Just Culture – Entry 3

Dear Diary:

Today I listened to a webinar on “just culture” and I realized that this is something that I have put on the back burner for quite some time. Since working with the staff on not looking for someone to blame, like the nursing assistant who they pointed fingers at when Hattie fell last year, I realized that we haven’t made any significant changes in our culture to make it more fair and just. We did a great root cause analysis (RCA) on what was the real cause of that fall. And, sure enough, Sherry, the nursing assistant, was not to blame. Hattie had been in the middle of transferring herself, so Sherry didn’t have time to assist her with a transfer belt. We used that incident to help us change our focus when we are doing RCAs. Instead of assuming that education or training of an individual is the problem, we focus on what was going on at the time that allowed the problem to occur and then look for opportunities to change the process in order to minimize the chance of the problem happening again.

I think we are doing a pretty good job at focusing on systems rather than individual behavior. However, the webinar made me think more about how we need to work on establishing a culture in which caregivers do not fear retaliation for reporting quality concerns. To do this, we must hold everyone accountable for their performance, but not punish for unintentional errors.

As I review the QAPI self assessment, I see that our organization does not have a process in place to distinguish between unintentional errors and intentional reckless behavior. I am overwhelmed –changing a culture is hard! The webinar speaker referred to the Minnesota Alliance for Patient Safety (MAPS) Road Map to a Safety Culture. I checked out the audit questions under the Justice Domain and found specific actions that will help our home. Looks like the first step is having a chat with our administrator, Dan, since we need to start by educating our senior leadership. I know I can’t do this alone!

I wonder what other efforts will help result in a safer environment for our residents and a fair and just culture for our staff?

Signed, Donna


  • At our last QAPI it was noted that the majority of our Vulnerable Adult reports are related to staff not following a residents care plan. Current practice has been to bring staff in for education asking them to sign a performance discussion tool. Documenting that they have received the information and understand the importance of following residents care plans.
    At our QAPI meeting we determined that we needed to focus on systems and find out what barriers are keeping staff from following the care plan. We have always asked the question and looked at the why’s to implement changes. We are taking this one step further and looking at the system to determine if process changes are necessary.

  • We have have worked on just process by “blame the system not the people” unless it is obvious reckless behavior. We involve staff from all departments to look at the system to look at changes that could occur thru root cause analysis to improve quality and decrease recurrence of incident.
    Staff are encouraged to speak up and be an active part of the change.
    For example at one of our QAPI meetings we did a root cause analysis of how to ensure “anti roll backs on w/c’s are working properly and started a “maintenance prevention audit”.

  • We are moving in that direction…we use the term adaptive culture. The biggest piece is for every worker to understand they do have “power”. I still hear the verbiage of management versus “us”. This is were we are focusing our attention, in the power we all have to make change and recognizing those that use their power respectfully and wisely.

Share your nursing home perspective on this quality improvement issue.