Medical Staff Seated In Circle Talking At Case Meeting.Organizational leaders must set the standard and, more importantly, demonstrate the behaviors and expectations essential to a safe and transparent culture. The Agency for Healthcare Research and Quality (AHRQ) defines a culture of safety as one “in which healthcare professionals are held accountable for unprofessional conduct, yet not punished for human mistakes; errors are identified and mitigated before harm occurs; and systems are in place to enable staff to learn from errors and near misses and prevent recurrence” (AHRQ PSNet Safety Culture 2014).

Teresa Haatvedt, RN, BSN - Great Plains QIN SD“The Just Culture concept is a cultural change with an organization.  Over time this culture will build trust from leadership to the front-line staff, which ultimately provides positive outcomes for their patients,” shared Teresa Haatvedt, RN, program manager for the Great Plains Partnership to Advance Tribal Health (PATH) team.

The purpose of the Just Culture is to ensure the organization’s culture focuses on prioritizing, developing, and sustaining the delivery of healthcare to the patients by reducing harm.  The Great Plains PATH Team provides assistance for Great Plains IHS service units and Area Office with setting goals to develop and achieve a positive Just Culture.

Developing a safe culture within an organization ensures there is a balance between staff accountability and punitive response to each reported error.  The American College of Healthcare Executives developed “Leading a Culture of Safety: A Blueprint for Success” as a useful resource for organizations.  This provides an overall guide for leaders to assist in transforming their organizations into system wide cultures of safety.  AHRQ also offers a Culture of Safety Survey for organizations to use in order to gauge their level of culture throughout an organization.

As part of the effort to set goals and support a strong positive culture within the IHS service units, PATH distributed the Culture of Safety Survey to IHS facilities throughout the Great Plains region.The facilities completed the Culture of Safety Survey in order to collect a baseline for the current status of their organizational culture. Based on the results, leaders within IHS have obtained Just Culture certification, which was provided in Albuquerque, New Mexico.  In addition, leaders from each facility have set goals to implement action plans to incorporate Just Culture within their service unit.

Lori Hestad, program manager for Great Plains QIN - SDLori Hestad, MBA, PATH team member, stated, “As the service units continue to set goals, we hope to provide support with implementing a strong, safe and positive culture throughout IHS.”



PATH will continue Just Culture education through the Learning and Action Network (LAN) events and support from IHS Great Plains Area Office. The most recent LAN event, titled Just Culture Implementation, was held on August 7. Resources and webinar recordings are available on the Comagine Health web site.