How to Implement a Just Culture

The shift of a health care organization to a just culture is a slow process that can take years to be fully ingrained but improvements can start to be seen almost immediately as safety is moved to the forefront of the organization’s mission.

The commitment from leadership of a health care organization to a culture of learning and safety is crucial to the development and implementation of a Just culture. Management is a great unifier and has the strongest chance of unifying the diverse groups of an organization by communicating the values, reinforcing acceptable behaviors, and providing incentives for excellence. The commitment to a just culture is needed at all levels of an organization for it to become part of the norm of safety rather than a passing idea.39, 43

Committment by Leadership

Leadership must do more than just verbalize its commitment to a just culture, they must show it through observable actions. The board of directors of a health care organization can show their commitment to a just culture by consistent and close oversight of patient safety initiatives and error events.

Actions leadership can take to communicate their commitment to a just culture within their organization:

  • Undergoing just culture training to gain an understanding of safety culture concepts and practices
  • Make safety a priority in the strategic plans of the organization
  • Enact patient safety policies and procedures that clearly state supervisor responsibility and accountability and empower each employee to understand how his or her performance can affect patient safety within the organization
  • Scheduled reviews of the safety policies
  • Empower employees to have a questioning attitude on safety issues
  • Enact objectives for directly improving safety in each manager’s unit
  • Keep informed of safety trends to ensure that safety objectives are timely
  • Have a genuine interest in safety improvements and recognizing those who achieve them in the organization
  • Reviewing safety of the organization on a regularly scheduled basis and identifying short-term and long-term safety goals
  • Direct resources for improved safety43, 38

The March 2017 Joint Commission’s Sentinel Event Alert pointed to the role of leadership in patient safety outcomes. The Joint Commission found that leadership must highlight the accountability for the environment in which clinical staff operate, and develop a non-punitive approach to error reporting. 21

The adoption of a national definition of Just Culture would assist organizations in measuring outcomes and creating a larger data field from which to improve safety.21

The development of error reporting policies within a just culture has the potential to improve liability exposure of organizations.51

All employees must be empowered and engaged in the safety outcomes of their organization. Just culture organizations recognize that errors happen and system designers and management cannot foresee every problem.38

Management can set the tone of responsibility for safety in an organization but it is the responsibility of all employees to report errors or system failures to ensure improvement in safety. In just culture, everyone who works within the organization is actively involved in identifying and resolving safety issues and are empowered to take appropriate action to prevent adverse events.43

Communication is Essential

An organization must communicate effectively to its employees the need to make fundamental changes in organizational policies and procedures to reduce errors and to improve safety. Management must be open to issues detected by employees that indicate potential systems issues or safety issues. 38

In effective safety cultures the patterns of communication are not hierarchical. Hierarchical communication with can negatively affect a safety culture. They often entail waiting for orders, unquestioning agreement to directives, and an unwillingness to questioning or relay negative information up the chain of command in an organization. In organizations with an effective just culture, communication moves up and down the chain of command and across organizational divisions freely. Employees should be encouraged to speak up regardless of their rank or level of authority if they see system issues or become aware of an error event. Individuals should feel empowered to report any system or process issues that could lead to error.39

In a just culture, individuals are rewarded for their participation in safety improvements.43, 38


Stages of Just Culture - Where Are You?

Take the quiz to see which stage your organization is in!


Stage 1 - Organizational culture is based on rules and regulations


Stage 2 - Just culture becomes an organizational goal


Stage 3 - Organizational culture is seen as dynamic and continuously improving

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