UI hospitals expect better culture to bring better results

Reporting errors first step to solving them, concept advocates

University of Iowa Hospitals and Clinics Chief Executive Officer Suresh Gunasekaran meets Nov. 19 with The Gazette's edi
University of Iowa Hospitals and Clinics Chief Executive Officer Suresh Gunasekaran meets Nov. 19 with The Gazette’s editorial board. UIHC is looking for a consultant to help it instill the concepts of a “just culture” that encourages employees to report mistakes — the first step in improving outcomes — without undue fear of retribution. (Liz Martin/The Gazette)

IOWA CITY — Health care workers, like any other typical employees, can fear being punished for making mistakes.

But not all industries face the same real-life consequences for letting problems go unsolved as does, say, a hospital that admits some 40,000 patients a year and employs thousands.

So Iowa’s largest medical facility — the University of Iowa Hospitals and Clinics — is looking to instill a work atmosphere across its campus that encourages employees to communicate errors and improve outcomes.

There’s a name for the philosophy: A “just” culture.

“The name ‘just culture’ comes from differentiating it from a ‘blame culture,’” said UIHC Chief Executive Officer Suresh Gunasekaran in an interview.

The model — which emerged for health care providers nearly two decades ago — “holds organizations accountable for the systems they design and how they respond to staff behavior fairly and justly, rather than holding an individual accountable,” according to the initiative’s architect, engineer and lawyer David Marx.

“It’s about finding the middle ground between a punitive environment and a blame-free one,” Marx told the UIHC in October, before speaking at its annual Quality and Safety Symposium.

Although UIHC leaders have been public about their efforts to improve patient and employee satisfaction, Gunasekaran said this “just culture” push is more proactive than reactive.


“This is one of those things where we think we’re doing pretty well,” he said. “But we think we can continue to do things to make us better, and we think it’ll have an impact on the whole organization — meaning I think it’ll help us with patient satisfaction and employee engagement. I think it’s just about being a better organization.”

This isn’t the first time UI Health Care has waded into “just culture” territory, but administrators recently took efforts further by issuing a call for potential consultants interested in helping UIHC implement “key concepts of being a high-reliability organization.”

“We are looking for a partner to help us address our operational, quality, and safety challenges,” according to the request for qualifications, issued Dec. 23 with a Jan. 20 deadline.

A resulting contract would require the university’s new partner to assess the current state of UIHC; create a “just culture” framework for the hospital; craft key concepts; provide online and in-person training to achieve and sustain “culture transformation”; support policy creation and implementation; support rollout; and prepare a sustainment plan.

UIHC — in its association with the University of Iowa — serves as the state’s only academic medical center with a mission of providing “world-class family-centered health care, extensive medical research, and comprehensive teaching programs for many health care professions.”

The system has more than 760 staff physicians and dentists, about 480 resident physicians and dentists; 180 fellow physicians; 1,565 nurses; and 4,640 other professional and support staff.

The hospital recently reported lower-than-average patient satisfaction scores for things like nurse and doctor communication; prompt help; and room and bathroom cleanliness.

The hospital, according to a government report, has complication and death outcomes on par with national figures — and better-than-average scores for things like preventive care and cancer treatment.


Hospital officials didn’t immediately have specific numbers on provider errors and the rate at which they’re reported. But Gunasekaran said the more reporting, the better — and the “just culture” push should help encourage as much.

“Reporting is just a sign of communication, and what we’d really like is for communication to improve,” he said. “That’s the bottom line. Leading health care organizations try to make sure that they support their staff and proactive communication at all times to make patients safer, to help the care team be more efficient, and figure out new ways to make therapies effective.”

So often, he said, work is hard-wired into habit, and hospitals aren’t focusing on making their processes better.

“What we’re really trying to do is teach our staff the skills and teach ourselves the discipline to allow ourselves to make something better,” Gunasekaran said. “Reporting is just a first step in improving. If you don’t report, then you don’t improve.”

Marx — who today is CEO of the risk management agency Outcome Engenuity — created the concept of “just culture” out of his background as an aircraft design engineer focused on preventing human error, among other things.

He characterizes his culture-centered program as a five-skill behavioral management model that incorporates values and expectations; system design; behavioral choices; learning systems; and accountability.

That accountability piece involves striking a balance between creating safe spaces for employees to report errors while also holding workers accountable.

“Few people are willing to come forward and admit to an error when they face the full force of their corporate disciplinary policy, a regulatory enforcement scheme, or our onerous tort liability system,” according to Marx’s 2001 paper on “Just Culture.”


“Yet, no one can afford to offer a ‘blame-free’ system in which any conduct can be reported with impunity — as society rightly requires that some actions warrant disciplinary or enforcement action.”

The system aims to answer the question, “Where do you draw the disciplinary line?”

Having a “just culture” acknowledges that some actions demand punishment or require it — particularly in the highly-regulated health care industry.

But, Marx’s paper argues, “Our system has been too focused on blaming the individual provider, with too little emphasis on how we could have learned from the errors of the past.”

“There need be no loss of accountability because of disciplinary system changes. It is instead a different type of accountability — one that requires an employee raise her hand in the interests of safety,” according to Marx’s paper. “Not reporting your error, preventing the system and others from learning — this is the greatest evil of all.”

Gunasekaran acknowledged that UIHC still will respond to errors, at times, based on the severity of harm done. Last month, The Gazette reported the state agreed to a $1.2 million settlement after UIHC discovered a surgical towel and silver staple had been left inside a cancer patient in one of its operating rooms.

But, Gunasekaran said, by opening the lines of employee-supervisor communication, UIHC can more honestly assess its practices and processes in its pursuit of excellence.

“Most of our goals do lie around educational excellence, delivering high quality care, high patient satisfaction, and using resources efficiently,” he said.

Comments: (319) 339-3158;

Give us feedback

We value your trust and work hard to provide fair, accurate coverage. If you have found an error or omission in our reporting, tell us here.

Or if you have a story idea we should look into? Tell us here.