Just Culture refers to a values-supportive model of shared accountability. It’s a culture that holds organizations accountable for the systems they design and for how they respond to staff behaviors fairly and justly. That’s the definition according to Health Leaders Media.

The premise is instead of hospitals punishing people for making mistakes, they should concentrate on fixing the system problems causing mistakes to be made.

The concept of Just Culture has been proposed as a way to improve medical quality and safety for almost 20 years.

So how is it working out?

Back in 2012 and well after Just Culture had supposedly been adopted by many institutions, I blogged about some problems with Just Culture. At that time, a survey of 600,000 staff of over 1100 hospitals by the Agency for Healthcare Research and Quality found that half believed their mistakes were being held against them and more than half felt investigations into mishaps were more about the individual than the problem itself. These figures had not changed significantly since an AHRQ survey done in 2007.

It will come as no surprise to those in the medical community that the situation is about the same in 2018.

A new study from the American Journal of Medical Quality looked at the most recent AHRQ survey data and compared it to results from a survey of clinical peer review practices in a number of acute care hospitals in the US. In all, 211 (79%) of 270 responding hospitals had adopted Just Culture.

When hospitals that had not established a Just Culture were compared to those that had, there was no difference in the impact of clinical peer review. Subgroup analysis showed that the 33 hospitals whose survey informant rated the impact of Just Culture in their hospital as strongly positive had a somewhat better peer review process.

However, the author, Marc T. Edwards MD MBA, said, “This study found no correlations [of Just Culture] with publicly reported measures of safety beyond what might be expected by chance alone.”

Here is a chart from the paper showing the modest improvements in the nonpunitive response to error section of the AHRQ survey since 2007.

Just over 50% of staff felt their mistakes were held against them, and only 45% said hospitals responded to error in a nonpunitive way.

Edwards pointed out that for the responses to the nonpunitive response to error portion of the survey, “management ratings…run about 20% higher than staff ratings.”

Can management be trusted? Based on this experience, Dilbert doesn’t think so.

Another interesting study finding was, “For 25 hospitals (9%), self-reporting was one of the top 3 sources by which cases are identified for review. Among these, there was no association with Just Culture adoption or its impact.” So in 91% of hospitals, self-reporting is not a top source of case finding.

The author concluded, “In the absence of proof of efficacy, hospital leaders who are committed to the pursuit of high reliability in quality and safety should be cautious about the Just Culture model.”

Hospital staff should be cautious too.


Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last 8 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 3,000,000 page views, and he has over 18,000 followers on Twitter.