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The Four Cornerstones of a Just Culture:

Create a Learning Culture
A learning culture is the foundation of customer safety. It is a culture that is hungry for knowledge. In the case of patient safety, it is a culture that is eager to understand risk at both the individual and organizational level. We can see risk through events and near misses. We can see risk by observing the design of the systems in which we work, our behaviors, and the behaviors of those around us. We must all be willing to learn from our mistakes and to share this learning in a manner that supports system design and continued safe choices.

Create an Open and Fair Culture
To create a learning environment, organizations must move away from an overly-punitive reaction to events and errors. We must ask the erring employee or provider to report the event so that others may not be denied the learning opportunity. That being said, a strong safety culture is one that reinforces accountability for safety across all levels of the organization. It is a system of accountability that does not focus on the human error or the unintended consequences but rather focuses on the quality of our decisions as components of the system. From the CEO to the entry level employee, we must be accountable to our customers for the choices we make.

Design Safe Systems
It is the system in which we work that has the greatest overall influence on the safety of our cusotmers. We must design systems based on robust engineering principles as seen in high reliability industries like power and aviation. Our systems must anticipate human error, capture errors before they become critical, and permit recovery when errors do reach the customer.

Manage Behavioral Choices
While we must anticipate that we as humans will make mistakes, it is our management of behavioral choices that will allow us to achieve the outcomes we desire. A strong safety culture puts a premium on critical decision making skills and asks everyone to continuously evaluate the risks inherent in the choices they make. Good event investigation and coaching/mentoring skills are vital to successfully managing the choices of your staff.