Are Hospitals Not Getting Any Closer to Having “Just Cultures?”
For a long time, I've been an advocate for the parallels between Lean and an approach called “Just Culture.” See previous blog posts on this topic. Here's a good overview of Just Culture, which says, in part:
“A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture also recognizes that many individual or active errors represent predictable interactions between human operators and the system in which they work.
However, in contrast to a culture that touts no blame as its governing principle, a just culture does not tolerate conscious disregard of clear risks to patients or gross misconduct, such as falsifying a record, performing professional duties while intoxicated, etc.”
Leaders in a Lean culture also don't blame individuals for system failings “over which they have no control.”
Can CEOs, however, be held accountable for the culture in their organizations since they DO have control over their behaviors, the tone they set, and the example they set for others?
I can see parallels in situations where a CEO says they “endorse” or “support” something like Lean or Just Culture.
But, support isn't enough if there isn't action. Is the CEO leading by example? Is the CEO saying one thing and doing another?
You'll never make progress with Lean or Just Culture if the CEO says they support it, but then go blaming and firing individuals who are involved in systemic errors.
Neither Lean or Just Culture can take root in a culture of fear.
So, how are organizations doing on this front?
A recent blog post from Physician's Weekly explores this and I'd like to build upon it:
The post cites a journal article (requires paid access):
457 hospitals (presumably American) were surveyed.
“In all, 211 of 270 respondents (79%) indicated that their hospital has adopted Just Culture.”
But what does “adopted” mean? When people ask me how many hospitals have “adopted” or “implemented” Lean, I can only answer, “I have no idea.” It's not binary. You might say you are “implementing” or “practicing” Lean. Adopting Just Culture and changing a culture isn't like flipping a light switch. It takes time. Is there really a consistent Just Culture in those 211 hospitals, or is it their goal or vision? Or is it wishful thinking?
“More than half believe that it has had a positive impact.”
They believe or they know? How would they know? By what measures?
Just Culture implementation and its degree of impact are associated with somewhat better peer review process, but not with objective measures of hospital performance.
So does that mean that Just Culture doesn't work? Or that organizations just haven't been practicing it diligently or long enough to see an impact yet? Do the hospital performance measures lag?
What about the process and culture that is supposed to lead to better results?
“Widespread adoption of Just Culture has not reduced reluctance to report or the culture of blame it targets.”
Well, there's a real Catch-22. If “widespread adoption” (again, what does “adoption” mean?) hasn't reduced the culture of fear or the culture of blame, then has it actually been adopted?
It sounds like it hasn't.
The Physician's Weekly post shared a chart from the journal article that shows progress (or a lack thereof) over the past decade.
Using the methods of “process behavior charts” (see my book Measures of Success), it looks like there isn't much of a change in any of those process metrics.
Nonpunitive response to error: We'd want to see that going up. The first data point (about 42%) is lower than the last data point (about 44%), but it's hard to argue that's a significant change.
Staff feel like their mistakes are held against them: We'd want to see this measure going down and it's actually flat or it's just fluctuating around an average. So, no progress there.
When an event is reported, it feels like the person is being written up, not the problem: We'd want this to be going down and, if anything, it has increased slightly (but there's not enough data points to prove that there's a shift in performance there – looking for eight data points above an old average).
Staff worry that mistakes they make are kept in their personnel file: We'd want this to be going down… it appears not to be.
Well, that's discouraging.
It appears that the AHRQ survey looks across a broad set of hospitals, not just those adopting “Just Culture.”
So, the nonpunitive response to error rate is up just a bit to 47%? That still means HALF of healthcare professionals think there's a punitive response to errors.
The old habit of “naming, blaming, and shaming” is hard to break.
While Just Culture, like Lean, is sound theory… and the approaches work, in practice, when really embraced with the right style of leadership… that doesn't mean that everybody is going to adopt it. Or it means that some want to adopt it, but they're stuck or they don't know how to get there.
The use of “Lean tools” won't fix these cultural challenges. Heck, Lean tools might not even be effective in a blaming, punitive culture. How can we ask people to identify waste and quality/safety risks, if they have reasons to fear doing so?
That's one reason that I, and many others, have focused on the need for real executive engagement (not just support or lip service) and the need for culture change.
Here's an AHRQ webinar (more info) on Just Culture and patient safety:
How can we make more progress on these fronts?