Just Culture

Just Culture

Just Culture

The benefit of this approach is that the process is up-front and transparent to the staff, which helps achieve trust and accountability.

A Just Culture, “Just Culture Not Blame, Also not Carefree”:

  • Recognizes that individual practitioners should not be held accountable for system failings over which they have no control (8o% of medical error are system-driven).
  • Recognizes many errors represent predictable interactions between human operators and the systems in which they work; and recognizes that competent professionals make mistakes.
  • Acknowledges that even competent professionals will develop unhealthy norms (shortcuts, “routine rule violations”).
  • Has zero tolerance for reckless behavior.


Establishment of just culture

Establishment of just culture

Establishment of a just culture is the first vital step in engineering a safer culture. While employees will be disinclined to report errors and near misses in a wholly punitive culture, a totally blame-free culture is equally undesirable given that some unsafe acts warrant retribution. Importantly, leadership strikes a balance between the systems approach that emphasizes organizational learning, and the need to retain personal accountability and discipline. In the end, hospital leaders must hold individuals accountable for the safety environment while also providing them with the security of knowing they will not be blamed for system failures beyond their control. In short, formation of a just culture requires the establishment of a zero tolerance policy for reckless conduct, counterbalanced by a widespread confidence that unintended unsafe acts will generally go unpunished (Please see Code of Ethics for Healthcare Practitioners, Ed. 2014).

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Leadership Commitment

Leadership Commitment

Leadership Commitment

Hospital Leaders acknowledge that the healthcare environment is a high-risk environment and seek to align vision/ mission, staff competency, and fiscal and human resources from the boardroom to the frontline.

The role of senior leadership is a key element to designing, fostering, and nurturing a culture of safety. Engaged senior leaders are critical to an organization’s successful development of a culture of safety. Engaged leaders drive the culture by designing strategy and building structure that guide safety processes and outcomes identified administrative leadership as one of the most significant facilitators for establishing and promoting a culture of safety.

Creating a culture of safety must begin with the Chief Executive Officer (CEO), but it must permeate throughout every level of the healthcare system. Leadership’s commitment and education on safety culture is key to an organization’s move toward a safety culture. Leaders require basic insight into safety problems and need rationales for focusing on patient safety. They need to be educated on the science of safety and the power of data.

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  1. Chief Executive Officer and Hospital Executive Leadership
  • Establishes and supports the hospital’s culture of safety program that promotes accountability and transparency.
  • Develops and documents code of conduct and identifies and corrects behaviors that are unacceptable.
  • Provides education and information (such as literature and advisories) relevant to the hospital’s culture of safety to all staff.
  • Defines how issues related to a culture of safety within the hospital are identified and managed.
  • Provides resources to promote and support the culture of safety within the hospital.
  • Provides a simple, accesible and confidential system for reporting issues relevant to a culture of safety in the hospital.
  • Ensures that all reports related to the hospital’s culture of safety are investigated in a timely manner.
  • Identifies systems issues that lead healthcare providers to engage in unsafe behaviors.
  • Uses measures to evaluate and monitor the safety culture within the hospital and implement improvements identified from measurement and evaluation.
  • Implements a process to prevent retribution against individuals who report issues related to the culture of safety.

Quality Management Department

  1. Supports the hospital’s culture of safety program that promotes accountability and transparency.
  2. Coordinates with Safety team, Infection Control team, Pharmacy team, Nursing team and other concerned according to the requirement.
  3. Receives, investigates and acts upon issues or incidents related to the hospital’s culture of safety.
  4. Ensures that all reports related to the hospital’s culture of safety are investigated in a timely manner.
  5. Provides education and information relevant to the hospital’s culture of safety to all staff.
  6. Manages and provide summary reports to leaders on a quarterly basis.
  7. Encourages staffs to report issues relevant to a culture of safety in the hospital.
  8. Identifies systems issues that lead healthcare providers to engage in unsafe behaviors.
  9. Uses measures to evaluate and monitor the safety culture within the hospital and implement improvements identified from measurement and evaluation.

Heads of Department/ Service:

As a commitment to the culture of safety program, each head of the department/ service is responsible for:

  1. Implementing the hospital’s culture of safety program within the department.
  2. Identifies, documents and corrects behaviors that are unacceptable within the department.
  3. Provides education and information relevant to the department’s culture of safety in coordination with QM.
  4. Encourages staffs to report issues relevant to a culture of safety in the hospital.
  5. Helps evaluate and monitor the safety culture within the department or service and implement improvements identified from measurement and evaluation.

Departmental QI Officers

  1. Assists in the implementation of departmental and hospital-wide culture of safety program
  2. Collaborates with the Head of the Department/ Service and the Quality Management Department in monitoring, reporting and communicating issues relevant to a culture of safety in the department.

Hospital Staff Members

  1. Holds a proactive and positive attitude towards reporting culture of safety occurrences.
  2. Initiates and reports culture of safety related incidents using the hospital’s OVR system.

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To maintain and improve patient safety, departments/ units partnered/ collaborated with other departments/ units to be able to formulate measures/ indicators that focuses in patient safety and harm reduction. Some of the above measures/ indicators have been around for years, modified/ revised according to new requirements while others are newly created. Hospital leaders fully supported for these significant improvements to be carried out for patient care outcomes which includes (but not limited to):

  1. 100% compliance with patient identification
  2. 95% compliance with the use of SBAR in Nursing
  3. Consistent Hand Hygiene compliance of 9o%
  4. 0% of patients on ventilator contracted VAP
  5. 0% incidents of Surgical Site Infection (551)
  6. Central line bloodstream infection rate sustained at o%
  7. 100% compliance with completion of WHO Surgical Safety Checklist in OR setting (SIGN IN, TIME OUT, SIGN OUT) and TIME OUT in Non-OR setting
  8. 0% incident of Medication Error
  9. Zero incident on Patient Fall
  10. > 95% compliance with antibiotic prophylaxis given within 6o minutes before surgical incision
  11. 95% compliance with VTE assessment on admission (including prescribing prophylaxis)
  12. Reduction of Hospital Acquired Pressure Ulcer (HAPU) to 03%
  13. 95% compliance in Pain assessment and documentation


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What is JCI Accreditation?

What is JCI Accreditation?

Joint Commission International Accreditation is a voluntary process in which an entity separate and distinct from the health care organization which assesses the health care organization to determine if it meets a set of requirement (standards) designed to provide a visible commitment by an organization to improve the safety and quality of care which is optimal and achievable. It is an effective quality evaluation and management tool for ensuring a safe care environment which helps continuous improvement process to reduce risk to patient and staff.

Who are JCI?

Joint Commission International is a U.S. based not for profit accreditation body which sets and designs standards and processes to create a culture of ethics, safety and quality within an organization that strive to continually improve patient care processes and results.

Benefits of JCI Joint Commission International teaches and leads us to:

  1. Improve patient trust by improving patient safety, quality and care.
  2. Provide a safe and efficient work environment that contributes to staff satisfaction
  3. Listen to patients and their families, respect their rights, and involve them in the care process as partners; and
  4. Helps establish collaborative leadership that sets priority for and continuous leadership for quality and patient safety at all levels.

What is Tracer Methodology?

Tracer methodology is an evaluation method in which a surveyor selects a patient and uses that individual’s record as a roadmap to assess and evaluate an organization’s compliance with selected standards and the organization’s system for providing care and services.


What is the role of the staff in the survey/during a tracer?

As surveyors move around the hospital, they will ask to speak with the staff members who have been involved in the tracer patient’s care, treatment and services. Assume they will want to talk with you, so have confidence in yourself—you provide awesome care, so let them see it! Remember that you are prepared to answer their questions.


Consider the following recommendations:

  • Be certain to greet the surveyor (good morning/ good afternoon) with a smile, introduce yourself, including your title, and accompany the surveyor to your area and/ or to you department head/ supervisor/ in-charge
  • Be confident and remain calm, don’t attempt to hide, ignore or run from them.
  • Answer their questions directly (keep your answers short and sweet) and ask the surveyor to repeat or rephrase the question if you don’t understand it.
  • Be polite and smile—do not let the questions make you feel defensive or angry.
  • Be honest—if you do not know the answer, do not make one up; tell them you don’t know but you will ask your senior staff or your colleague who knows the answer.
  • Be specific, provide examples for an answer and refer to policies or procedures whenever possible
  • Be enthusiastic about what you do.


To serve the healthcare needs of the region by giving comprehensive care.

To treat and to prevent illness.

To provide advanced procedures & modern technology combined with the traditions of caring & compassion.


Our CORE VALUES as healthcare providers

RESPECT: We interact professionally with others and affirm that each person has special value, unique talents and varied gifts. We offer open mindedness, recognition a rid appreciation to the perspectives and experiences that others bring to the table and are willing to share.

TEAMWORK: We work together to achieve our goals. We make effective teams through respectful interpersonal communication dynamics building a supportive teamwork environment and camaraderie with our co-workers.

INTEGRITY: We do the right thing. We Act ethically arid responsibly in all services we do.

EXCELLENCE: We do the best thing. The best service, best experience and best practices to provide the highest quality care for our patients and their families.

COMPASSION: We are advocates for a compassionate and just society through our actions and our words. Be empathic by listening, reflecting and accepting people and where they are in life, conscientiously care for our environment, be with those most vulnerable and recognize that not only patients, but also their families and our co-workers need help from time to time.

JCI Standards (5th Edition)

Accreditation Participation Requirements (APR): 12 Chapters Total Number: 16

  • Patient Centered Chapters: 8
  • Organization Management Chapters: 6
  • Academic Medical Center Hospital Chapters: 2

Standards: Total Number: 304

Standards are set around the important functions; they are common to all healthcare organizations.

Intent statement: Easy explanation of the standards

Measurable Elements: 1218 (total number), measurable elements are those requirements of standards which are reviewed and assigned a score during survey.

Survey: Assesses the hospitals compliance on JCI standards

Chapters Details

  • Accreditation Participation Requirements
    Accreditation Participation Requirements (APR)-Introductory
  • The Patient Centered Standards are:
    • International Patient Safety Goals (IPSG)
    • Access to Care and Continuity of Care (ACC)
    • Patient and Family Rights (PFR)
    • Assessment of Patients (AOP)
    • Care of Patients (COP)
    • Anesthesia and Surgical Care (ASC)
    • Medication Management and Use (MMU)
    • Patient and Family Education (PFE)
  • The Organization Management Standards are:
    • Quality Improvement and Patient Safety (QPS)
    • Prevention and Control of Infections (PCI)
    • Governance, Leadership, and Direction (GLD)
    • Facility Management and Safety (FMS)
    • Staff Qualifications and Education (SQE)
    • Management of Information (M01)
  • The Academic Medical Center Hospital Standards are:
    • Medical Professional Education (MPE)
    • Human Subjects Research Programs (HRP)

JCI addresses the following issues very intensively:

  1. International Patient Safety Goals
  2. Patient & Family Education
  3. Patient & Family Rights & Responsibilities
  4. Pain Management
  5. Quality Indicators & Monitoring
  6. Hand Hygiene & Prevention and Control of Infection
  7. Fire Safety and Emergency Codes
  8. Removal of Barriers to Care
  9. Patient Identifiers
  10. Care of High Risk Patients (Vulnerable patients)
  11. Restraint Order
  12. Rights of Drug administration
  13. Discharge Planning & Components of Discharge Summary
  14. Time Out process
  15. Biomedical Waste Disposal
  16. Personal Protective Equipments (PPE)
  17. HAZMAT, Lab, Radiation, Facility Safety
  18. DNR (Do Not Resuscitate)
  19. End of Life Care
  20. Hospital Mandatory Trainings

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Safety & Loss Prevention Officer – JOB DESCRIPTION

  • Responsible for :

The implementation of Environment Of Care Programs and activities, and shall assist the Senior Safety Officer. Responsible for gathering Safety information as well as relevant applicable laws and regulations in order to identify safety risk to patients, visitors, and personnel. He will provide quarterly reports to the Safety & Loss Prevention Manager on Environment of Care Six (6) Planning areas: Safety & Security Management; – Hazardous Materials & Waste Management; – Emergency Management; – Fire/Life Safety Management; – Medical Equipment Management; – and the Utility System Management issues including actions and recommendations of the FMS Committee.

Responsible for the day-to-day work activity scheduling of Safety Technician & Fire Watch

He shall report to the Senior Safety Officer and accountable to the Group Safety & Loss Prevention Manager and the Deputy Chairman, have a direct line of communication to the all Department Heads and Department Safety Officer (DSO).

The Safety & Loss Prevention Officer is subject to being on-call 24 hours/7 days /week to respond to emergencies.

  • Liaises with:                             Heads of the Departments/DSO/Supervisors, FMS
    Committee Chairman/Other Committee
  • Duties and Responsibilities:
  1. The Safety Officer manages a hazard surveillance program that collects and analyzes data for the Facility Management & Safety (FMS) Committee.
  2. Serves as a member of the Facility Management & Safety (FMS) Committee. Monitors Facility Management & Safety Committee recommendations and actions to measure effectiveness and reports to Safety & Loss Prevention Manager.
  3. Develop/s, implements and monitor/s hospital-wide safety management programs based on evaluation of organizational expertise, applicable law, regulations and accepted practice. Ensures that the hospital complies with relevant laws and safety regulations, JCIA & CBAHI Facility Management & Safety requirements deemed
  4. Establishes an incident reporting system in conjunction with the occurrence variance reporting and tracking system which triggers investigation of all incidents involving property damage, occupational illness, or patient, personnel or visitor injury
  5. Establishes a safety surveillance program involving personnel throughout the facility to identify hazards and unsafe practices
  6. Reviews published and internal reports of failures, hazards, use errors and other deficiencies related to safety management (physical and chemical hazards), life safety management (fire prevention), equipment management (safe medical devices) and utilities management (emergency power).
  7. Reviews summaries of other monitoring activities (quality improvement, infection control).
  8. Prepares and submits annual management reports for Safety & Loss Prevention Department, Facility Management & Safety Committee, and (when required) for outside regulatory agencies.
  9. Represents the hospital in meetings with regulatory agencies that address safety related issues
  10. Coordinates the development, implementation and monitoring of departmental Facility Management & Safety policies and procedures
  11. Develops and conducts formal safety related training programs for the hospital to include:
    1. General safety
    2. Department safety
    3. Specific job-related hazards
    4. Accidents, injury and hazard reporting
    5. Fire and life safety
    6. Smoking regulations
    7. Electrical safety (use of extension cords, frayed cords, broken outlets, broken prongs);
    8. Hazardous materials and waste management programs
    9. External and internal emergency preparedness; and
    10. Occurrence variance reporting
  12. Maintains training records on all of the above safety training programs and reports to Department Heads, Senior Safety Officer, SLP Manager on the compliance rate for attendance at mandatory safety training sessions
  1. Responds to employee, patient and visitor safety concerns by examining safety related issues, preparing recommendations for corrective actions and ensures appropriate follow-up.
  2. Serves as a resource to departments in developing safe working practices and in maintaining a safe working environment
  3. The Safety & Loss Prevention Officer is required to coordinate and monitor the activities of FMS Committee and departments such as those dealing with;
    1. Safety Management
    2. Security Management
    3. Hazardous Materials and Waste Management
    4. Emergency Preparedness
    5. Fire and Life Safety Management
    6. Medical Equipments
    7. Utility Systems
    8. Radiation Safety, Laser Safety
  4. The Safety & Loss Prevention Officer directly evaluates the work of management and other personnel engaged in safety related projects as well as teams, task forces and committees engaged in safety matters
  5. Challenges encountered by the Safety & Loss Prevention Officer include dealing with sensitive issues relating to occupational exposures that have the potential for significant legal liability. The position requires a high degree of inductive/deductive thinking in devising new approaches/innovations to deal with highly complex and/or previously unsolved problems.  The work will often require the application of imaginative and original thinking to deal with new situations that will arise
  6. The Safety & Loss Prevention Officer has the authority to intervene whenever conditions exist that pose an immediate or potential risk to life, health or damage to equipment or the physical environment and to take corrective action as necessary

Photo by West Midlands Police

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Hospital Culture of Safety

Over a decade ago, the Institute of Medicine (IOM) urged health care organizations to adopt proven organizational models and strategies from other high-risk industries to minimize error and reduce harm to patients. To promote a culture of safety and ensure safer systems of care, the IOM emphasized the importance of developing clear, highly visible patient safety programs that focus organizational attention on safety; use non-punitive systems for reporting and analyzing errors; incorporate well-established safety principles such as standardized and simplified equipment, supplies, and work processes; and establish proven interdisciplinary team training programs for providers.

The IOM also noted that, “the biggest challenge to moving toward a safer health system is changing the culture from one blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm”.

By developing a “systems” orientation to understanding and addressing medical errors, hospitals can foster an organization-wide continuous learning environment where members of the workforce feel comfortable reporting and discussing adverse events without fear of reprisal.

The Safety Culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.

In the healthcare environment there are many competing variables in the culture of an organization. The conflicting needs of patients, families, providers, institutions, regulators, etc. create many inconsistencies and mixed messages. In addition to the issues of hierarchy, there are “silos”, where each role or unit operates independently, without understanding the full implications of its actions on others. Key features of this program for a culture of safety include:

  • acknowledgment of the high-risk nature of a hospital’s activities and the determination to achieve consistently safe operations;
  • an environment in which individuals are able to report errors or near misses without fear of reprimand or punishment;
  • encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems;
  • organizational commitment of resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns.



This program covers elements from leadership commitment, just culture, systems reporting, teamwork, staff training and patient involvement. To implement an effective culture of safety program in a Hospital it entails continuous support and coordination from all levels of authority in the organization, continuous reporting of quality and safety incidents, continuous education about culture of safety and interdisciplinary communications and planning to address issues in the implementation of a safe culture.


  • To establish a system that supports the culture of safety among different staff levels within the organization.
  • To encourage teamwork between hospital members and create program that allow positive culture of safety to flourish.
  • To establish a system that address undesirable behaviors of individuals working at all levels of the hospital, including management, clinical and administrative staff, licensed independent practitioners, and governing body members.
  • To identify and address issues related to systems that lead to unsafe behaviors.
  • To increase the level of awareness and encourage all staff to report issues concerning culture of safety.



  • To educate all staff members on a regular basis about culture of safety.
  • To evaluate the hospital’s culture of safety on an annual basis using a variety of methods, such as formal surveys, focus groups, staff interviews, and data analysis.
  • To continuously analyze issues related to culture of safety and strategize timely investigations and resolutions to address the issue.
  • To report on a regular basis to hospital leaders all summary findings related to culture of safety.


Culture of Safety:

The U.K. Health and Safety Commission developed one of the most commonly used definitions of safety culture (adapted also by AHRQ- Agency for Healthcare Research &Quality): “The product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.” Organizations with positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures.

The Safety Culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.



ELEMENTS of the Culture of Safety Program:

  1. Leadership Commitment
  2. Just Culture
  3. System (reporting)
  4. Teamwork
  5. Training
  6. Patient Involvement


LEVELS of the Culture of Safety Program

All six (6) elements were distributed into three (3) LEVELS as:


LEVELS of the Culture of Safety Program

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