Arkansas Hospitals Health & Science

A Linchpin of Innovation

Safety Culture Essential for Excellence

By Anne Marie Benedicto, MPP, MPH, Joint Commission Center for Transforming Health Care

Despite serious and widespread efforts to improve quality and safety in health care, many patients still suffer harm every day within the very organizations where they seek healing and treatment.

Hospitals find improvement difficult to sustain. Leaders and employees within health care organizations suffer “project fatigue” because so many problems need attention.1 This current state is very different from the goal of high reliability health care – health care that is consistently safe and consistently excellent across all services and settings – that many health care organizations have adopted.

Yet our work with health care organizations has shown that hospitals and health systems can and do progress toward excellence and innovation through specific foundational changes that transform an organization and its care delivery. These three foundational changes are leadership’s commitment to achieving zero harm, a fully functional culture of safety throughout the organization, and the widespread deployment of highly effective process improvement tools.

While these three domains are interrelated, I’d like to focus on safety culture.

Safety culture is the sum of what an organization is and does in the pursuit of safety.2 It is the product of individual and group beliefs, values, attitudes, perceptions, competencies and patterns of behavior.3 That culture facilitates your organization’s commitment to quality and patient safety.

Trust is the foundation of a safety culture, leading concerned employees to report unsafe conditions and identify opportunities for improvement. When reports are taken seriously and employees see positive results from the actions they take, they are further motivated to speak up and point out improvement opportunities.

This, in turn, builds greater levels of trust and leads to more improvement, driving the innovation that transforms organizations. However, the “virtuous cycle” of trust-report-and-improve can easily stall. For example, progress stops when employees believe that there are negative consequences to speaking up about errors, mistakes and unsafe conditions.4

The vast majority of errors that contribute to harm result from flawed systems and processes.5 Unfortunately, health care organizations don’t always act on this knowledge, and individuals are still blamed for mistakes they could not prevent.

In addition, some employees experience intimidating behaviors at work, such as condescending language, verbal abuse and bullying. The Institute for Safe Medication Practices describes disrespectful behaviors as ranging from “overt acts of abuse and bad behavior to insidious actions so embedded in our culture that they seem normal – gossip, for example.”

A punitive and disrespectful culture is a dangerous culture where there is little trust, teamwork is difficult, reports are inhibited, and where the communication and collaboration that are essential for excellent patient care are compromised. Organizations with such cultures are not likely to learn from mistakes, making harm more likely. According to The Joint Commission, adverse events result from the following behaviors:

  • Insufficient support for patient safety event reporting.
  • Lack of feedback or response to staff and others who report safety vulnerabilities;
  • Intimidation of staff who report events;
  • Inconsistent, or lack of priority for, implementation of safety recommendations; and
  • Failure to address staff burnout.


As hospitals, where do you begin? You begin at the top. Effective leadership sets the tone for values and behaviors within an organization, including the paramount importance of safety among many competing priorities. Creating a thriving safety culture at your hospital is the direct responsibility of leadership, including the governing board. Your governing board, senior leaders, physician leaders and nurse leaders must work together to make it a priority.

Given the important link between reporting and improvement, it is crucial for leaders to identify, understand and eliminate the barriers employees experience when reporting unsafe conditions, including close calls when an unsafe condition is addressed and mitigated before harm occurs.

For instance, staff members do not always recognize unsafe conditions, and they don’t always know what to report. Therefore, a strong safety culture includes a corporate commitment to provide employees with the knowledge, skills and support they need to identify situations and conditions that may lead to harm.

In addition, health care leaders need to address intimidating behaviors and create safe environments for employees, patients and visitors. Disrespectful cultures lead to a disengaged and disempowered workforce – a truly dangerous condition in health care, which relies on the care and dedication of a skilled workforce.

High reliability organizations have vibrant cultures where engaged and empowered employees not only prevent harm, but also are inspired to generate ideas, improvements and innovations that drive transformation. The workforce of a health care organization is its most expensive and valuable asset. As leaders adopt more high reliability practices, engineering a culture that maximizes the talent and capabilities of its employees should be a focus and a pathway to a stronger safety culture.


This is important to understand: Safety culture is not a “blame-free” culture. Highly reliable organizations balance learning and accountability by separating blameless errors that are learning opportunities
from the errors that are cause for discipline. Intimidating behaviors must be eliminated. Everyone must be accountable for consistent adherence to safe practices with uniform assessment of errors.

Joint Commission standards provide a foundation. They require leaders to create and maintain a culture of safety and quality throughout the organization through requirements that serve as essential steps:

  • Regularly evaluating the culture of safety and quality using valid and reliable tools;
  • Developing a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety; and
  • Creating and implementing a process for managing behaviors that undermine a culture of safety.

Recently, leaders of our Center for Transforming Health Care have been blogging about 11 tenets of safety culture that The Joint Commission laid out in its Sentinel Event Alert Issue 57: The essential role of leadership in developing a safety culture.

I encourage you and your teams to follow the series on The Joint Commission website, (Daily Update), as we examine each of these 11 actionable steps toward safety culture with additional insight and practical resources:

  1. Absolutely crucial is a transparent,non-punitive approach to reporting and learning from adverse events, close calls and unsafe conditions.
  2. Establish clear, just and transparent risk-based processes for recognizing and separating human error and error that arises from poorly designed systems from those unsafe or reckless actions that are truly blameworthy.
  3. To advance trust within the organization, CEOs and all leaders must adopt and model appropriate behaviors, as well as champion efforts to eradicate intimidating behaviors.
  4. Establish, enforce and communicate to all team members the policies that support safety culture and the reporting of adverse events, close calls and unsafe conditions.
  5. Recognize care team members who report adverse events and close calls, who identify unsafe conditions or who have good suggestions for safety improvements.
  6. Establish an organizational baseline measure on safety culture performance using the Agency for Health Care Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS) or another tool, such as the Safety Attitudes Questionnaire.
  7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement.
  8. In response to information gained from safety assessments and/or surveys, develop and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety.
  9. Embed safety culture team training into quality improvement projects and into organizational processes to strengthen safety systems.
  10. Proactively assess system (such as medication management and electronic health records) strengths and vulnerabilities, and prioritize them for enhancement or improvement.
  11. Repeat an organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement.


One way you can determine how well your organization is doing on its journey to zero harm is through application of the “High Reliability Maturity Model,” a practical framework for hospitals and health systems. This is the model our Center developed through our work with The Joint Commission, and we collaborate with hospitals to apply it in their own organizations.

It emphasizes leadership commitment, safety culture and Robust Process Improvement® as the three domains critical to high reliability within a health care organization. And, it works.

For hospital leaders seeking tools to assess their safety culture, leadership and Robust Process Improvement® performance, our Center for Transforming Health Care offers an Oro™ 2.0 High Reliability Organizational Assessment and Resources Tool (

The assessment helps to establish a baseline to prioritize action planning and gauge progress on the road to high reliability.

By committing to strengthen their organization’s safety culture, hospital leaders can create high-reliability workplaces in which team members trust peers and leadership, report vulnerabilities and hazards that require risk-based consideration, implement solutions to the problem identified, and communicate the benefits of these improvements back to involved staff. I have seen it first-hand.

Strengthening your organization’s safety culture decreases the likelihood of sentinel events. It is one of the most important steps for leadership to take on the road to high reliability, and it is the linchpin of innovation for better patient care.

1 Chassin MR and Loeb JM, “High-reliability health care: getting there from here,” The Milbank Quarterly 2013; 91(3):459–490.
2 Reason J and Hobbs A., Managing Maintenance Error: A Practical Guide. Ashgate Publishing Company: 2003.
3 The Joint Commission, Comprehensive Accreditation Manual for Hospitals: The Patient Safety Systems Chapter, Update 2. January 2015.
4 Chassin and Loeb, note 1 above.
5 Connor, M., D. Duncombe, E. Barclay, S. Bartel, C. Borden, E. Gross, C. Miller, and P.R. Ponte. 2007. “Creating a Fair and Just Culture: One Institution’s Path Toward Organizational Change,” Joint Commission Journal on Quality and Patient Safety 33 (10):617-24.
6 The Joint Commission Sentinel Event Alert, Issue 57,, (accessed August 14, 2007). Internal citations omitted; see original text for references.
7 Connor, et al., note 5 above.

Anne Marie Benedicto is the Vice President of the Joint Commission Center for Transforming Health Care. She is an expert in Robust Process Improvement (RPI®) and high reliability methods applied to health care clinical and business processes.

At the Center for Transforming Health Care, Ms. Benedicto leads the Center’s initiatives to transform health care into a high reliability industry through systemic approaches that address today’s most critical safety and quality issues.

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