A Just Culture Takes Courage and TimePosted: October 5, 2012
I recently spoke with Diane Miller, VP & Executive Director of the Virginia Mason Institute about what it takes to change the culture of a healthcare organization in order to reach high reliability. She spoke of leadership and of teamwork–but she also mentioned courage. If, on any given day, 1 of the 30 leaders at Virginia Mason Medical Center (VMMC) needs a supportive boost to overcome an obstacle challenging their hospital pointed true north in the patient’s best interest, the well-established just culture at VMMC ensures that one of the other 29 leaders will pick that person up–the team never losing stride. They have honed a collective courage, and have one another’s back, as the saying goes. The journey then continues, all now stronger for having overcome the challenge together.
It’s well documented in the literature, that the existing culture of a healthcare organization is an indicator of the challenges that will lie ahead on the high reliability journey. According to James Reason, existence of a just culture is one of four subcultures it takes to ensure an informed culture, a safe culture–one that maintains “…states of wariness…to collect and disseminate information about incidents, near misses and the state of a system’s vital signs” (Weick & Sutcliffe’s Managing the Unexpected 2007). According to Reason, the sophistication of error reporting that contributes to an informed culture requires a level of trust throughout an organization that overcomes controversy–that is courageous. The three subcultures Reason believes an informed culture also includes are:
- Reporting culture—what gets reported when people make errors or experience near misses
- Flexible culture—how readily people can adapt to sudden and radical increments in pressure, pacing, and intensity
- Learning culture—how adequately people can convert the lessons that they have learned into reconfigurations of assumptions, frameworks, and action
Patrick Hudson, a psychologist who has done extensive and notable work in the oil and gas industry, and has published a number of papers on high risk industries, shares a model of cultural maturity in his article, Applying the lessons of high risk industries to health care (Qual Saf Health Care 2003 (12):i7-i12). His adapted model shows a safety culture to be evolutionary, moving up from:
- Pathological: safety is a problem caused by workers. Main drivers are the business and the desire not to get caught.
- Reactive: safety is taken seriously only after harm occurs.
- Calculative/Beaurocratic: safety is imposed by management systems, data is collected but workers are not on board.
- Proactive: workforce starts to embrace the need for improvement and problems found are fixed.
- Generative: there is active participation at all levels of the organization; safety is inherent to the business and chronic unease (wariness) is present.
According to Hudson, organizations with an advanced safety culture possess the following qualities, he refers to as dimensions:
- It is informed
- It exhibits trust at all levels of the organization
- It is adaptable to change
- It worries
Moving an organization through the cultural evolutionary continuum, to an advanced safety culture is not an overnight task. In fact, during our conversation, Diane also reminded me that the journey to achieve VMMC’s level of success took time. Time and courage in a day and age where quick fixes and status quo no longer work, but are challenging to change. But both time and courage will be necessary to address the culture change needed in medicine, and recently called for in the Institute of Medicine (IOM) report on September 6th. VMMC was mentioned during the IOM webcast covering the report, as an example of the bold leadership it took to get to where they are today, and where others will soon need to follow. (More information on the recent IOM Report can be found here).