Creating a Just Culture Policy

Creating a just culture policy

A just culture policy is a high level statement of the values and commitment of an organization to treat healthcare workers fairly when a patient is harmed or nearly harmed by healthcare delivery. It is an important step in being open with healthcare workers and patients about what to expect in a situation where patient safety has been compromised.

A just culture policy can be a board policy or an operations policy.

  • A board policy will be more high level and make a general commitment to a just culture for the organization. It is a clear signal that just culture is a leadership priority.
  • An operations policy will be more specific and set expectations for processes and procedures. 

Another option is to create a policy guidelines document that commits the organization to embedding a just culture approach into all organizational policies and procedures, not just those that relate to situations in which patients are harmed or almost harmed by healthcare delivery. 

Suggested policy elements

To make a strong, specific statement about just culture, consider incorporating one or more of the following elements into the just culture policy:

Healthcare providers are accountable for their actions. They are not accountable for system factors that are beyond their control.

Healthcare workers’ actions will always be assessed fairly taking into consideration the influence of system factors.

Healthcare workers’ actions will be assessed without considering the patient’s outcome.

A range of responses to a person’s actions is possible. An appropriate response is determined after following a fair assessment that considers system factors.

The spectrum of responses to a person’s actions ranges from commendation, through a number of different corrective actions that can be taken to improve system safety, to discipline.

A healthcare worker will face discipline and the matter will be referred to the appropriate legal authority for investigation when their actions were undertaken with the intent to harm a patient.

Example: Covenant Health Just Culture Board Policy
Covenant Health has developed a Board level policy related to just culture.

Example: Alberta Health Services Just Culture Guiding Principles document

Alberta Health Services (AHS) chose to develop a guiding principles document rather than a policy. The guiding principles are applied to all policies that are developed by the organization. This ensures that the just culture principles are embedded in all organizational policies and that policies do not conflict with a just culture. AHS also developed seven posters, one for each of the guiding principles. Links to these documents are available in the AHS Just Culture Resources tab in the Resources section.