PATH team members at Just Culture training


Just Culture is a clear and easy-to-use healthcare quality tool used to manage risk and prevent adverse events.   Leaders use the system to determine if an action was a simple human error, a risky choice or a reckless choice and how that behavior or choice should be managed.

On April 4, 2019, the Partnership to Advance Tribal Health (PATH) team hosted Just Culture training for the Great Plains Area Office (GPAO) and service units in Aberdeen, SD. Carrie Howard, PATH project manager from Stratis Health in Minnesota, presented the training which included an introduction of Just Culture along with the use of the decision algorithm. The Great Plains service units plan to implement Just Culture within each facility with support from GPAO and PATH.

“We hope the service units will be able to utilize this training in order to ensure a strong balance of accountability for staff along with ensuring safe practices throughout all organizations,” stated Lori Hestad, MBA, PATH program manager.

Just Culture is based on Outcome Engenuity’s model of shared accountability and enables the organization and its leaders to be held accountable for the designed systems and supporting the safe choices of both management and staff. All employees are accountable for their choices, behavior and actions and have a responsibility to report events, near misses and risks for potential errors or harm.

The system allows leaders to proactively identify and address risk versus reacting to events, errors or unwanted outcomes that have already occurred. In a Just Culture, each reported event or risk receives an in-depth investigation that leads to improvement of systems and processes. Depending on how the employee choices and actions contributed to the event or risk, the analysis provides insight for the appropriate counsel, coaching or punitive action.

The implementation of Just Culture should be measured, monitored and built into the facility’s QAPI program and internal incident reporting system. In order to measure outcomes from Just Culture Implementation, service units have completed Culture of Safety Surveys to evaluate employee satisfaction, communication among employees and encouragement of safety reporting. As Just Culture continues to evolve throughout service units, incident reporting should increase resulting in better patient outcomes. Culture of Safety Survey results should increase along with staff satisfaction and retention.

To expand and ensure implementation of Just Culture, representatives from the Great Plains IHS service units have been invited to attend the Just Culture Training in Albuquerque on May 14-16. This training will also include a train-the-trainer course, which will create master trainers in each facility to enhance sustainability of the Just Culture model.

Howard emphasized the value for quality improvement, “The concepts learned in Just Culture training help us see and understand the workplace and the world in a new way. This training provides tools and a support system to help organizations learn from mistakes, proactively identify and address areas of risk and nurture the most precious resource: employees.”