Just Culture: learn from patient safety to promote trust between your data teams


Zach Bork is on a mission to reframe what it means to make a mistake.

“I want our teams to know it’s okay to fail—because we can fail forward, and we can learn from those things,” says Zach, who is vice president of enterprise analytics and transformation at CentraCare, a sprawling organization that runs eight hospitals and 30 clinics throughout Central Minnesota.

There’s a name for that.

Many organizations call this approach “Just Culture”—where mistakes are met with curiosity, teamwork, and a shared desire to improve, instead of with blame or reprimand.

The aerospace and nuclear industries were pioneers of Just Culture, recognizing that the only way to prevent dangerous errors is to analyze and learn from every mistake. Healthcare leaders have also embraced Just Culture when it comes to patient safety, teaching this approach as early as med school, and making a significant (and increasing) impact on surgical errors, medication errors, and hospital-acquired infections, just for starters.

Alison Whelan, MD, is the chief medical education officer at the Association of American Medical Colleges (AAMC), and, in a recent article, she talked about Just Culture this way: “Our culture has shifted from shame and blame to recognizing the need to continuously learn and improve through collaborative practices.”

Zach sees a place for Just Culture beyond just patient safety, and he’s leading the charge to instill this approach with his data and analytics teams, and the teams they serve.

How Just Culture applies to data

“Analytics is one of those spaces where, when the end user sees data or a report, the reaction tends to be, ‘Let’s poke holes in it,’ or ‘Let’s figure out what’s wrong with it,’” says Zach, “which is challenging if you’re the data expert—because you feel like people are constantly challenging work that you’re confident is solid.”

This “challenge the data” problem can snowball if there actually is an error in the data, which, inevitably, happens. “When we occasionally deliver errors, people feel justified in poking more and assuming that all of the data is flawed,” says Zach. It becomes an “it’s not my problem, it’s your problem” situation.

“When this happens,” he says, “data analysts might become a little more guarded and less receptive to feedback because they’ll think, ‘I feel like I get criticized every time I share this—but I did my best.’” And, as a result, the organization misses out on important insights about where improvement is needed.

So what’s the solution?

This kind of finger-pointing and mistrust is a real problem for healthcare. It can prevent organizations from honestly addressing what their data is revealing. As Zach helps lead CentraCare toward a data-driven culture, he sees a Just Culture as key to making that shift. Here are seven ways he plans to do so:

1. Make sure everyone understands the purpose of the data.
“If we’re clear up front that the data is to be used for improvement and understanding—and not to be punitive or to say someone’s not doing a good job or to attack their work—then I think everyone’s guard comes down a little bit, and they go more to a place of curiosity,” says Zach. “When everyone at the table is genuinely curious, it goes a lot better.”

2. Redefine the meaning of mistakes.
Zach wants everyone at CentraCare to feel safe to uncover errors, own mistakes, and talk about issues with fellow teams or colleagues. “It’s okay to be wrong,” says Zach. “Then what do we do to fix it? And is there something bigger we can learn?”

3. Stay focused on learning what’s true.
In a Just Culture, everyone at the table is open to being questioned, as long as the questions are driven by curiosity. “We want the questions to be motivated by a desire to know what’s true,” says Zach, “not to just confirm existing views.”

4. Fix the systems to improve for the future.
Zach points out that mistakes are often made possible by the system a person is working within, instead of being caused by the person. “Maybe today Zach made that error, right?” he says, “but that process is bigger than just Zach. And so if we don’t fix it, tomorrow Julie might make an error. And then Kevin could make the same error a few days later. So if we’re always working on improvement—and fixing those errors—we can prevent that from happening to others. Most often, it’s about the process, not the person.”

5. Learn to collaborate on quality.
“I think you have to generally be okay with letting your guard down a little bit,” he says. “So you can say, ‘Hey, Julie, will you take a look at this for me?’ And it’s going to be okay if Julie identifies a couple of things that might be wrong. And I’ll receive those out of my own curiosity—to investigate it a little bit and end up with a better product.”

6. Celebrate mistakes.
“I think at a bare minimum, we could celebrate when we find errors,” says Zach. “Not because it’s an error, right? But because we found it and we did something about it to prevent it from happening again.” Which, ultimately, makes the analytics—and the organization—better.

7. Provide ongoing support.
Zach plans to huddle a couple times a week with his data teams to check in on what errors have been found, what’s been prevented, and what’s been learned. He’ll also gauge where support is needed: “A big part of my role is to support the team and help them design processes and prevent these things so that they can continue to do the great work that they do.”

A better way to work

Zach envisions a day where the data team could present a report that reveals room for improvement within another CentraCare team, and—instead of that team getting defensive—everyone would approach the information with curiosity.

He’s starting this approach within his data teams, encouraging them to work together to uncover their own mistakes, so their data is better trusted throughout the organization. They are modeling the Just Culture Zach hopes others will embrace.

Is your data team embracing a Just Culture?

If so, we’d love to feature your organization in our Just Culture series. Let’s connect!

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