Expo Precon: Creating an Accountable and Just Culture

Organizations create the system in which employees work. They provide guidance and support for employees as they work within that system.

“Your organization has a culture, whether you created it deliberately or not,” said Brian Lacroix, BS, FACPE, CPPS, NRP (Ret.), during the preconference session "Creating an Accountable and Just Culture" Oct. 10, 2022 during EMS World Expo.

Lacroix is executive advisor and cofounder of the Cambridge Consulting Group and EMS coordinator at the Center for Patient Safety, a St. Louis-based nonprofit whose mission is to reduce preventable harm. Lacroix is a retired EMS chief at Allina Health EMS in Minnesota.

How to handle employee mistakes is a large part of defining an organization's culture. In the 1990s, health care companies began to move away from a punishment model for mistakes, said Kathy Wire, JD, MBA, executive director of the Center for Patient Safety, and more toward a goal of how an individual provider and a health care system can learn from those errors. Punishing employees for mistakes runs counter to learning from them, Wire said.

What is Just Culture?

According to the presenters, Just Culture (capitalized) offers tools and a framework to develop a system “that provides safe, reliable, and successful outcomes, staffed by the people you want to keep.” Just culture (uncapitalized) supports staff as they make choices every day.

Just culture can improve many EMS-related benchmarks:

• Retention rate/turnover rate
• Voluntary and involuntary turnover
• New hire retention/attrition
• Cost of turnover
• Average tenure
• Employee satisfaction
• Employee engagement

Just culture is a risk management system, Wire said. “Everybody deals with risk all the time,” she said, and it’s not inherently bad. We all make mistakes, and we all “drift” away from good choices because we feel it’s OK. To attempt to eliminate risk is not realistic.

Striking a Balance

The Just Culture algorithm starts with clear, articulated values, continues with effective investigations of current practices, and then addresses the barriers and obstacles between them. The system’s values must support the culture, and must strike a balance between the extremes of individual punishment and treating every mistake as though it is a system problem (which eliminates individual accountability).

Wire and Shelby J. Cox, EMT-P, patient safety project coordinator of the Center for Patient Safety, led conference attendees through interactive hypothetical scenarios for discussion, such as an instance in which an intruder steals medications from an unlocked medication box in an open ambulance bay. Tables were asked whether they, as a supervisor, would do nothing, coach the employee, discipline the employee, or terminate. Discussions centered around differing approaches and their pros and cons.

In the end, an organization's goal should be that mistakes are expected and used as a learning opportunity. This is not the same as tolerating bad behavior, which will become your new normal if it’s not addressed effectively, Lacroix said.