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Just Culture. www.justculture.org. Just Culture is about:. Creating an open, fair, and just culture Creating a learning culture Designing safe systems Managing behavioral choices. Adverse Events. Human Errors. System Design. Managerial and Staff Behaviors.

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just culture

Just Culture


just culture is about
Just Culture is about:

Creating an open, fair, and just culture

Creating a learning culture

Designing safe systems

Managing behavioral choices






Managerialand StaffBehaviors

Learning Culture / Just Culture

a model that focuses on three duties balanced against organizational and individual values
A Model that Focuses on Three Duties balanced against Organizational and Individual Values

The Three Duties

The duty to avoid causing unjustified risk or harm

The duty to produce an outcome

The duty to follow a procedural rule

Organizational and Individual Values








Two Specific Classes of Duty

  • Leave the house at 6:45 pm. Go south on Independence Ave, turn right on Parker. At the third light, hang a left, go three blocks, turn right and go to the fourth house on the right.
  • Meet me at 7:00 pm at 410 Chestnut Street

The Duty to Produce an Outcome

The Duty to Follow a Procedural Rule

the behaviors we can expect
The Behaviors We Can Expect

Human error - inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.

At-risk behavior - behavior that increases risk where risk is not recognized, or is mistakenly believed to be justified.

Reckless behavior - behavioral choice to consciously disregard a substantial and unjustifiable risk.

accountability for our behavioral choices
Accountability for our Behavioral Choices







Product of our current

system design

Unintentional Risk-Taking

Intentional Risk-Taking

  • Manage through changes in:
  • Processes
  • Procedures
  • Training
  • Design
  • Environment
  • Manage through:
    • Removing incentives for at-risk behaviors
    • Creating incentives for healthy behaviors
    • Increasing situational awareness
  • Manage through:
  • Remedial action
  • Disciplinary action




we need
We need…..
  • A culture that truly supports learning
  • A common understanding about how to treat people when things happen
the minnesota agenda
The Minnesota Agenda
  • Formation of a stakeholder group - The Minnesota Alliance for Patient Safety (MAPS)
  • Change state law
  • Developed principles of justice, learning and accountability
  • Change the policies and practices of:
    • The Boards
    • The Dept of Health
    • Delivery systems
our goal
Our Goal

The behavior of people involved in care delivery in the state of Minnesota will be judged using a common philosophy and a common set of principles across healthcare organizations, the Department of Health, the professional boards and professional associations

minnesota statement of support
Minnesota Statement of Support

Given that:

  • Medical errors and patient safety are a national concern to all involved in health care delivery.
  • We are legally and/or ethically obligated to hold individuals accountable for their competency and behaviors that impact patient care.
  • A punitive environment does not fully take into account system issues, and a blame-free environment does not hold individuals appropriately accountable
We resolve that our organization will:
  • Strive for a culture that balances the need for a non-punitive learning environment with the equally important need to hold persons accountable for their actions.
  • Seek to judge the behavior, not the outcome, distinguishing between human error, at-risk behavior, and intentional reckless behavior.
  • Foster a learning environment that encourages the identification and review of all errors, near-misses, adverse events, and system weaknesses.
Promote the use of a wide range of responses to safety-related events caused by lapses in human behavior, including coaching, non-disciplinary counseling, additional education or training, demonstration of competency, additional supervision and oversight and disciplinary action when appropriate to address performance issues.
  • Support and implement systems that enable safe behavior to prevent harm
  • Work to share information across organizations to promote continuous improvement and ensure the highest level of patient and staff safety.
  • Collaborate in efforts to establish a statewide culture of learning, justice, and accountability to provide the safest possible environment for patients.