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How can individual departments in my organization move towards a just culture to ensure effective quality improvement?


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Effective quality improvement (QI) demands the involvement of all staff members who participate in the operational process, and it demands their willingness to view themselves as part of a system. If physicians, nurses, management, and others cling to a belief that quality outcomes could be ensured if everyone would just do their jobs more carefully, you won't be able to develop truly high-reliability and high-quality care processes.

Further, as long as staff members believe they will be punished if they reveal personal shortcomings, errors, and potential errors, they will simply not identify those issues that could actually improve the process. The terms "blame-free culture" and "just culture" are beginning to circulate in the healthcare field to denote an environment in which it is openly acknowledged that people make mistakes, care is delivered as part of a system, and improvement of that system is the only way to improve care. Such a culture asserts-and demonstrates-that staff will not be punished for identifying ordinary human error (as opposed to malicious, criminal, or flagrantly reckless conduct). And such a culture proves itself by in-vesting resources in systems improvement that makes the work and care environment safer, more productive, more rewarding, and more deserving of trust.

This kind of culture is not achieved quickly. Not only do physicians maintain a powerful concept of personal accountability, but both physicians and nurses are aware that their licenses can be at risk for certain kinds of errors and quality out-come failures.

Within an individual department, steps you can take toward a just or systems culture include:

  • Maintaining an overriding focus on the ultimate goal of your department, such as care or service that measurably meets the needs of the patient/customer
  • Paying most of your attention to systems measurement and improvement
  • Ensuring that interdisciplinary communication is always respectful and appropriate
  • Keeping all discussions of performance focused on the system of care and barriers to the effective use of the system
  • Prohibiting group or public discussions that focus on identified individual performance issues
  • Building an effective system that screens for individual performance problems and a confidential, effective method to address them
  • Adhering to principles of confidentiality, fairness, and equitable treatment of all staff members


- Cynthia Barnard, MBA, MSJS, CPHQ, and Barbara J. Hannon, RN, MSN, CPHQ

(March 2012)