Information For Senior Leaders

Why senior leaders are important to a just culture

The Board and senior leadership of a healthcare organization set the tone for a commitment to deliver safe and effective care. Regarding errors and close calls as an opportunity to learn about weaknesses in the system is an important aspect of this. 

Leadership support for a just culture through policy development and public endorsement of a fair assessment process for healthcare workers involved in patient safety events is critical to achieving safe patient care.

Leadership actions can create an organization-wide sense of trust which encourages healthcare workers to report threats to patients’ safety that can be acted on to improve safety.

Senior leaders have to ‘walk the just culture talk’ through actions that are consistent with a just culture. They have to hold front line leaders accountable for their actions related to a just culture.

Top 5 things organizational leaders can do to foster a just culture:

  1. Support the fair assessment of people who are involved in a patient safety incident.
    • Ensure the organization has a consistent, systematic and fair approach for gathering, organizing and interpreting information about patient safety incidents and the actions taken by those involved.
    • Ensure those who assess the actions of people involved in patient safety incidents use the process.
    • Develop clear messaging about how workers will be treated if they are involved in a patient safety incident.
  2. Consistently and repeatedly communicate the principles of a just culture to healthcare workers. Consider embedding them in an organizational policy.
  3. When a patient safety incident occurs demonstrate the principles of a just culture in communication about the situation.
    • Emphasize the importance of learning from situations that don’t go as planned.
    • Avoid blaming the people involved for what happened (or nearly happened) to a patient. 
    • Commit to systematically examining the role system factors played in the incident.
    • Acknowledge the influence hindsight and outcome bias can have on assessing what happened, and state how bias is minimized.
    • Be clear that while healthcare workers are accountable for their actions, that accountability will be assessed in the context of the situation. Healthcare workers are not accountable for system factors over which they had no control.
    • Communicate about how the organization is supporting the individual(s) involved – patients and healthcare workers.
  4. Work with other organizations (e.g., health professions regulators) who have influence over a healthcare worker’s ability to practice, to ensure there is alignment of just culture principles and practices.
  5. Publicly commit to creating a just culture in your organization.