David Marx, JD – Outcome Engenuity – A Just Culture

Just Culture – What is it exactly?  Are bad outcomes always the result of an individual intentionally causing harm?

David Marx and Outcome Engenuity have worked closely with the Center for Patient Safety (CPS) in the past, and CPS offers a number of options for Just Culture training and implementation through our OE certified trainers.  Here is David’s message:

How we think about workplace accountability is inherently important.  The concept of justice is the foundation of our society and is something that every American expects, including in the workplace.

Safety in the workplace is important, but how do we establish a culture that encourages open reporting of adverse events and risky situations, yet hold people and organizations accountable in a just manner?  The challenge lies in distinguishing between a system that might create risks, human error which may result in a bad outcome, and reckless behavior that intentionally puts lives or organizations at risk.

As the result of a movement in the aviation industry, Just Culture is redefining our system of work place justice in many other industries over the last 20 years, including health care.

As an example, currently there is a 60% compliance rate for hand washing in health care.  Why?  Is it because human error results in our forgetting to wash our hands prior to patient contact, or is it a reckless choice made by individual healthcare providers intentionally disregarding the need to wash their hands, or is it a system perpetuated by the organization that presents barriers and lack of incentives for proper hand washing?

Just Culture reshapes our understanding of accountability, the role of the system, and the role of human behavior, allowing us to distinguish between human behaviors to help us arrive at a consistent way to establish a safe environment by managing the system, and behavior.

For more information, or to set up training at your facility, contact the Center for Patient Safety at 573.636.1014.

For more information on Just Culture, visit Outcome Engenuity.


Learn more about the applications of Just Culture at your organization.

Contact the Center for Patient Safety to request more information, or to find training near you or to host training at your site.


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