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March 2, 2023

Leadership & Building a Culture of Safety


Serving as Part 3 in our Leadership Series, this article is based on one of the lessons from a new course being offered by the American Institute of Healthcare Compliance in April, 2023 entitled “Quality, RCA and the 8D Approach”.  

Leadership must gradually change the culture so that the need to report and do something about a safety issue outweighs the fear of being punished.  Senior leaders, C-Suite executives, unit leaders, physicians, nurses, and all other staff must be held to the same standards.

Sentinel Event Alerts are published for Joint Commission-accredited organizations and interested health care professionals.  Sentinel Event Alert identifies specific types of sentinel and adverse events and high-risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences.

Accredited organizations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives. The Joint Commission urges organization to route Sentinel Event Alert issues to appropriate staff within your organization.

In any health care organization, leadership’s first priority is to be accountable for effective care while protecting the safety of patients, employees, and visitors.

Competent and thoughtful leaders contribute to improvements in safety and organizational culture.  The Joint Commission accreditation manual glossary defines a leader as: “an individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization's governance, management, and clinical and support functions and processes. At a minimum, leaders include members of the governing body and medical staff, the chief executive officer and other senior managers, the nurse executive, clinical leaders, and staff members in leadership positions within the organization.”

Leaders understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.  James Reason compared these flaws – latent hazards and weaknesses – to holes in Swiss cheese. These latent hazards and weaknesses must be identified and solutions found to prevent errors from reaching the patient and causing harm.

  • Examples of latent hazards and weaknesses include poor design, lack of supervision, and manufacturing or maintenance defects.

The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.

In addition, through the results of its safety initiatives, The Joint Commission Center for Transforming Healthcare has found inadequate safety culture to be a significant contributing factor to adverse outcomes. Inadequate leadership can contribute to adverse events in various ways, including but not limited to these examples:

  • Insufficient support of patient safety event reporting;
  • Lack of feedback or response to staff and others who report safety vulnerabilities;
  • Allowing intimidation of staff who report events; and
  • Refusing to consistently prioritize and implement safety recommendations.

In essence, a leader who is committed to prioritizing and making patient safety visible through every day actions is a critical part of creating a true culture of safety. Leaders must commit to creating and maintaining a culture of safety; this commitment is just as critical as the time and resources devoted to revenue and financial stability, system integration, and productivity.

Maintaining a safety culture requires leaders to consistently and visibly support and promote everyday safety measures. Culture is a product of what is done on a consistent daily basis. Hospital team members measure an organization’s commitment to culture by what leaders do, rather than what they say should be done.

Leaders can build safety cultures by readily and willingly participating with care team members in initiatives designed to develop and emulate safety culture characteristics.  Effective leaders who deliberately engage in strategies and tactics to strengthen their organization’s safety culture see safety issues as problems with organizational systems, not their employees.  They also view adverse events and close calls (“near misses”) as providing “information-rich” data for learning and systems improvement. 

Individuals within the organization respect and are wary of operational hazards, have a collective mindfulness that people and equipment will sometimes fail, defer to expertise rather than hierarchy in decision making, and develop defenses and contingency plans to cope with failures. These concepts stem from the extensive research of James Reason on the psychology of human error. Among Reason’s description of the main elements of a safety culture are:

Just culture – people are encouraged, even rewarded, for providing essential safety related information, but clear lines are drawn between human error and at-risk or reckless behaviors.

Reporting culture – people report their errors and near-misses.

Learning culture – the willingness and the competence to draw the right conclusions from safety information systems, and the will to implement major reforms when their need is indicated.

In an organization with a strong safety culture, individuals within the organization treat each other and their patients with dignity and respect. The organization is characterized by staff who are productive, engaged, learning, and collaborative.  Having care team members who gain joy and meaning through their work has been found to have an important role in establishing and maintaining a safe culture.

When team members know that their well-being is a priority, they are able to be meaningfully engaged in their work, to be more satisfied, less likely to experience burnout, and to deliver more effective and safer care.

Leaders who encourage transparency in response to reports of adverse events, close calls and unsafe conditions, and who have established processes that ensure follow-up to ensure reports are not lost or ignored (or perceived to be lost or ignored), help mitigate intimidating behaviors because transparency of action itself discourages such behavior.

On the opposite end of the spectrum, intimidating and unsettling behaviors causing emotional harm, including the use of inappropriate words and actions or inactions, has a detrimental impact on patient safety and should not occur in a safety culture. This includes terminating, punishing or failing to support a health care team member who makes an error (the “second victim”).

Unfortunately, as attention to the need for a culture of safety in hospitals has increased, “so have concomitant reports of retaliation and intimidation targeting care team members who voice concern about safety and quality deficiencies,” according to a National Association for Healthcare Quality report.

Intimidation has included overtly hostile actions, as well as subtle or passive-aggressive behaviors, such as failing to return phone calls or excluding individuals from team activities. Survey results released by the

Institute for Safe Medication Practices (ISMP) show that disrespectful behavior remains a problem in the health care workplace. Most respondents reported experiences with negative comments about colleagues, reluctance or refusal to answer questions or return calls, condescending language or demeaning comments, impatience with questions or hanging up the phone, and a reluctance to follow safety practices or work collaboratively.


Building a safety culture must be implemented using a top-down approach. In a safety culture, health care organization leaders are ultimately responsible for developing highly reliable systems. In turn, staff members are personally responsible for what is considered largely under their control, making good choices when working within these systems.

By building trust and encouraging reporting, leaders empower an organization’s most valuable resource – its people – to be always vigilant for hazards in the face of varying conditions.

  1. Joint Commission Sentinel Events
  2. Sentinel Event Alert: Issue 57   https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea-57-safety-culture-and-leadership-final2.pdf

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