Moving from a Culture of Blame to a Just Culture

By Michael “Mike” J. Jones

Well-known public speaker Wolfgang Riebe noted, “No one is perfect… That’s why pencils have erasers.” And, while the first part––none of us is perfect––is true, the second part is a bit glib. Some mistakes aren’t easily erased.

In recent weeks, I’ve been in multiple conversations about the prevailing “blame culture” in healthcare. When something happens, the finger-pointing begins — those involved in the incident look at who to blame––an individual at fault. A consequence of a culture of blame is that those who make mistakes, or who see something that’s not right, may put themselves at risk if they bring it to the attention of leadership. This is because, very often, the person who blows the whistle risks termination.

Contrary to Culture of Blame, I believe only in cases of egregious or defiant errors should termination of an individual be the final outcome. Rarely is it this simple…that one person bears sole responsibility for a mistake. In introducing his article in “The Ochsner Journal,” Dr. Philip G. Boysen says, “An individual may be at fault, but frequently the system is also at fault. Punishing people without changing the system only perpetuates the problem rather than solving it.”

Regardless of the type of organization you represent––a healthcare entity, a product manufacturer, a nonprofit agency, an education institution––one of the most important steps to risk management is mitigating errors and failures. Healthcare organizations often react carelessly, making rash termination decisions, propagating “blame culture.” This is especially true if the leadership isn’t aware of high-risk procedures or ignore physicians and staff who raise issues of potential errors or mistakes. Often, failures and mistakes result from a series of actions, often by more than one person, or from a breakdown in the system.

A recent article published by Modern Healthcare aggregated reports spanning 18 months of investigations and reports of patient deaths and injuries at prominent U.S. healthcare centers: 

The revelations of systematic problems at these major hospitals have disturbed safety experts, who wonder whether healthcare leaders have truly learned the painful lessons of how to reduce patient harm. These cases, they say, demonstrate holes in the culture of safety, transparency, and routine measurement of errors and adverse events.

In some of the examples provided in the article it highlights that many healthcare leaders do not:  admit errors, listen to stakeholders (physicians clinical staff, support staff, patients, families) who raise concerns, take a “systems approach” to performance improvement and error prevention, or take shared accountability at all levels for issue resolution.  In fact, they tend to “point fingers” and blame individuals.

What is the Systems Approach? 

If you adopt an interdisciplinary Systems Theory perspective of organizational design, you accept that a system is “a cohesive conglomeration of interrelated and interdependent parts which can be natural or human-made…bounded by space and time, influenced by its environment, defined by its structure and purpose, and expressed through its functioning. A system may be more than the sum of its parts if it expresses synergy or emergent behavior.”  

Systems Theory applied to healthcare organizations fosters a leadership framework based on Just Culture, 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.” By adopting this understanding of the nature of a “system” in healthcare, leadership teams more easily embrace a framework based on Just Culture as opposed to a Culture of Blame: 

• Healthcare leaders move from looking at errors as individual failures to realizing errors are caused by system failures.
• For physicians and staff, the punitive environment shrouded in secrecy becomes a just environment encouraging transparency.
• Healthcare changes from provider/physician-centered to patient-centered.
• Service delivery emphasizes interdependent, collaborative, inter-professional teamwork and moves away from independence and performance excellence for the individual professional.

The How of Just Culture

This shift to Just Culture in healthcare requires engaging stakeholders from all levels in the organization: physicians and providers, clinical and support staff, leadership and managers, governing bodies and the community, payers, and employers. Within the organization, leaders are collecting data to make informed decisions by monitoring and measuring performance at all levels, with full transparency and a common understanding. Leadership teams can manage processes by implementing programs such as LEAN, Six Sigma, Total Quality Management, or Continuous Improvement.

The What of Just Culture

The outcomes of engaged stakeholders, data collection, and process management are operations excellence, service excellence, and clinical excellence. When combined, this forms a sustainable leadership action plan:

• Operations Excellence: improved KPIs for the medical workforce and physician experience and satisfaction.
• Service Excellence: improved KPIs for patient, employer, and family member experience and satisfaction.
• Clinical Excellence: improved KPIs for acute care, long-term care, ambulatory, and population health measures.

Cultural shifts are not easily undertaken by organizational leadership. Working in a strategic partnership with system experts, leaders must assess the healthcare system’s physician alignment, engagement, and integration strategies; facilitate strategic planning to design and implement improvement efforts; and develop Governance, Leadership and Management structures and processes that facilitate the transition from a culture of blame to a Just Culture.