will improve employee morale. When our staff feel that they will be treated fairly when something happens, they are more likely to report errors and to feel safe doing so. Most health care workers choose this industry to help and improve the lives of the people they serve. As leaders, we need to embrace changes that will foster excellence at the sharp end of care, at the resident’s bedside. Resilient leaders absorb the experiences of failure and incorporate them into their ability to evaluate anticipated actions for the future.9 We must implement a just culture to improve the future of long-term care.


1. Khatri N, Brown GD, Hicks LL. From a blame culture to a just cultre in health care. Health Care Management Review 2009;34(4):312-322.
2. Dekker PS. (2007) Just Culture: Balancing Safety and Accountability. Burlington, Vermont: Ashgate.
3. Salas E & Maurino D. (2010) Human Factors in Aviation. Burlington:Elsevier Inc.
4. European Organization for the Safety of Air Navigation. (2006, March 31). Aero Bookshelf. Retrieved April 23, 2011 from Sky-brary:
5. Griffith KS. Error Prevention in a Just Culture; System Designor Human Behavior? The Joint Commission Perspectives on Patient Safety. 2010;10 (6):10-11.
6. Veteran’s Administration. (2009, Nov. 10). Culture Change: Prevention, Not Punishment. Retrieved Apr. 23, 2011, from VA National Center for Patient Safety:
7. The Joint Commission. (2009, August 27). Sentinel Event Alert Issue 43. Retrieved April 23, 2011, from The Joint Commission:
8. Agency for Healthcare Research and Quality. (2011). Nursing Home Survey on Patient Safety Culture. Retrieved April 23, 2011, from Agency for Healthcare Research and Quality:
9. Malloch K & O’Grady TP. (2009). The Quantum Leader. Sudbury: Jones and Bartlett Publishers.

Dorothy Geffken-Eddy is in the Masters in Nursing and Healthcare Administration program at University of Pennsylvania, Philadelphia.

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