Just Culture
Building a Just Culture Community in Nursing Home Environments in North Carolina
BACKGROUND
In January 2005, the FNE sponsored its first invitational conference focused on improving health care delivered to citizens of NC. The Patient Safety Symposium was held to update attendees on patient safety initiatives nationally and across North Carolina and to identify opportunities to enhance patient safety through collaboration among NC’s leading health care entities. By 2006, the concept of a “Just Culture” approach to analyzing unsafe practices was being introduced in North Carolina.
Just Culture a term coined by David Marx, an engineer and attorney, is described as follows: On one side of the coin, it is about creating a reporting environment where staff can raise their hand when they have seen a risk or made a mistake. On the other side of the coin, it is about having a well-established system of accountability. A Just Culture must recognize that while we as humans are fallible, we do generally have control of our behavioral choices.
Just Culture uses a framework designed to enhance patient safety by implementing a learning and quality improvement approach to reducing errors and potential for errors. Both regulatory and provider organizations behaviors leading to the event, and taking corrective action based on cause(s) rather than patient outcome. Implementing such a framework requires changing from the old “blame and shame” culture of organizations to the more “Just Culture” of learning and quality improvement.
PARTNERSHIP TO EXTEND JUST CULTURE INTO THE NURSING HOME ENVIRONMENT
In 2010, The Foundation for Nursing Excellence, working in collaboration with Outcomes Engineering, Inc., the NC Department of Health and Human Services, The NC Healthcare Facilities Association, FutureCare of NC, Lutheran Services for the Aging, The Carolinas Center for Medical Excellence, the NC Center for Hospital Quality and Patient Safety, and other key stakeholders in North Carolina, initiated efforts to extend this learning and quality improvement framework into nursing home environments. Selected nursing homes received staff training in Fall 2010 with feedback being used to lay the groundwork for North Carolina becoming a pilot state for nursing home-focused Just Culture training. State surveyors as well as nursing home administrators and interns in training are also receiving education regarding Just Culture.
By Spring 2011, several nursing homes will have the opportunity to participate in statewide Just Culture training. As these facilities implement this framework, data will be collected to examine the change in staff expectations of the culture for reporting errors and improving quality. Partners will begin to work with federal regulators to incorporate basic philosophies of Just Culture into the premise of facility compliance and regulation.
The long term goal is to effect change within the CMS regulatory/oversight system as well as within the culture of nursing home environments.
GOAL OF JUST CULTURE INTIATIVE
Just Culture philosophy makes a distinction between human error, at-risk behavior, and intentional reckless behavior by looking at why an event happened in a systematic manner and determining whether the actions of the individual warrant counseling, remediation or punishment.
The Foundation for Nursing Excellence, working in collaboration with key stakeholders in North Carolina, seeks to extend this learning and quality improvement framework into a variety of healthcare settings and regulatory systems with the long term goal of creating a statewide Just Culture Healthcare Community.
