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Just Culture as a Foundation for Joy in Work: The Impact of Leaders

Posted By Administration, Thursday, March 2, 2017
Updated: Thursday, March 2, 2017

What can health care leaders do to help reduce burnout among their colleagues?

by Barbara Balik, EdD, MS, RN


Burnout and lack of joy in work pose significant risks to health care organizations: 54% of US physicians are burned out and 33% of new nurses seek another job within one year. Burnout is a syndrome characterized by exhaustion, cynicism or depersonalization, and a sense of loss of personal effectiveness. This problem takes a personal toll on health care team members and also seriously impacts patient safety. The correlation between greater engagement and safer patient care is well documented. Reducing burnout results in improved quality, safety, and efficiency with lower turnover rates.

Joy in work occurs when all team members,

no matter their role, find meaning and

purpose in what they do.


Abundant evidence points to leadership behaviors that are an antidote to this significant problem. What leaders do makes a difference in reduced burnout, enhanced teamwork, lower turnover and safer care. 


Health care leaders can reduce burnout and achieve safer care by focusing on selected cultural essentials. Through the same leadership actions, they can get a two-for-one outcome: just culture and joy in work. Leaders who ensure just culture behaviors will nurture environments for both safe care and enable colleagues to find joy and meaning in work. 


Steps for leaders to integrate just culture and joy in work include:

  • Definitions of what are they are so everyone has a common understanding
  • Clear purpose statements of why they are important, which offers a clear focus
  • Actions that describe how we make gains in both



Just culture: a learning environment based on respect, trust, and fairness to achieve safe, highly reliable care.


It is an environment where:

  • Consistent clarity exists between human error in unreliable systems and intentionally unsafe acts.
  • Reporting and learning from system flaws and mistakes are the norm and are valued.
  • Safety science is used to understand human fallibility with systems designed to mitigate that fallibility.
  • Response to harm is not based on patient outcome.
  • There is confidence that it is safe to report and learn from mistakes.
  • Accountability is clear for all roles. (See Pichert et al. 2013.)

 In short, team members will know they will be treated respectfully, consistent with organizational values.


Joy in work: when all team members, no matter their role, find meaning and purpose in what they do. It results when colleagues have an intellectual, behavioral, and emotional connection to the organization’s mission (IHI in press). These environments are characterized by psychological safety. Psychological safety means an environment where all team members feel secure and capable of changing; they experience respectful interactions among all; are able to ask questions, seek feedback, admit mistakes, and propose ideas (Edmondson 2012).



The primary way leaders embed culture is what they pay attention to and how they react to critical incidents (Schein 2004). Leaders are responsible for paying attention to and developing organizational behaviors that promote psychological safety, which enables both engagement and safety.


For instance, of seven drivers of team engagement identified, three are greatly enhanced by psychological safety (Edmondson 2012):

  • Organizational culture and values are evidenced in the behaviors that are consistent with a just and fair environment. How leaders react to critical incidents involving patient harm is a key behavior that reflects consistency –or lack of– with the intended organizational culture and values.
  • Social support and community at work are illustrated by respectful interactions among all team members no matter their role. Members feel they can speak up without fear of retribution; are supported by colleagues and leaders to do their best; and experience a sense of camaraderie in their daily work. 
  • Workload and job demands show a balance between the work to be done and the time/resources available. Excessive workload is frequently due to ineffective systems that waste time, energy, and good will. These same ineffective systems lead to unsafe conditions.


As part of a well-designed leadership development process, leaders can ask the following organizational assessment questions to further advance their outcomes in safety and joy in work.

  • How well do we demonstrate just culture principles in every part of the organization? 
  • What happens when an error occurs?  What are leaders’ responses? Do the responses vary depending on level of harm or by what role was involved?
  • Are we as focused on much on system failures as we are on harm events?
  • Do we act daily to show that respecting others and treating them fairly is essential?
  • What fairness gaps do we have in our current actions?
  • Do we promote psychological safety through the following:

o   Be accessible, visible and approachable to develop relationships with team members.

o   Acknowledge the limits of current knowledge; frame the work as highly complex requiring all to contribute for great outcomes.

o   Be willing to show fallibility and humility; acknowledge that we do not have all the answers and are learning.

o   Invite participation.

o   View failures as learning opportunities.

o   Use direct, clear language.

o   Set boundaries about what is acceptable behavior and hold others accountable for boundary violation (Edmondson 2012).


This list of what, why, and how is a means of strengthening the leadership journey towards safer care and an environment where joy and meaning thrive.


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Do you find joy and meaning in your work? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.



Edmondson, A. 2012. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: Jossey-Bass.

Institute for Healthcare Improvement. 2017. Joy in Work White Paper. In press.


Schien E. 2004. Organizational Culture, 3rd Ed. San Francisco: Jossey-Bass



Barbara Balik, EdD, MS, RN, is co-founder of Aefina Partners and a longtime member of the NPSF Board of Advisors.

Tags:  burnout  culture  workforce safety 

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Culture Change on the Agenda

Posted By Administration, Friday, September 30, 2016

Dana Siegal, RN, CPHRM, prompts attendees to think
30 years into the future and imagine how
health care culture has changed for the better.

The 9th Annual NPSF Lucian Leape Institute Forum & Keynote Dinner focused on safety culture, leadership, and strategies for the real world.

by Patricia McTiernan, MS

Imagine it is 2046. What changes will have taken place to improve the safety of patients and the health care workforce? What would you like to see happen over the next 30 years—and what are you willing to do to make it a reality?

Those were among the questions posed to attendees of the 9th annual NPSF Lucian Leape Institute Forum & Keynote Dinner held in Boston on September 15. Dana Siegal, RN, CPHRM, CPPS, director of patient safety services, CRICO Strategies, led an afternoon session punctuated by skits illustrating one dramatic change in health care culture over the years: the move to tobacco-free health care organizations.

Ms. Siegal recounted how, 30 years ago when she was a new nurse, smoking in hospitals was not uncommon among doctors, nurses, and even patients (unless on oxygen, of course!). Slowly, things began to change; smoking was confined to the “back room,” then to the outdoors. And finally, not all that long ago, tobacco was largely banned from the grounds of most hospitals, including parking lots.

What does smoking have to do with patient safety? The point Ms. Siegal hit upon is that culture change does not happen overnight. It takes time, sometimes a very long time, for norms and attitudes to spread throughout an organization, a community, a region, an industry, and in this case, across the country. She invited attendees to share their wishes for what health care and patient safety would look like in 30 years.


Here are just a few:



What would you want to see happen over the next 30 years?

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Looking Forward: New Models of Safety and Risk

The afternoon keynote speaker, renowned patient safety researcher Charles Vincent, PhD, MPhil, gave attendees a glimpse of what the future might look like.

    Charles Vincent 
     Prof. Charles Vincent provided an overview of new models
of assessing risk and promoting safety in health care.

Currently Emeritus Professor, Clinical Safety Research, at Imperial College, London, Prof. Vincent has an extensive background in research on the causes of harm to patients, consequences for patients and staff, and methods of improving the safety of health care. His most recent book, Safer Healthcare: Strategies for the Real World (co-authored with René Amalberti) is available at no charge as an e-book (download at

Prof. Vincent’s talk centered on the question of whether it is possible to develop a framework or menu of interventions around patient safety, rather than addressing issues by project or outcome. He noted the correlation to a recent NPSF report calling for an overarching shift from piecemeal approaches to total systems safety.

Prof. Vincent hypothesizes that a framework of strategies and interventions could be applicable across all settings (hospital, home, primary care) and across all levels of care (frontline, organizational, regulatory, and patient self-care). He outlined three models of safety:

  • Avoiding risk (ultra-safe): Examples from outside of health care include the airline industry. This model is characterized by a tough regulatory system and the need to avoid risk as much as possible.
  • Managing risk (high reliability): Risk is not sought out, but is inherent in the work, for example, firefighting. This model is marked by group intelligence and adaptation, with training and safety focused on flexibility and personal resilience being a key component.
  • Embracing risk (ultra-adaptive): An apt example here is deep-sea fishing, where risk is the essence of the profession. Working conditions are unstable and unpredictable.

While some areas of health care may fall into the ultra-safe category, where the goal is to avoid risk altogether, other areas may be categorized by the need to manage or mitigate risk.

Another example Prof. Vincent offered to illustrate the point is home dialysis. Patients and families performing dialysis in the home are trained in how to do it and in safety practices. But they are also schooled in what to do if something goes wrong, which Prof. Vincent said works better than drilling in to people that they have to do things perfectly every time.

“Absolute safety is not the aim,” he said. “We know it is never going to be safe; we need to manage the risk.”

Looking Back to Make Advances

    Dr. Pamela Cipriano, president of the American Nurses
Association, discussed the need to assess the impact and
success of patient safety initiatives.


During the evening keynote address, Pamela Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association, noted that those in attendance are already on board with the need to make patient safety the priority. “You’re all converted,” she said. “We can be zealots. The people who are missing haven’t gotten the message.”

Quoting Max DePree, Dr. Cipriano noted that, “When we talk about patient safety, the leader is the servant.” Leaders of health care organizations are the key to setting the bar for safety in their organizations, but not all health care leaders are aligned with the principles that are so important to patient safety.

Dr. Cipriano also cautioned that unintended consequences can result from aggressive agendas. “We don’t always go back and look at the impact” of initiatives, she said.

She offered the example of the practice of isolating patients with Methicillin-resistant Staphylococcus aureus (MRSA) and using contact precautions (gloves and gowns). For years, clinicians and regulators supported the practice of implementing contact precautions of patients found to have MRSA. This process was mandated in a number of states. In 2015, a study argued that the benefits of contact precautions had not been proven, no study had directly compared the effectiveness of contact precautions to standard precautions, even as we know that the use of contact precautions has deleterious effects (psychological and otherwise) on patients. As a result, some hospitals are now moving away from the use of contact precautions and isolation for patients with MRSA.

Excelling in patient safety requires that practices, protocols, and initiatives get reviewed and, if necessary, revised over time. Or, as Prof. Vincent notes in his book, patient safety is "a moving target." “In a very real sense innovation and improving standards create new forms of harm in that there are new ways the healthcare system can fail patients,” he writes.


So, we zealots have work to do.

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What would you like to see change about safety culture in health care? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  culture  leadership  Leape 

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When Behavior Undermines Safety

Posted By Administration, Thursday, May 12, 2016

A Breakout Session at the NPSF Patient Safety Congress will detail a systematic method for
addressing colleague reports of unprofessional behavior.

by Patricia McTiernan, MS



Safety protocols are only effective if people follow them. Take hand hygiene, for example. While effective hand hygiene can reduce the spread of certain infections, the Centers for Disease Control and Prevention reports that, on average, health care professionals practice hand hygiene less than half the time that they should.


The difference between an inadvertent slip and an intentional disregard for a safety practice has been discussed before. So what is a health care worker to do if he or she sees a colleague behave in a way that undermines safety?


The Center for Patient and Professional Advocacy (CPPA) at Vanderbilt University Medical Center recently published results of a robust program to address colleague reports of unprofessional behavior. Lynn Webb, PhD, assistant dean for faculty development and lead author of the recent paper documenting the program, will be one of the speakers discussing this work at the NPSF Patient Safety Congress in Scottsdale later this month.


A Nonpunitive System of Change

  "It’s really important to emphasize
that this is not a punitive process."
—Lynn Webb, PhD

The Vanderbilt CPPA team already had experience with patient reports of unprofessional behavior. The Vanderbilt Patient Advocacy Reporting System (PARS) is a method of collecting and aggregating patient complaints of physician behavior. According to Dr. Webb, PARS data have shown that 5% of physicians and advanced practice professionals (APPs) are associated with 35-40% of patient complaints about their medical professionals. The PARS method for graduated interventions has been adapted and put into place at more than 140 hospitals and medical groups nationwide.


Now, the principles behind the PARS program have been utilized to develop the Co-worker Observation Reporting SystemSM (CORS).


“The CORS program was established to provide systematic feedback to professionals associated with reports from co-workers about what appeared to be unsafe or disrespectful behavior,” Dr. Webb says. The system involves a method of capturing, reviewing, coding, and tracking data. Peer “messengers” are trained to share reports with professionals associated with the reports. The time between when a report is received by the system and the peer discussion is usually less than one week.


Dr. Webb emphasizes that the system is designed to address behavior that seems inconsistent with the Vanderbilt “Credo,” a statement of values shared by professionals and staff. “It’s important to share reports as soon as possible, giving professionals an opportunity to reflect on the issues raised in them,” says Dr. Webb.


In analyzing reports over a 3-year period, the CPPA team found that 3% of professionals were associated with 45% of reports. After the CORS intervention process was implemented, 70% of identified professionals have not been associated with another report.


At Vanderbilt, CPPA also compared physicians identified in the CORS program with those identified in the PARS process. “We found little overlap of professionals having high numbers of patient complaints and those having a pattern of coworker concerns,” says Dr. Webb.


The Vanderbilt CPPA team has compiled a “project bundle” for use by other organizations considering the implementation of such a system. The bundle includes elements of the program that organizations should have in place to help ensure successful implementation. These include strong leadership commitment, program champions, and policies that address expectations for professional conduct. Co-presenter Roger Dmochowski, MD, Vanderbilt’s executive medical director for quality, safety, and risk prevention, believes that success of the CORS program at Vanderbilt was linked to the early involvement of physician and nursing leaders in the development phase.


“It’s really important to emphasize that this is not a punitive process,” Dr. Webb says. “By having a colleague share an observation with another colleague, the intent is to be restorative and change unsafe or disrespectful behavior.”

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Lynn Webb, PhD, and Roger Dmochowski, MD, will present details of the CORS program in Breakout Session 202 at the NPSF Patient Safety Congress. Find out more about the Congress agenda at


Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  2016 NPSF Congress  culture 

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Leadership, Culture, and Patient Experience Take Center Stage

Posted By Administration, Thursday, September 24, 2015
Updated: Thursday, September 24, 2015


     Afternoon keynote speaker Dr. Skip Campbell
A video tribute to Dr. Lucian Leape
kicked off the evening program.

    Dr. Sands (left) with panel participants (from left): Dr. Richard Whyte;
Dr. Pat Folcarelli; Mary Fay, RN; Jeff Catalano, Esq.;
and Nancy Watson, JD.


The 8th Annual NPSF Lucian Leape Institute Forum & Keynote Dinner touched upon issues that are the keys to moving the patient safety agenda forward.

by Patricia McTiernan, MS


Would your hospital allow a news reporter to follow along as the leadership team conducted WalkRounds? What does your hospital do to provide support to clinicians involved in medical errors? Would you ever hesitate to recommend your physician or hospital to a friend or loved one?


These questions may not come up in day-to-day patient safety work, with its focus on numbers, data, protocols, and checklists. But they are among the thoughts provoked by the presentations at this year’s NPSF Lucian Leape Institute Forum & Keynote Dinner, held in Boston last week. Leadership, culture, patient experience, and workforce safety took center stage as the event’s presentations demonstrated the value of transparency in health care and the importance of leaders in influencing behavior within our health care organizations.


The Institute’s most recent report argues that greater transparency in health care – at all levels – can fuel better, safer care. With that report as the backdrop, Dr. Darrell “Skip” Campbell shared experiences from his work as a surgeon, researcher, and chief medical officer as well as from his current role as director of the Michigan Surgical Quality Collaborative.


Dr. Campbell pointed to research that showed that staff who had participated in Leadership WalkRounds were more likely than those who had never participated to say they would speak up when faced with a potential or actual medical error. During his time at University of Michigan Health System, Dr. Campbell was so confident in the promise of WalkRounds to drive improvement, he invited a news reporter to observe the ritual.


In his role as director of MSQC, Dr. Campbell works on a different level of transparency—between providers. MSQC is certified by the Agency for Healthcare Research and Quality as a patient safety organization and is made up of 73 member organizations across the state that agree to share data on surgical outcomes and not compete on safety.


MSQC works to identify top performers through the analysis of data; visits them, talk to them, and figures out what it is that they are doing to achieve the good results; and then distributes that information to the other members. One of their early successes has been a state-wide decrease in surgical site infections after colectomy.


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Breakout Knowledge

Dr. Gary Kaplan, chairman and CEO of Virginia Mason Health System and chair of the NPSF Lucian Leape Institute noted in his opening remarks that there are challenges and opportunities around the issue of transparency, as well as significant barriers. The Institute’s current focus is on translating its recommendations into action.


In breakout sessions, forum attendees discussed these issues. Rick Boothman, JD, chief risk officer at University of Michigan Health System and a member of the NPSF Board of Directors summarized the key points of consensus from the groups:

  • The single biggest area of concern is leadership’s role and the widespread failure to set expectations to create and support a safety culture.
  • Education is valuable, but it needs to be done correctly and embedded in the organization’s behavior.
  • Transparency can be powerful tool, but it needs to be used responsibly, with data that make sense and are delivered in useful ways.
  • There is a lack of appreciation for engagement by boards of directors in the issue of patient safety; board education on the issue is needed.
  • Provider-to-provider sharing of data and information is difficult to achieve, but is essential for progress.
  • Everyone in the organization needs to support the core mission of patient and workforce centricity – whether they are a housekeeper or a lawyer.
  • Information without action is not productive. It is the responsibility of the person reporting substandard care to be accurate, fair, and thorough, and the responsibility of the receiver to listen and understand the problem with the goal of fixing it if possible.

Where Does Apology Come In?

The afternoon concluded with an overview of the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) and a panel discussion featuring staff of Beth Israel Deaconess Hospital in Boston, an organization that helped pioneer the MACRMI roadmap to respond to adverse events and suspected medical errors.


Dr. Alan Woodward was instrumental in starting MACRMI in 2005, when he was president of the Massachusetts Medical Society. “We were beating our heads against the wall with tort reform,” he said. “But we wanted to do something about patient safety.” He met with Rick Boothman at the University of Michigan, and eventually formed an alliance of hospitals in Massachusetts. Dr. Kenneth Sands, chief quality officer of Beth Israel Deaconess, served as principal investigator of MACRMI’s study, funded by the Agency for Healthcare Research and Quality, to identify the major impediments to apology and disclosure and strategies to overcome them. This work led to the MACRMI roadmap, known as CARe—communication, apology, and resolution following medical injury.


Dr. Woodward described CARe as a proactive process to review the case, advocate for the patient’s medical needsand if the injury was found to be avoidable, their financial needs—and to render appropriate apology, which he said, "is therapeutic for both clinicians and patients.”


Dr. Sands facilitated a panel discussion of a case that was handled through the CARe process. In the case presented, a communication breakdown led to a delayed cancer diagnosis. Speaking via a video, the patient explained that she found out she had cancer only after persisting in telling her doctor that something wasn’t right after her gallbladder surgery. “Patients shouldn’t have to figure this out for themselves,” she said.


In an important part of the process, the patient met with the vice chair of the department of surgery, who explained what happened and how, and what the organization was doing to prevent it from happening again.


Pat Folcarelli, RN, PhD, director of patient safety at BI Deaconess said that “physicians usually leave such a meeting feeling very positive. We prepare them beforehand, [telling them] that it is a critical meeting to communicate openly about what happened. Despite anxiety, most leave thinking they’ve been given a gift in terms of interaction with the patient and family that they hadn’t had before.”


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Making It Personal

Dr. Jonathan Perlin, the evening keynote speaker, began his talk, "To Care Is Human," by asking the question, “Would you ever hesitate to recommend your physician or hospital to a friend or loved one?” A former, long-time member of the NPSF Board of Directors, current chair of the American Hospital Association, and chief medical officer of Hospital Corporation of America, Dr. Perlin argued that patient safety and patient experience go hand-in-hand. He told four patient stories, each through the lens of the HCAHPS survey (Hospital Consumer Assessment of Healthcare Provider and Systems).


Would you ever hesitate
to recommend your physician or
hospital to a friend or loved one?

Two of the cases involved breaches of hand hygiene. In one case, the patient, a retired nurse, did not speak up to the anesthesiologist because she knew “for the next four hours, my life would be in his hands.” In another case, speaking up to a clinician about hand hygiene led to a rebuke about how “disruptive visitors can be asked to leave.”


Apart from noting that the most common mode of transmission of pathogens is via the hands, and that there are roughly 80,000 hospital acquired infections each year, Dr. Perlin also fixed on the patient’s perceptions: how would those patients respond to HCAHPS survey questions such as “Would you recommend this hospital?” and “How would you rate the nurses’ response to concerns or complaints?”


A noted expert in health information technology, Dr. Perlin suggested that better use of data could also help providers improve care and safety. “If each of us read two articles per night, we’d only be behind by 10,000 articles,” he said. “Care informs care.” More effective use of the digital records we are creating can be part of a learning health system.


Making it personal, Dr. Perlin concluded by saying that each patient he had discussed was a member of his own family. “Patient experience isn’t just about being nice,” he said. “Patient safety is inextricably linked to patient experience. It involves culture and leadership, with the patient at the center.”

Have you done work to improve the culture or the patient experience in your organization? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

About the Author: Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  apology  Boothman  Campbell  communication  culture  Gandhi  Kaplan  leadership  Leape  Sands  transparency 

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