About the authors: John Bustle, MD, Chief Medical and Operations Officer at QuadMed, Charlene Thiede, RN, Clinical Quality Specialist at QuadMed, and David Huntsman, Ph.D., Research Scientist at The Just Culture Company, coauthored this article to summarize QuadMed’s Just Culture implementation journey.

About QuadMed

QuadMed (www.quadmedical.com) is a nationally recognized provider of health and wellness solutions designed specifically for employers. The model features a full continuum of high-quality, patient-centered services proven to decrease costs by increasing accessibility and engagement. The company’s 33-year track record of success is rooted in integrating prevention-focused, comprehensive primary care and occupational health with leading-edge technology and analytics.

Introduction

QuadMed successfully integrated Just Culture into the organization, leading to substantial improvements in workplace safety, transparency, and employee trust. By fostering a non-punitive environment for reporting errors and building a culture of psychological safety, QuadMed achieved:

A 35% increase in perceptions of a non-punitive response to errors (from 28% to 63%), surpassing national benchmarks.
A 15% overall improvement in workplace justice and safety.
Engagement of 100% of QuadMed staff in formal Just Culture training.

This article explains why QuadMed adopted Just Culture, the best practices used, and the factors behind QuadMed’s success.

Motivation

While there was strong internal interest in the concepts of Just Culture within QuadMed, previous efforts were inconsistent and lacked the structure required to drive a true culture change. By adopting Just Culture, QuadMed’s goal was to build a safer, more transparent environment where errors could be reported without fear of punitive action, fostering psychological safety, and supporting continuous improvement.

Working with The Just Culture Company, QuadMed began a full implementation in June 2023. By January 2024:

100% of personnel received formal training in Just Culture principles.
725 staff members completed the Workplace Justice for Staff training.
21 QuadMed Just Culture Champions were certified across various departments.
All leaders not already trained as Champions, 65 in total, were trained in Just Culture management and influencing strategies.

Supported by the Data

The Just Culture Company (JCC) measured the impact of QuadMed’s full Just Culture implementation on workplace justice and safety using the Just Culture Improvement Index (JCII). Pre-measurement was conducted in June 2023 with a sample of 257 employees, followed by a post-measurement one year later in June 2024 (N=261).

The JCII evaluates an organization’s baseline across nine critical behaviors: open reporting¹, peer-coaching², search for causes³, system design⁴, transparency⁵, non-punitive response to errors⁶, accountability⁷, lack of severity bias⁸, and equity⁹. Additionally, QuadMed measured bottom-up and top-down coaching as extra metrics, for a total of 11 measured behaviors.

Five Key Factors

Explaining QuadMed’s Success

The Just Culture Company identified five critical factors that contributed to the successful implementation of Just Culture at QuadMed. These factors illustrate the alignment of leadership, cross-department collaboration, and ongoing commitment to continuous learning, all of which played pivotal roles in their achievement.

Dedicated Leadership and Champions

(1) Principal Advocates: Charlene Thiede played a pivotal role as an advocate for Just Culture. As the face of Just Culture within QuadMed, Charlene was instrumental in conducting training, fostering interdepartmental collaboration, and pushing forward the initiative with unwavering dedication.

(2) Structured Coordination: The structured biweekly meetings of the Just Culture workgroup facilitated ongoing coordination and adaptation of strategies, ensuring consistent focus and momentum with leaders among key departments, including Quality, Legal, Compliance, HR, Operations, and Marketing.

Collaborative and Inclusive Culture

(3) Multidisciplinary Collaboration: By involving a diverse range of departments and perspectives, QuadMed fostered a culture of collaboration that ensured Just Culture principles were applied holistically across the organization. This comprehensive approach ensured that safety, transparency, and accountability became shared values throughout the company.

Continuous Learning and Adaptation

(4) External Benchmarking and Continuous Learning: Learning from the experiences of respected institutions like Children’s Wisconsin allowed QuadMed to refine its approach and preemptively address potential challenges.

(5) Ongoing Training and Case Reviews: Monthly case reviews facilitated continuous learning, enabling leaders to internalize Just Culture principles and apply them consistently.

Aggregate Findings

The JCC analyzed the data and compared QuadMed’s pre-post JCII scores across all 11 measures. The graph on the prior page shows the percent agreement scores for clinical employees across each behavior as it relates to safety issues, comparing pre (light blue bar) and post (dark blue bar) Just Culture implementation. The light grey shaded bar represents the U.S. healthcare benchmark for clinical employees (N=324) for further reference. Results included:

A 15% improvement in learning and justice, with all 11 behaviors rated significantly higher post-implementation.
A notable 35% improvement in perceptions of a non-punitive response to errors, rising from 28% to 63%.

This score not only marked a significant internal achievement but also represented the highest non-punitive score among all other peers and high-risk industries (e.g., healthcare, EMS, police, aviation, etc.). The score also surpassed the Agency for Healthcare Research and Quality’s (AHRQ) Surveys on Patient Safety Culture (SOPS) U.S. hospital benchmark for perceptions of non-punitive responses to errors (45%).

It is also worth noting that prior to exposure to Just Culture in June 2023, QuadMed scored nearly 10% more punitive than U.S. healthcare clinicians (bottom percentile); post implementation / training, however, QuadMed scored nearly 30% higher, jumping to the top percentile. The scores and differences are slightly lower when analyzing non-clinical staff, likely due to their unfamiliarity with certain questions involving safety.

Before implementation, the disciplinary process was largely subjective. An objective process was defined within the Progressive Discipline Policy, but there was insufficient evidence to assist in understanding how to respond to events and where the disciplinary threshold existed for various situations. After implementation, leaders were able to look at events in a consistent manner and shift focus to understanding how an event occurred, what led to the employee’s decision involved in that event, and how to prevent it in the future. Challenging the severity bias was key to enhancing employees trust of management.

Key Implementation Practices

Several key practices were essential to ensuring an effective, efficient, and successful Just Culture implementation for QuadMed. These are not listed in order of importance, as each played a crucial role in the QuadMed journey.

Learning from External Organizations
Benchmarking and Collaboration: Prior to implementing Just Culture, QuadMed benchmarked its approach by collaborating with Children’s Wisconsin. Learning from their experiences and challenges helped them anticipate potential issues and ensure a smoother implementation process.
Leadership Commitment
Top-Down Priority: QuadMed leadership, including CEO Dr. Kathryn Quadracci Flores and John Bustle, MD, CMO, established Just Culture as a critical long-term strategic priority. This commitment was embedded not only in messaging but within QuadMed’s organizational values, signifying a shift toward a culture of safety and transparency.
Extensive Certification and Training
Broad Certification: QuadMed took an inclusive approach by certifying a broad range of leaders as Just Culture Champions, extending beyond clinical and compliance staff to include managers from multiple departments. Widespread certification ensured that Just Culture principles were understood and embraced across the organization.
Ongoing Training Programs: Monthly training sessions were embedded into the organization’s routine, ensuring continuous education and reinforcement. Managerial training sessions and organization-wide training modules ensured that all staff were conversant with Just Culture principles. This approach achieved 100% training among 725 staff members and 65 QuadMed leaders.
Robust Communication and Involvement
Regular Town Halls: Monthly town halls provided a platform for transparent communication and continuous feedback. During these meetings, the importance of Just Culture and progress with implementation were routinely discussed to maintain momentum and demonstrate unwavering leadership support.
Just Culture Case Reviews: To promote practical learning, monthly case reviews were implemented where different departments presented scenarios for discussion. These reviews always began by assuring leaders they were “free to speak, safe to learn.” The case reviews promoted open dialogue, shared learning, and the opportunity to understand and learn from a diverse range of issues.
Clinical Quality Newsletter: The monthly clinical quality newsletter played a crucial role in maintaining transparency. The newsletter communicated system changes and improvements resulting from reported incidents, reinforcing the message that employee input leads to tangible changes. At the end of the year, a special edition compiled all positive changes made, reiterating the importance and impact of reporting.
Direct Feedback Channels: Various channels were promoted to encourage feedback and open communication, including direct communication with senior leadership during town halls and through formalized feedback mechanisms within the Clinical Incidents (CI) program.
Integration with Continuous Improvement
Foundation for CI: Just Culture became the foundation for QuadMed’s Continuous Improvement (CI) initiatives. By aligning CI activities with Just Culture principles, QuadMed ensured that systematic fixes were built on a foundation of safety, transparency, and accountability.
Personalized Onboarding for New Leaders
Introduction Training: New leaders received personalized onboarding, including an introductory video from CMO John Bustle, MD, emphasizing the importance of Just Culture. This approach reinforced that Just Culture is integral to QuadMed’s values.
Collaborative Multidisciplinary Workgroups
Just Culture Workgroup: QuadMed’s multidisciplinary Just Culture workgroup meets biweekly to discuss progress, communication strategies, and ongoing education. The diverse composition of this group ensures that a wide range of perspectives and collaborative efforts contribute to sustaining and enhancing Just Culture practices.
Regular Incident Reviews Beyond Safety
Comprehensive Weekly Reviews: Every week, a multidisciplinary team consisting of compliance, legal, quality, and medical directors meet to review all reported clinical incidents through the lens of Just Culture. This practice ensures consistency in applying Just Culture principles and fosters collective accountability and learning.
Application Beyond Safety: Just Culture principles are not only applied to safety, but extend to service, performance, privacy, and DEI. Leaders collaborate across departments to address incidents consistently.
Change Punitive Culture and Outcome Bias
Changing Perceptions: A critical aspect of success focused on changing perceptions of punitive responses to errors by emphasizing learning and systematic fixes over punishment. Staff were encouraged to report errors, including self-reported mistakes, without fear of reprisal. Demonstrating this approach during incident investigation showed staff that the organization was practicing what it preached. Removing severity bias also put the focus on decision-making processes rather than outcomes, further enhancing trust among employees.
Outcome-Independence: Training focused on removing severity bias, ensuring that the severity of an outcome did not dictate the disciplinary response. This shift put the focus on system issues and decision-making processes rather than outcomes alone, further enhancing trust among employees.

Conclusion

QuadMed’s successful implementation of Just Culture highlights the importance of leadership commitment, ongoing education, transparent communication, and collaboration. By embedding these principles into QuadMed’s core values, an environment was created that focused on continuous improvement, transparency, and psychological safety. QuadMed’s journey may serve as a guide for other health care organizations looking to implement Just Culture successfully.

Just Culture Information

The Just Culture framework acts as a blueprint for high-risk systems and institutions. Just Culture seeks a balance of accountability between individuals and the organization for safe outcomes. It prompts leaders to consider the systemic issues and behavioral choices within these systems that lead to errors. A “just culture” encourages reporting errors without fear of punishment, holding the organization accountable for system design issues rather than individual staff when identified. It emphasizes analyzing the situation leading to an error to prevent recurrence. This approach redefines error management and highlights the significance of nurturing a balanced, safety-oriented culture that values both customer and employee well-being.

While the JCII survey used here was applied to the value of safety only, it now evaluates workplace culture using nine key behavioral markers tied to seven generally universal organizational values: customer service; patient/customer safety; employee safety; financial stewardship; data privacy & protection; environmental protection; and diversity, equity and inclusion. We use the survey as a key measurement tool aiding organizations’ implementation of Just Culture.

References

Cite as: Bustle, J., Thiede, C., & Huntsman, D. (2024). Just Culture Success with QuadMed. The Data Series, (2), 1–2. www.justculture.com

Open Reporting: The reporting of hazards, errors and near misses
Peer-Coaching: Coaching peers when they see risky behavioral choices
Search for Causes: The investigation of hazard sources and near miss events to identify any system or behavioral contributions
System Design: The continuous evaluation and improvement of the systems and processes in which team members work
Transparency: Appropriate transparency within work groups, so that all team members can learn
Non-Punitive Response to Errors: Refraining from disciplinary sanction as a de-facto response to human errors and at-risk behaviors
Accountability: Little tolerance for behaviors that deliberately & unjustifiably compromise the mission or protected values
Lack of Severity Bias: Rejecting no harm, no foul (removing severity bias) as a risk management practice
Equity: Being fair and equitable in response to less-than-desired behavior across disciplines and work groups

Smarter Decisions

Just Culture Implementation: Celebrating QuadMed's Success