Information For Managers

Why managers are important to a just culture

Managers establish a foundation for a just culture in their area by regarding reports of patient safety concerns and errors from patients and staff as signals of possible system weaknesses (rather than problems with healthcare workers) that need to be addressed. 

When a patient is harmed or almost harmed by the care they received, the way a manager assesses a person’s actions  sends a strong message about the presence or absence of a just culture.

A consistently applied and fair assessment process that considers the actions of individuals in the context of the system builds trust with healthcare workers.

A focus on identifying system factors that influenced the person’s actions signals a belief that errors are often a symptom that something is wrong with the system, and that fixing the system is the most effective way to reduce the likelihood of future errors. 

When healthcare workers trust the system they work in, they willingly report serious threats to patients’ safety – hazards, hazardous situations, errors and patient safety incidents.

Top 7 things managers can do to foster a just culture:

  1. Welcome reports about patient safety concerns or errors as an opportunity to learn about weaknesses in the system that may put patients at risk of harm.
  2. When a patient is harmed or almost harmed by the care they receive, take the time to gather all the facts about what happened and why. Do not make hasty judgments about the situation.
  3. Avoid blaming someone for what happened (or nearly happened) to a patient.
  4. When something goes wrong, treat the people involved – healthcare workers, patients, families – with respect, dignity and compassion.
  5. Use a structured, systematic approach to understand why people did what they did in the context of the situation.
    • Create a timeline of events.
    • Use knowledge of human factors to inform a system view of events and how people’s actions were influenced by the context of the situation.
    • Organize the information to determine how system factors influenced the actions of the individual(s) involved.
  6. Use a systematic approach to determine what an appropriate response to a person’s actions should be in the context of the situation.
  7. Communicate with your staff proactively about the organization’s process for assessing an individual’s actions and how decisions are made about what an appropriate response to those actions will be.