Information for Regulators & Government

Why regulators and government are important to a just culture

Healthcare profession regulators and government can influence safe patient care through the policies they set and by how they act when something goes wrong with care delivery.

A just culture is more likely to develop when the entire system (healthcare delivery organizations, healthcare regulators, policy makers in the government, patients and the public):

  • Share the same values, principles and intent to foster and support a just culture.
  • Regards errors and close calls as an opportunity to learn about weaknesses in the system that create safety hazards.
  • Acknowledge that people are imperfect and make errors. Avoid blaming people for making errors.

Healthcare workers are more willing to report threats to patients’ safety when they know that if they are involved in a situation where a patient is harmed, they and their colleagues will be treated fairly by:

  • The care delivery organization who employs them (or gives them an appointment / privileges).
  • The organization who regulates their practice.
  • The government who can influence what others think by what statements are made when something goes wrong with care delivery.

Top 5 things regulators and government can do to foster a just culture:

  1. Develop regulations and policies that support just culture practices. Consider the direct and indirect implications of policy on just culture.
  2. Promote and support organizations that have declared their intent to follow the principles and practices of a just culture.
  3. Require that a fair assessment process be used to determine what consequences, if any, are warranted for individuals who are involved in a patient safety incident.
  4. When a patient safety incident occurs use the opportunity to publicly demonstrate support for a just culture in communication about the situation:
    • Acknowledge that people aren’t perfect and that errors can happen due to factors beyond the control of those involved.
    • Communicate the intent to look at all the factors that played a role in the incident, including those related to the system.
    • Do not blame individuals for what happened (or nearly happened) to a patient.
  5. Work with others in the healthcare system to ensure there is alignment of just culture principles and practices.