Just culture

{{Short description|Balanced accountability for both individuals and the organization}}

{{Use dmy dates|date=February 2025}}

Just culture is a concept related to systems thinking which emphasizes that mistakes are generally a product of faulty organizational cultures, rather than solely brought about by the person or persons directly involved. In a just culture, after an incident, the question asked is, "What went wrong?" rather than "Who caused the problem?".{{cite journal |last=Catino |first=Maurizio |title=A Review of Literature: Individual Blame vs. Organizational Function Logics in Accident Analysis |journal=Journal of Contingencies and Crisis Management |date=March 2008 |volume=16 |issue=1 |pages=53–62 |doi=10.1111/j.1468-5973.2008.00533.x |s2cid=56379831 |type=Review}} A just culture is the opposite of a blame culture. A just culture is not the same as a no-blame culture as individuals may still be held accountable for their misconduct or negligence.{{cite book |last=Reason |first=James |date=1997 |title=Managing the Risks of Organizational Accidents |publisher=Ashgate Publishing |isbn=9781840141054 }}

A just culture helps create an environment where individuals feel free to report errors and help the organization to learn from mistakes. This is in contrast to a "blame culture"{{cite journal |title=From a Blame Culture to a Just Culture in Health Care |last=Khatri |first=N. |journal=Health Care Management Review |date=October–December 2009 |volume=34 |issue=4 |pages=312–22 |publisher=Health Care Manage Rev |doi=10.1097/HMR.0b013e3181a3b709 |pmid=19858916 |s2cid=44623708 }} where individual persons are fired, fined, or otherwise punished for making mistakes, but where the root causes leading to the error are not investigated and corrected. In a blame culture mistakes may be not reported but rather hidden, leading ultimately to diminished organizational outcomes.

In a system of just culture, discipline is linked to inappropriate behavior, rather than harm.{{cite web |url= https://www.ems1.com/paramedic-chief/articles/374186048-Just-Culture-basics-for-EMS/ |title= Just Culture basics for EMS |last= Behn |first= Brian |date= 29 January 2018 |publisher= National EMS Management Association |access-date= 28 June 2019 |archive-date= 28 June 2019 |archive-url= https://web.archive.org/web/20190628194159/https://www.ems1.com/paramedic-chief/articles/374186048-Just-Culture-basics-for-EMS/ |url-status= dead }} This allows for individual accountability and promotes a learning organization culture.

In this system, honest human mistakes are seen as a learning opportunity for the organization and its employees. The individual who made the mistake may be offered additional training and coaching.{{cite web |url=http://lacdmh.lacounty.gov/ContractorsPolicies/Attachments/100_05_Att_2.pdf |title=Just Culture System and Behaviors Response Guide |date=9 August 2017 |publisher=Los Angeles County Department of Mental Health |access-date=28 June 2019 |archive-date=28 June 2019 |archive-url=https://web.archive.org/web/20190628194208/http://lacdmh.lacounty.gov/ContractorsPolicies/Attachments/100_05_Att_2.pdf }} However, willful misconduct may result in disciplinary action such as termination of employment—even if no harm was caused.

Work on just culture has been applied to industrial,{{cite book |chapter-url=https://www.onepetro.org/conference-paper/SPE-190594-MS |chapter=The Long and Winding Road to a Just Culture |last=Groeneweg |first=J. |title=SPE International Conference and Exhibition on Health, Safety, Security, Environment, and Social Responsibility |date=2018 |publisher=Society of Petroleum Engineers |doi=10.2118/190594-MS }} healthcare,{{cite journal |url=https://www.jacr.org/article/S1546-1440(17)30499-4/fulltext |title= The Just Culture Framework |last=Harvey |first=H. Benjamin |journal= Journal of the American College of Radiology |date=17 June 2017 |volume= 14 |issue= 9 |pages= 1239–1241 |doi= 10.1016/j.jacr.2017.04.030 |pmid= 28633924 }}{{cite journal |title=Just Culture: A Foundation for Balanced Accountability and Patient Safety |last=Boysen |first=Philip |date=Fall 2013 |volume=13 |issue=3 |pages=400–406 |journal=The Ochsner Journal|pmid=24052772 |pmc = 3776518}} aviation{{cite web |url=https://flightsafety.org/files/just_culture.pdf |title=A Roadmap To A Just Culture: Enhancing the Safety Environment |last=Gain Working Group E, Flight Ops/ATC Ops Safety Information Sharing |date=September 2004 |publisher=Global Aviation Information Network}}{{cite web |url=https://www.eurocontrol.int/initiative/just-culture |title=Just culture Finding the right balance between the aviation, judicial and political authorities |publisher=EuroControl |access-date=28 June 2019 }} and other{{cite book |last=Dekker |first=Sidney |date=1 January 2018 |title=Just Culture: Balancing Safety and Accountability |url=https://archive.org/details/justculture_dekk_2012_000_10663101 |publisher=Ashgate Publishing |isbn=9780754672678 |url-access=registration }} settings.

The first fully developed theory of a just culture was in James Reason's 1997 book, Managing the Risks of Organizational Accidents. In Reason's theory, a just culture is postulated to be one of the components of a safety culture. A just culture is required to build trust so that a reporting culture will occur. A reporting culture is where all safety incidents are reported so that learning can occur and safety improvements can be made. David Marx expanded the concept of just culture into healthcare in his 2001 report, Patient Safety and the "Just Culture": A Primer for Health Care Executives.{{cite web |url=https://www.chpso.org/sites/main/files/file-attachments/marx_primer.pdf |last=Marx |first=David |date=17 April 2001 |title=Patient Safety and the "Just Culture": A Primer for Health Care Executives |access-date=27 April 2021 |archive-date=20 January 2022 |archive-url=https://web.archive.org/web/20220120031819/http://www.chpso.org/sites/main/files/file-attachments/marx_primer.pdf |url-status=dead }}