Christy Villalobos, MPP

Frontline Supervisor Perspectives on Enabling High Reliability and Fostering a Just Culture at the VHA

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Frontline Supervisor Perspectives on Enabling High Reliability and Fostering a Just Culture at the VHA

Author(s)

Keith Essen, RN, PhD, MSS

Christy Villalobos, MPP

Ahnnya Slaughter, DNP, RN-C, CNS-BC

Charles D. Leiner, MD

Scott Mayo

The Veterans Health Administration (VHA) is now in the sixth year of its enterprise-wide transformation into a high reliability organization (HRO). This effort began with a 2016 pilot project and is now implemented in 170 VHA medical centers.^1-4 This transformation reflects a commitment to implementing standardized and reliable health care practices.

The VHA HRO implementation strategy includes a multifaceted approach to engage leadership through education, training, leader coaching, and change management initiatives.² Despite the diversity of facilities in terms of cultures, geographies, and complexities, US Department of Veterans Affairs (VA) medical centers (VAMCs) have increasingly embraced standardized HRO practices. These changes are evident in improvements in VHA All Employee Survey scores, which assess 4 key patient safety culture dimensions: risk identification and just culture, error transparency and mitigation, supervisor communication and trust, and team cohesion and engagement.⁵ Positive trends in these dimensions highlight a cultural shift toward greater reliability, even amid challenges introduced by the COVID-19 pandemic.

However, this progress has encountered some challenges. Leadership turnover, budgetary constraints, and extensive educational demands for implementing and sustaining HRO practices have created obstacles, particularly for frontline health care practitioners.⁶ Additionally, there are pockets of resistance similar to what the airline industry faced when implementing crew resource management (CRM). Specifically, senior pilots and legacy leaders were reluctant to abandon their high-status, autocratic management styles and embrace CRM, despite its proven benefits for enhancing commercial airline safety.⁷ Similarly, some VHA staff have expressed resistance to foundational HRO practices, which include safety huddles, safety forums, leader rounding, and visual management systems.^6,8

The training requirements for HRO practices range from a 25-minute introductory course (HRO 101) to a 7.5-hour team training session facilitated by the VHA National Center for Patient Safety (NCPS).⁹ While some supervisors view these requirements as burdensome, others have demonstrated strong enthusiasm for the process.⁶ Understanding the perspectives of unit and departmental managers regarding factors that enhance or hinder the adoption of HRO practices is critical for continuous improvement.^10-12 Research has suggested that fostering psychological safety can create an environment where new ideas are shared openly, helping organizations navigate resistance to change.^13-16

A 2024 quality improvement study, drawing on the perceptions of HRO leads, identified key facilitators, including training, coaching, leader approachability, and psychological safety, as well as barriers such as inadequate training and lack of accountability among managers.¹⁷ Building on this work, the current study focused on frontline supervisors, who are directly involved in integrating HRO practices into patient care activities. By addressing both barriers and facilitators, this expanded approach aims to provide a more comprehensive understanding of the challenges influencing HRO implementation in day-to-day operations.

Methods

This quality improvement initiative examined facilitators and barriers to establishing just culture and implementing high reliability practices, focusing on frontline supervisors overseeing clinical care teams (eg, emergency department, critical care) or patient-support functions (eg, dietary services). A questionnaire was sent to a randomized sample of VHA facility supervisors.

A qualitative grounded theory approach was employed to provide a deeper understanding of nuanced phenomena that cannot be captured through numerical data alone. This method enables systematic analysis using open, axial, and thematic coding, ensuring that emerging themes achieve saturation.^18,19 It is particularly suited for this study, given the limited prior data on frontline supervisors. Additionally, qualitative methods help mitigate biases common in Likert-style scales, where respondents may lean toward agreement, potentially skewing results.²⁰

Inclusion Criteria

Participants were required to have served as a frontline supervisor for ≥ 6 months. Frontline supervisors are assigned responsibility for supporting staff who deliver services to VHA patients, including clinical care, dietary support, and other functions. These staff must complete baseline HRO cultural training as well as NCPS team training and are responsible for supporting quality, safety, and patient experience. Potential participants were identified from a list of frontline supervisors provided by VHA management. A subset was chosen through random sampling across geographically distributed VHA hospital facilities that vary in size and complexity. Invitations to participate in completing the questionnaire were sent via email, explaining the quality improvement initiative’s purpose, and encouraging voluntary participation. Of 2000 frontline supervisors invited to participate in the initiative, 97 completed the questionnaire. Participants represented a mix of VHA sites in terms of geography, size, and complexity.

Procedures

The authors used a qualitative approach and administered a confidential online survey. Demographic data were collected within the survey to understand characteristics of the participant population, including length of time as a frontline supervisor, facility complexity level, and professional background (clinical vs nonclinical). Survey questions were developed to elicit responses to specific areas of interest based on existing literature related to HRO and just culture.

Facilitators were defined as factors that increase the likelihood of establishing or sustaining high reliability practices and/or culture. Barriers were defined as factors that decrease or inhibit the likelihood of establishing or sustaining high reliability practices and/or culture. The questionnaire consisted of open-ended questions asking frontline supervisors to describe HRO practices and just culture at their individual facility and within their role. Participants also were asked to identify facilitators and barriers that helped or hindered their efforts to establish and maintain high reliability practices and just culture. The questionnaire solicited recommendations for additional support, training, resources, or leadership interventions to strengthen high reliability practices and just culture from each participant.

Analysis

Participant characteristics were analyzed using descriptive statistics. Responses to the 7 open-ended questions were coded and analyzed using ATLAS.ti v.24 qualitative data analysis software by an experienced researcher and coauthor. Grounded theory methodology allowed themes to emerge from the data and although the response rate was limited, the themes reached a saturation point.^18,19

Ethical Considerations

Institutional review board (IRB) review and approval were not required for this quality improvement initiative. Formal IRB review and approval of a quality improvement initiative are not required by VHA. Participation was confidential and voluntary, and participants could withdraw at any time without consequences. Completion of the survey indicated consent, and facility names and participant identifiers were not used. Unique numbers were assigned to each participant and all responses were kept confidential and nonattributional. Frequency coding was used to identify the facilitators and barriers to high reliability practices implementation and just culture among frontline supervisors until thematic saturation was obtained.

Results

A total of 2000 frontline supervisors were invited to participate, of whom 97 completed the questionnaire (response rate, 4.9%). Participants were first asked to describe just culture and high reliability practices in their own words. The consensus was that a just culture emphasizes a nonpunitive environment where employees can report errors or incidents without fear of retaliation. It encourages accountability at the systems level, focusing on learning from mistakes to improve processes. In response to a question asking respondents to describe HRO practices and just culture in their own words, participants noted that organizations with a just culture promote open communication, allowing staff to discuss safety issues and concerns without fear of personal blame. Additionally, participants agreed that HRO practices were defined as a set of principles and practices aimed at minimizing errors and promoting safety, especially within complex and high-risk environments. Participants responded that key characteristics include a preoccupation with failure, sensitivity to operations, reluctance to simplify, and a commitment to resilience. HRO practices entail proactively identifying and mitigating risks through open communication and collaboration among team members, they added.

Overall, participants were aligned with their view of the role a frontline supervisor plays in supporting just culture and HRO principles at their facility by fostering open communication and psychological safety, encouraging continuous learning and improvement, and promoting team collaboration and shared accountability. Among frontline supervisors, 93 (96%) identified their role as being critical to creating a safe space and reinforcing just culture and HRO principles at their facility, while 4 (4%) failed to identify a single duty.

Identified Themes

Table 1 summarizes 6 key themes identified from participants’ responses, highlighting the most frequently cited facilitators and barriers to implementing and sustaining high reliability practices and a just culture. Table 2 shows the classification of several themes in relation to facility complexity, emphasizing leadership commitment and support as a pivotal facilitator, while listing resistance to change and entrenched attitudes as a prominent barrier.

Role of Leadership

Facilitators. Leadership commitment and support were the most frequently identified facilitator, accounting for 44 mentions (45%). This aligns with participants’ descriptions of leadership involvement as crucial, particularly in setting standards and fostering accountability throughout the organization. For example, a frontline supervisor with < 5 years of experience from a nonclinical background at a 1B facility remarked, “Facility leadership are involved, which trickles down to lower-level leads and supervisors, which keeps everyone accountable and holds everyone to the same standards.” Participants frequently identified that leaders setting the standard and communicating expectations as paramount facilitators for strengthening high reliability practices and just culture at their facility.

Barriers. A lack of leadership commitment and support was a significant barrier, cited in 17 responses (18%). Participants described this barrier as a deficiency in follow-through, transparency, and presence, which undermines efforts to sustain just culture and high reliability principles. Notably, the lack of leadership commitment and support stood out as a distinct and recurring theme, underscoring its critical role as an independent challenge to achieving organizational goals. “Many leaders are not yet fully bought in,” a respondent explained. “They take the training and pass it off and go right back to their units and focus on blaming or chastis[ing] people for speaking up.” This theme frequently intersected with mentions of insufficient resources and entrenched attitudes, amplifying other challenges.

Open Communication and Transparency

Facilitators. Open communication and transparency were identified as facilitators in 12 responses (12%). Participants emphasized the importance of mechanisms such as HRO meetings and the sharing of “real” examples of positive outcomes from applying HRO principles. Transparent communication fosters psychological safety, allowing staff to report concerns without fear of reprisal. One participant with < 5 years of experience from a clinical background at a 1A facility encapsulated this theme by saying, “Quarterly ‘fireside chats’ are helpful, [this] creates open dialogue about where the next safety issue may occur, what staff need to do their job safely, while also imparting more of the philosophy of HRO that staff may not be aware of.”

Barriers. While communication serves as a facilitator, participants also highlighted barriers such as siloed communication and fear of reprisal. These reflect challenges in creating open and transparent feedback loops essential to high reliability. For example, a participant concluded, “Leadership does not communicate problem-solving efforts and resolution down the chain, they do not see the problems.” Another participant added, “[HRO principles] are not discussed that much.” While this theme presented as a barrier, it was noted less frequently.

Education and Training

Facilitators. Education and training were noted as facilitators in 10 responses (10%), underscoring their role in establishing high reliability practices. Participants suggested tailored training, simulation-based exercises, and mentorship to enhance practical application. However, they noted the importance of linking training to real change and ensuring leadership enforcement of learned behaviors. This theme is best represented by a participant who concluded, “Trainings have helped, but I think as a supervisor, being involved and interacting with your staff, observing, doing the work they do to help identify potential problems areas, especially when new systems are introduced are key. Being hands-on is the only way to successfully manage your team.”

Barriers. Insufficient resources, including time and staffing constraints, were identified as barriers to education and training, accounting for 24 responses (25%). Participants observed that mandatory training without mentorship or application diminishes its effectiveness.

Insufficient Resources and Funding

Barriers. Resource constraints, including low staffing levels and budget cuts, accounted for 24 responses (25%). Participants reported these limitations prevented staff from attending training and affected the overall implementation of just culture and HRO principles. “Low staffing in supporting services as well as in my own service line have created barriers,” a participant reported. Another participant responded that barriers to HRO were primarily “…financial, as the focus is how to curb costs and bring in more funding rather than taking the time to review and apply the concepts of high reliability.”

Resistance to Change and Entrenched Attitudes

Barriers. Resistance to change was the most frequently identified barrier, with 31 responses (32%). One participant described a persistent “gotcha” culture, where blame and punishment hinder progress toward just culture. This entrenched mindset creates significant obstacles to adopting HRO practices and requires active leadership and supervisor intervention to overcome. This theme is best captured by a respondent who noted that “culture change is difficult, especially among staff with such long tenure. It’s a long game.”

Synthesis and Integration of Findings

The data in Table 1 and Table 2 reinforce the themes identified in the qualitative analysis. Leadership commitment and support are pivotal, both as a facilitator and barrier. Open communication and education and training, while recognized as facilitators, were less frequently mentioned, but still critical. Resistance to change and insufficient resources were the most prominent barriers, indicating where organizational efforts should focus to further foster a culture of high reliability.

By addressing these barriers, particularly resistance to change and resource constraints, and leveraging facilitators like leadership engagement and transparent communication, organizations can enhance their implementation of just culture and high reliability practices. These efforts require deliberate strategies, including effective training, mentorship, and the active presence of leadership.

Discussion

This quality improvement initiative builds on prior research by examining the implementation of HRO practices from the perspective of frontline supervisors. Unlike earlier research focused on HRO leads, this study explores the critical role of supervisors who integrate HRO principles into clinical and administrative operations.¹⁷ By analyzing their experiences, this study offers practical insights into facilitating HRO implementation across organizational levels.

The findings highlight broad agreement on the value of just culture and HRO principles in fostering safe, accountable health care environments. Participants described just culture as promoting system—level accountability rather than individual blame, encouraging error reporting and learning for continuous improvement. Similarly, HRO practices—emphasizing a preoccupation with failure, operational sensitivity, and resilience— were seen as vital for patient safety in complex settings.

Frontline supervisors play a pivotal role, with 96% of respondents identifying their influence on fostering open communication, psychological safety, and shared accountability. Key facilitators included leadership commitment, open communication, and mentorship. Active leadership involvement was particularly valued, as it trickles down to reinforce standards across all organizational levels. HRO meetings using real-world examples were seen as instrumental in demonstrating the tangible benefits of these principles, helping embed them into daily practices.

Despite these facilitators, several barriers to implementation were noted. Resistance to change and entrenched attitudes, and a persistent gotcha culture undermined efforts to establish just culture. Resource constraints, including staffing shortages and budget limitations, further hindered the adoption of HRO practices. The lack of consistent leadership engagement, marked by limited visibility, follow-through, and transparency, exacerbated these challenges.

HRO leads are important for promoting education and embedding HRO principles into daily operations. These individuals provide vital support to frontline supervisors, translating HRO concepts into actionable practices. However, organizational challenges such as staff turnover and redirected funding have weakened the infrastructure supporting HRO initiatives. The elimination of HRO lead roles due to budgetary pressures at several facilities reflects a short-term focus on operational demands at the expense of long-term cultural transformation.

Additional barriers included siloed communication, fear of reprisal, bureaucratic obstacles, and outdated technology. These challenges limit progress toward high reliability and diminish the effectiveness of HRO principles.

Participants proposed strategies focused on education, training, and leadership engagement. Simulation-based training tailored to specific roles was identified as an effective tool for preparing staff to apply HRO principles in real-world scenarios. Enhanced communication, such as regular leadership rounding and transparent updates on safety concerns, was also emphasized. Participants stressed the importance of showing staff how their feedback influences organizational decisions to build trust and accountability. Finally, standardizing procedures and protocols across facilities was seen as critical for aligning practices and reducing variability in safety processes.

This study underscores the need for sustained leadership commitment and infrastructure to ensure the long-term success of HRO implementation. Addressing the identified barriers and leveraging the proposed mitigation strategies can foster a culture of safety and reliability across the organization.

Limitations

This quality improvement initiative used qualitative grounded theory methods and sampled a relatively small group of experienced leaders specifically involved in implementing HRO within the VHA. In addition, while saturation of themes was reached, the number of responses represents a small sample of VHA frontline supervisors. As such, the findings may not be fully representative of the perspectives of all unit and departmental leaders across the VHA or other health care systems. A previous qualitative quality improvement initiative focused on the perceptions of HRO leads regarding facilitators and barriers to just culture.¹⁷ This quality improvement initiative broadened that focus by examining the perspectives of frontline supervisors in the operational environment, who may not be HRO experts but work to implement HRO principles with the guidance of HRO leads (HRO subject matter experts).

There remains an opportunity to address a critical gap by assessing facilitators and barriers beyond the facility level, incorporating both the Veterans Integrated Service Networks (VISN) and VHA Central Office (VHACO). While qualitative methods, such as those used in this study, provide deep insights and detailed understanding, they are limited in their ability to identify system-wide trends and variations at a more strategic VISN and VHACO level. Addressing this could enhance the broader applicability of HRO principles across the VHA.

Conclusions

Successful implementation of the recommendations reported in this study will require sustained focus and continued commitment from all stakeholders across the VHA. As the VHA enters its seventh year on the HRO journey, the risk of organizational drift remains an ongoing concern. Progress has been made, as evidenced by incremental improvements in All Employee Survey scores and increased reporting of adverse events and near misses, but the challenge will be to maintain focus and continue to build upon progress amid the current climate of budgetary constraints.

This study builds on previous quality improvement efforts and provides valuable insights into the barriers and facilitators that can either hinder or support the VHA’s ongoing pursuit of high reliability. The findings offer a model for understanding the complexities of this journey—one that requires continuous effort and adaptation, as there is no definitive endpoint in the quest for high reliability.

Since completion of this study in 2024, the VHA has entered a period of organizational transition and restructuring. Such transitions are often accompanied by increased operational demands and organizational strain. These include realignments, personnel changes, staffing adjustments, workforce reductions, and continued implementation of a new electronic health record system. In this context, maintaining attention to culture, communication, frontline engagement, and mechanisms that provide visibility into organizational climate is essential to sustain momentum in high-reliability efforts.

References

Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68:151-157. doi:10.1097/jhm-D-23-00056
Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: A multiyear implementation strategy and associated outcomes. J Patient Saf. 2022;18:64-70. doi:10.1097/pts.0000000000000788
Murray JS, Clifford J, Larson S, Lee JK, Sculli GL. Implementing just culture to improve patient safety. Mil Med. 2023;188:usac115. doi:10.1093/milmed/usac115
Merchant NB, O’Neal J, Montoya A, Cox GR, Murray JS. Creating a process for the implementation of tiered huddles in a Veterans Affairs Medical Center. Mil Med. 2023;188:901-906. doi:10.1093/milmed/usac073
Mohr DC, Chen C, Sullivan J, et al. Development and validation of the Veterans Health Administration Patient Safety Culture Survey. J Patient Saf. 2022;18:539-545. doi:10.1097/PTS.0000000000001027
Leonard C, Gilmartin H, Starr L, Anderson T. Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. J Healthc Risk Manag. 2024;44:17-23. doi:10.1002/jhrm.21580
Sculli G, Essen K. Soaring to Success: The Path to Developing High-Reliability Teams. HCPro; 2021.
Gupta JI, Sivils S, Reppert J, Paulot W, Houchens N, Hummel S. Visual management board implementation to enhance high reliability at a large VA health care system. Fed Pract. 2024;41:242-246. doi:10.12788/fp.0507
Veterans Health Administration. High Reliability Organization Learning Catalog. US Dept of Veterans Affairs; 2024. Internal document.
Jahn JLS, Black AE. A model of communicative and hierarchical foundations of high reliability organizing in wildland firefighting teams. Manag Commun Q. 2017;31:356-379. doi:10.1177/0893318917691358
Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31:845-848. doi:10.1136/bmjqs-2021-014141
Abrams J. Model the way to navigate difficult topics. The Learning Professional. 2022;43:14-18.
McCausland T. Creating psychological safety in the workplace. Research-Technology Management. 2023;66:56-58. doi:10.1080/08956308.2023.2164439
Murray JS, Kelly S, Hanover C. Promoting psychological safety in healthcare organizations. Mil Med. 2022;187:808- 810. doi:10.1093/milmed/usac041
Sutton RI, Rao H. The friction project: how smart leaders make the right things easier and the wrong things harder. St. Martin’s Press; 2024.
Clark TR. The 4 stages of psychological safety: defining the path to inclusion and innovation. Berrett-Koehler Publishers, Inc.; 2020.
Essen K, Villalobos C, Sculli G, Steinbach L. Establishing a just culture: implications for the Veterans Health Administration journey to high reliability. Fed Pract. 2024;41:290- 297. doi:10.12788/fp.0512
Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. 4th ed. SAGE Publications; 2014.
Patton MQ. Qualitative research & evaluation methods: integrating theory and practice. 4th ed. SAGE Publications, Inc.; 2015.
Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47:2025- 2047. doi:10.1007/s11135-011-9640-9

Article PDF

0526FED Just Culture.pdf

Author and Disclosure Information

Keith Essen, RN, PhD, MSS^a; Christy Villalobos, MPP^b; Ahnnya Slaughter, DNP, RN-C, CNS-BC^c; Charles D. Leiner, MD^d,e; Scott Mayo^f

Author affiliations
^aVeterans Affairs National Center for Patient Safety, Ann Arbor, Michigan
^bAccenture Federal Services, Arlington, Virginia
^cVeterans Affairs Long Beach Healthcare System, California
^dCentral Virginia Veterans Health Care System, Richmond
^eVirginia Commonwealth University Health System School of Medicine, Richmond
^fVeterans Health Administration, Office of Sterile Processing, Washington, DC

Author disclosures The authors report no actual or potential conflicts of interest regarding this article.

Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.

Ethics and consent Based on review with government leaders overseeing this initiative and past precedents, the authors did not pursue and were not required to obtain formal institutional review board approval. The study was determined to be a quality improvement initiative, which is exempt from review in the Veterans Health Administration. All authors adhered to ethical standards of research, including asking participants for verbal consent and preserving participants’ confidentiality.

Artificial intelligence The transcribed data were organized, coded, and analyzed using Atlas.ti (version 24) qualitative data software to identify key themes and patterns for this publication.

Funding Contractor support for completion of this study was funded by the US Department of Veterans Affairs under contract number 36C10X24F0031.

Correspondence: Keith Essen (keith.essen@va.gov)

Fed Pract. 2026;43(5):e0693. Published online May 28. doi:10.12788/fp.0693

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Original Research

Author(s)

Keith Essen, RN, PhD, MSS

Christy Villalobos, MPP

Ahnnya Slaughter, DNP, RN-C, CNS-BC

Charles D. Leiner, MD

Scott Mayo

Author(s)

Keith Essen, RN, PhD, MSS

Christy Villalobos, MPP

Ahnnya Slaughter, DNP, RN-C, CNS-BC

Charles D. Leiner, MD

Scott Mayo

Author and Disclosure Information

Keith Essen, RN, PhD, MSS^a; Christy Villalobos, MPP^b; Ahnnya Slaughter, DNP, RN-C, CNS-BC^c; Charles D. Leiner, MD^d,e; Scott Mayo^f

Author disclosures The authors report no actual or potential conflicts of interest regarding this article.

Artificial intelligence The transcribed data were organized, coded, and analyzed using Atlas.ti (version 24) qualitative data software to identify key themes and patterns for this publication.

Funding Contractor support for completion of this study was funded by the US Department of Veterans Affairs under contract number 36C10X24F0031.

Correspondence: Keith Essen (keith.essen@va.gov)

Fed Pract. 2026;43(5):e0693. Published online May 28. doi:10.12788/fp.0693

Author and Disclosure Information

Keith Essen, RN, PhD, MSS^a; Christy Villalobos, MPP^b; Ahnnya Slaughter, DNP, RN-C, CNS-BC^c; Charles D. Leiner, MD^d,e; Scott Mayo^f

Author disclosures The authors report no actual or potential conflicts of interest regarding this article.

Artificial intelligence The transcribed data were organized, coded, and analyzed using Atlas.ti (version 24) qualitative data software to identify key themes and patterns for this publication.

Funding Contractor support for completion of this study was funded by the US Department of Veterans Affairs under contract number 36C10X24F0031.

Correspondence: Keith Essen (keith.essen@va.gov)

Fed Pract. 2026;43(5):e0693. Published online May 28. doi:10.12788/fp.0693

Article PDF

0526FED Just Culture.pdf

Article PDF

0526FED Just Culture.pdf

Methods

Inclusion Criteria

Procedures

Analysis

Ethical Considerations

Results

Identified Themes

Role of Leadership

Open Communication and Transparency

Education and Training

Insufficient Resources and Funding

Resistance to Change and Entrenched Attitudes

Synthesis and Integration of Findings

Discussion

Limitations

Conclusions

Methods

Inclusion Criteria

Procedures

Analysis

Ethical Considerations

Results

Identified Themes

Role of Leadership

Open Communication and Transparency

Education and Training

Insufficient Resources and Funding

Resistance to Change and Entrenched Attitudes

Synthesis and Integration of Findings

Discussion

Limitations

Conclusions

References

Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68:151-157. doi:10.1097/jhm-D-23-00056
Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: A multiyear implementation strategy and associated outcomes. J Patient Saf. 2022;18:64-70. doi:10.1097/pts.0000000000000788
Murray JS, Clifford J, Larson S, Lee JK, Sculli GL. Implementing just culture to improve patient safety. Mil Med. 2023;188:usac115. doi:10.1093/milmed/usac115
Merchant NB, O’Neal J, Montoya A, Cox GR, Murray JS. Creating a process for the implementation of tiered huddles in a Veterans Affairs Medical Center. Mil Med. 2023;188:901-906. doi:10.1093/milmed/usac073
Mohr DC, Chen C, Sullivan J, et al. Development and validation of the Veterans Health Administration Patient Safety Culture Survey. J Patient Saf. 2022;18:539-545. doi:10.1097/PTS.0000000000001027
Leonard C, Gilmartin H, Starr L, Anderson T. Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. J Healthc Risk Manag. 2024;44:17-23. doi:10.1002/jhrm.21580
Sculli G, Essen K. Soaring to Success: The Path to Developing High-Reliability Teams. HCPro; 2021.
Gupta JI, Sivils S, Reppert J, Paulot W, Houchens N, Hummel S. Visual management board implementation to enhance high reliability at a large VA health care system. Fed Pract. 2024;41:242-246. doi:10.12788/fp.0507
Veterans Health Administration. High Reliability Organization Learning Catalog. US Dept of Veterans Affairs; 2024. Internal document.
Jahn JLS, Black AE. A model of communicative and hierarchical foundations of high reliability organizing in wildland firefighting teams. Manag Commun Q. 2017;31:356-379. doi:10.1177/0893318917691358
Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31:845-848. doi:10.1136/bmjqs-2021-014141
Abrams J. Model the way to navigate difficult topics. The Learning Professional. 2022;43:14-18.
McCausland T. Creating psychological safety in the workplace. Research-Technology Management. 2023;66:56-58. doi:10.1080/08956308.2023.2164439
Murray JS, Kelly S, Hanover C. Promoting psychological safety in healthcare organizations. Mil Med. 2022;187:808- 810. doi:10.1093/milmed/usac041
Sutton RI, Rao H. The friction project: how smart leaders make the right things easier and the wrong things harder. St. Martin’s Press; 2024.
Clark TR. The 4 stages of psychological safety: defining the path to inclusion and innovation. Berrett-Koehler Publishers, Inc.; 2020.
Essen K, Villalobos C, Sculli G, Steinbach L. Establishing a just culture: implications for the Veterans Health Administration journey to high reliability. Fed Pract. 2024;41:290- 297. doi:10.12788/fp.0512
Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. 4th ed. SAGE Publications; 2014.
Patton MQ. Qualitative research & evaluation methods: integrating theory and practice. 4th ed. SAGE Publications, Inc.; 2015.
Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47:2025- 2047. doi:10.1007/s11135-011-9640-9

References

Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68:151-157. doi:10.1097/jhm-D-23-00056
Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: A multiyear implementation strategy and associated outcomes. J Patient Saf. 2022;18:64-70. doi:10.1097/pts.0000000000000788
Murray JS, Clifford J, Larson S, Lee JK, Sculli GL. Implementing just culture to improve patient safety. Mil Med. 2023;188:usac115. doi:10.1093/milmed/usac115
Merchant NB, O’Neal J, Montoya A, Cox GR, Murray JS. Creating a process for the implementation of tiered huddles in a Veterans Affairs Medical Center. Mil Med. 2023;188:901-906. doi:10.1093/milmed/usac073
Mohr DC, Chen C, Sullivan J, et al. Development and validation of the Veterans Health Administration Patient Safety Culture Survey. J Patient Saf. 2022;18:539-545. doi:10.1097/PTS.0000000000001027
Leonard C, Gilmartin H, Starr L, Anderson T. Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. J Healthc Risk Manag. 2024;44:17-23. doi:10.1002/jhrm.21580
Sculli G, Essen K. Soaring to Success: The Path to Developing High-Reliability Teams. HCPro; 2021.
Gupta JI, Sivils S, Reppert J, Paulot W, Houchens N, Hummel S. Visual management board implementation to enhance high reliability at a large VA health care system. Fed Pract. 2024;41:242-246. doi:10.12788/fp.0507
Veterans Health Administration. High Reliability Organization Learning Catalog. US Dept of Veterans Affairs; 2024. Internal document.
Jahn JLS, Black AE. A model of communicative and hierarchical foundations of high reliability organizing in wildland firefighting teams. Manag Commun Q. 2017;31:356-379. doi:10.1177/0893318917691358
Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31:845-848. doi:10.1136/bmjqs-2021-014141
Abrams J. Model the way to navigate difficult topics. The Learning Professional. 2022;43:14-18.
McCausland T. Creating psychological safety in the workplace. Research-Technology Management. 2023;66:56-58. doi:10.1080/08956308.2023.2164439
Murray JS, Kelly S, Hanover C. Promoting psychological safety in healthcare organizations. Mil Med. 2022;187:808- 810. doi:10.1093/milmed/usac041
Sutton RI, Rao H. The friction project: how smart leaders make the right things easier and the wrong things harder. St. Martin’s Press; 2024.
Clark TR. The 4 stages of psychological safety: defining the path to inclusion and innovation. Berrett-Koehler Publishers, Inc.; 2020.
Essen K, Villalobos C, Sculli G, Steinbach L. Establishing a just culture: implications for the Veterans Health Administration journey to high reliability. Fed Pract. 2024;41:290- 297. doi:10.12788/fp.0512
Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. 4th ed. SAGE Publications; 2014.
Patton MQ. Qualitative research & evaluation methods: integrating theory and practice. 4th ed. SAGE Publications, Inc.; 2015.
Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47:2025- 2047. doi:10.1007/s11135-011-9640-9

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Establishing a Just Culture: Implications for the Veterans Health Administration Journey to High Reliability

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Establishing a Just Culture: Implications for the Veterans Health Administration Journey to High Reliability

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Keith Essen, PhD, MSS, RN

Christy Villalobos, MPP

Gary L. Sculli, MSN, ATP

Luke Steinbach, MSN

Medical errors are a persistent problem and leading cause of preventable death in the United States. There is considerable momentum behind the idea that implementation of a just culture is foundational to detecting and learning from errors in pursuit of zero patient harm.^1-6 Just culture is a framework that fosters an environment of trust within health care organizations, aiming to achieve fair outcomes for those involved in incidents or near misses. It emphasizes openness, accountability, and learning, prioritizing the repair of harm and systemic improvement over assigning blame.⁷

A just culture mindset reflects a significant shift in thinking that moves from the tendency to blame and punish others toward a focus on organizational learning and continued process improvement.^8,9 This systemic shift in fundamental thinking transforms how leaders approach staff errors and how they are addressed.¹⁰ In essence, just culture reflects an ethos centered on openness, a deep appreciation of human fallibility, and shared accountability at both the individual and organizational levels.

Organizational learning and innovation are stifled in the absence of a just culture, and there is a tendency for employees to avoid disclosing their own errors as well as those of their colleagues.¹¹ The transformation to a just culture is often slowed or disrupted by personal, systemic, and cultural barriers.¹² It is imperative that all executive, service line, and frontline managers recognize and execute their distinct responsibilities while adjudicating the appropriate course of action in the aftermath of adverse events or near misses. This requires a nuanced understanding of the factors that contribute to errors at the individual and organizational levels to ensure an appropriate response.

The Veterans Health Administration (VHA) is orchestrating an enterprise transformation to develop into a high reliability organization (HRO). This began with a single-site test in 2016, which demonstrated successful results in patient safety culture, patient safety event reporting, and patient safety outcomes.¹³ In 2019, the VHA formally launched its enterprise-wide HRO journey in 18 hospital facilities, followed by successive waves of 67 and 54 facilities in 2021 and 2022, respectively. The VHA journey to transform into an HRO aligns with 3 pillars, 5 principles, and 7 values. The VHA has emphasized the importance of just culture as a foundational element of the HRO framework, specifically under the pillar of leadership. To promote leadership engagement, the VHA has employed an array of approaches that include education, leader coaching, and change management strategies. Given the diversity among VHA facilities, each with local cultures and histories, some sites have more readily implemented a just culture than others.¹⁴ A deeper exploration into potential obstacles, particularly concerning leadership engagement, could be instrumental for formulating strategies that further establish a just culture across the VHA.¹⁵

There is a paucity of empirical research regarding factors that facilitate and/or impede the implementation of a just culture in health care settings.^16,17 Likert scale surveys, such as the Patient Safety Culture Module for the VHA All Employee Survey and its predecessor, the Patient Safety Culture Survey, have been used to assess culture and climate.¹⁸ However, qualitative evaluations directly assessing the lived experiences of those trying to implement a just culture provide additional depth and context that can help identify specific factors that support or impede becoming an HRO. The purpose of this study was to increase understanding of factors that influence the establishment and sustainment of a just culture and to identify specific methods for improving the implementation of just culture principles and practices aligned with HRO.

METHODS

This qualitative study explored facilitators and barriers to establishing and sustaining a just culture as experienced across a subset of VHA facilities by HRO leads or staff assigned with the primary responsibilities of supporting facility-level HRO transformation. HRO leads are assigned responsibility for supporting executive leadership in planning, coordinating, implementing, and monitoring activities to ensure effective high reliability efforts, including focused efforts to establish a robust patient safety program, a culture of safety, and a culture of continuous process improvement.

Virtual focus group discussions held via Microsoft Teams generated in-depth, diverse perspectives from participants across 16 VHA facilities. Qualitative research and evaluation methods provide an enhanced depth of understanding and allow the emergence of detailed data.¹⁹ A qualitative grounded theory approach elicits complex, multifaceted phenomena that cannot be appreciated solely by numeric data.²⁰ Grounded theory was selected to limit preconceived notions and provide a more systematic analysis, including open, axial, and thematic coding. Such methods afford opportunities to adapt to unplanned follow-up questions and thus provide a flexible approach to generate new ideas and concepts.²¹ Additionally, qualitative methods help overcome the tendencies of respondents to agree rather than disagree when presented with Likert-style scales, which tend to skew responses toward the positive.²²

Participants must have been assigned as an HRO lead for ≥ 6 months at the same facility. Potential participants were identified through purposive sampling, considering their leadership roles in HRO and experience with just culture implementation, the size and complexity of their facility, and geographic distribution. Invitations explaining the study and encouraging voluntary participation to participate were emailed. Of 37 HRO leads invited to participate in the study, 16 agreed to participate and attended 1 of 3 hour-long focus group sessions. One session was rescheduled due to limited attendance. Participants represented a mix of VHA sites in terms of geography, facility size, and complexity.

Focus Group Procedures

Demographic data were collected prior to sessions via an online form to better understand the participant population, including facility complexity level, length of time in HRO lead role, clinical background, and facility level just culture training. Each session was led by an experienced focus group facilitator (CV) who was not directly involved with the overall HRO implementation to establish a neutral perspective. Each session was attended by 4 to 7 participants and 2 observers who took notes. The sessions were recorded and included automated transcriptions, which were edited for accuracy.

Focus group sessions began with a brief introduction and an opportunity for participants to ask questions. Participants were then asked a series of open-ended questions to elicit responses regardingfacilitators, barriers, and leadership support needed for implementing just culture. The questions were part of a facilitator guide that included an introductory script and discussion prompts to ensure consistency across focus groups.

Facilitators were defined as factors that increase the likelihood of establishing or sustaining a just culture. Barriers were defined as factors that decrease or inhibit the likelihood of establishing or sustaining just culture. The focus group facilitator encouraged all participants to share their views and provided clarification if needed, as well as prompts and examples where appropriate, but primarily sought to elicit responses to the questions.

Institutional review board review and approval were not required for this quality improvement initiative. The project adhered to ethical standards of research, including asking participants for verbal consent and preserving their confidentiality. Participation was voluntary, and prior to the focus group sessions, participants were provided information explaining the study’s purpose, procedures, and their rights. Participant identities were kept confidential, and all data were anonymized during the analysis phase. Pseudonyms or identifiers were used during data transcription to protect participant identity. All data, including recordings and transcriptions, were stored on password-protected devices accessible only to the research team. Any identifiable information was removed during data analysis to ensure confidentiality.

Analysis

Focus group recordings were transcribed verbatim, capturing all verbal interactions and nonverbal cues that may contribute to understanding the participants' perspectives. Thematic analysis was used to analyze the qualitative data from the focus group discussions.²³ The transcribed data were organized, coded, and analyzed using ATLAS.ti 23 qualitative data software to identify key themes and patterns.

Results

The themes identified include the 5 facilitators, barriers, and recommendations most frequently mentioned by HRO leads across focus group sessions. The nature of each theme is described, along with commonly mentioned examples and direct quotes from participants that illustrate our understanding of their perspectives.

Facilitators

Training and coaching (26 responses). The availability of training around the Just Culture Decision Support Tool (DST) was cited as a practical aid in guiding leaders through complex just culture decisions to ensure consistency and fairness. Additionally, an executive leadership team that served as champions for just culture principles played a vital role in promoting and sustaining the approach: “Training them on the roll-out of the decision support tool with supervisors at all levels, and education for just culture and making it part of our safety forum has helped for the last 4 months.” “Having some regular training and share-out cadences embedded within the schedule as well as dynamic directors and well-trained executive leadership team (ELT) for support has been a facilitator.”

Increased transparency (16 responses). Participants consistently highlighted the importance of leadership transparency as a key facilitator for implementing just culture. Open and honest communication from top-level executives fostered an environment of trust and accountability. Approachable and physically present leadership was seen as essential for creating a culture where employees felt comfortable reporting errors and concerns without fear of retaliation: “They’re surprisingly honest with themselves about what we can do, what we cannot do, and they set the expectations exactly at that.”

Approachable leadership (15 responses). Participants frequently mentioned the importance of having dynamic leadership spearheading the implementation of just culture and leading by example. Having a leadership team that accepts accountability and reinforces consistency in the manner that near misses or mistakes are addressed is paramount to promoting the principles of just culture and increasing psychological safety: “We do have very approachable leadership, which I know is hard if you’re trying to implement that nationwide, it’s hard to implement approachability. But I do think that people raise their concerns, and they’ll stop them in the hallway and ask them questions. So, in terms of comfort level with the executive leadership, I do think that’s high, which would promote psychological safety.”

Feedback loops and follow through (13 responses). Participants emphasized the importance of taking concrete actions to address concerns and improve processes. Regular check-ins with supervisors to discuss matters related to just culture provided a structured opportunity for addressing issues and reinforcing the importance of the approach: “One thing that we’ve really focused on is not only identifying mistakes, but [taking] ownership. We continue to track it until … it’s completed and then a process of how to communicate that back and really using closed loop communication with the staff and letting them know.”

Forums and town halls (10 responses). These platforms created feedback loops that were seen as invaluable tools for sharing near misses, celebrating successes, and promoting open dialogue. Forums and town halls cultivated a culture of continuous improvement and trust: “We’ll celebrate catches, a safety story is inside that catch. So, if we celebrate the change, people feel safer to speak up.” “Truthfully, we’ve had a great relationship since establishing our safety forums and just value open lines of communication.”

Barriers

Inadequate training (30 responses). Insufficient engagement during training—limited bandwidth and availability to attend and actively participate in training—was perceived as detrimental to creating awareness and buy-in from staff, supervisors, and leadership, thereby hindering successful integration of just culture principles. Participants also identified too many conflicting priorities from VHA leadership, which contributes to training and information fatigue among staff and supervisors. “Our biggest barrier is just so many different competing priorities going on. We have so much that we’re asking people to do.” “One hundred percent training is feeling more like a ticked box than actually yielding results, I have a very hard time getting staff engaged.”

Inconsistency between executive leaders and middle managers (28 responses). A lack of consistency in the commitment to and enactment of just culture principles among leaders poses a challenge. Participants gave several examples of inconsistencies in messaging and reinforcement of just culture principles, leading to confusion among staff and hindering adoption. Likewise, the absence of standardized procedures for implementing just culture created variability: “The director coming in and trying to change things, it put a lot of resistance, we struggle with getting the other ELT members on board … some of the messages that come out at times can feel more punitive.”

Middle management resistance (22 responses). In some instances, participants reported middle managers exhibiting attitudes and behaviors that undermined the application of just culture principles and effectiveness. Such attitudes and behaviors were attributed to a lack of adequate training, coaching, and awareness. Other perceived contributions included fear of failure and a desire to distance oneself from staff who have made mistakes: “As soon as someone makes an error, they go straight to suspend them, and that’s the disconnect right there.” “There’s almost a level of working in the opposite direction in some of the mid-management.”

Cultural misalignment (18 responses). The existing culture of distancing oneself from mistakes presented a significant barrier to the adoption of just culture because it clashed with the principles of open reporting and accountability. Staff underreported errors or framed them in a way that minimized personal responsibility, thereby making it more essential to put in the necessary and difficult work to learn from mistakes: “One, you’re going to get in trouble. There’s going to be more work added to you or something of that nature."

Lack of accountability for opposition(17 responses). Participants noted a clear lack of accountability for those who opposed or showed resistance to just culture, which allowed resistance to persist without consequences. In many instances, leaders were described as having overlooked repeated instances of unjust attitudes and behaviors (eg, inappropriate blame or punishment), which allowed those practices to continue. “Executive leadership is standing on the hill and saying we’re a just culture and we do everything correctly, and staff has the expectation that they’re going to be treated with just culture and then the middle management is setting that on fire, then we show them that that’s not just culture, and they continue to have those poor behaviors, but there’s a lack of accountability.”

Limited bandwidth and lack of coordination (14 responses). HRO leads often faced role-specific constraints in having adequate time and authority to coordinate efforts to implement or sustain just culture. This includes challenges with coordination across organizational levels (eg, between the hospital and regional Veterans Integrated Service Network [VISN] management levels) and across departments within the hospital (eg, between human resources and service lines or units). “Our VISN human resources is completely detached. They’ll not cooperate with these efforts, which is hard.” “There’s not enough bandwidth to actually support, I’m just 1 person.” “[There’s] all these mandated trainings of 8 hours when we’re already fatigued, short-staffed, taking 3 other HRO classes.”

Recommendations

Training improvements (24 responses). HRO leads recommended that comprehensive training programs be developed and implemented for staff, supervisors, and leadership to increase awareness and understanding of just culture principles. These training initiatives should focus on fostering a shared understanding of the core tenets of just culture, the importance of error reporting, and the processes involved in fair and consistent decision making (eg, training simulations on use of the Just Culture DST). “We’ve really never had any formal training on the decision support tool. I hope that what’s coming out for next year. We’ll have some more formal training for the tool because I think it would be great to really have our leadership and our supervisors and our managers use that tool.” “We can give a more directed and intentional training to leadership on the 4 foundational practices and what it means to implement those and what it means to utilize that behavioral component of HRO.”

Clear and consistent procedures toincrease accountability (22 responses). To promote a culture of accountability and consistency in the application of just culture principles, organizations should establish clear mechanisms for reporting, investigating, and addressing incidents. Standardized procedures and DSTs can aid in ensuring that responses to errors are equitable and align with just culture principles: “I recommend accountability; if it’s clearly evidenced that you’re not toeing the just culture line, then we need to be able to do something about it and not just finger wag.” “[We need to have] a templated way to approach just culture implementation. The decision support tool is great, I absolutely love having the resources and being able to find a lot of clinical examples and discussion tools like that. But when it comes down to it, not having that kind of official thing to fall back on it can be a little bit rough.”

Additional coaching and consultationsupport (15 responses). To support supervisors in effectively implementing just culture within their teams, participants recommended that organizations provide ongoing coaching and mentorship opportunities. Additionally, third-party consultants with expertise in just culture were described as offering valuable guidance, particularly in cases where internal staff resources or HRO lead bandwidth may be limited. “There are so many consulting agencies with HRO that have been contracted to do different projects, but maybe that can help with an educational program.” “I want to see my executive leadership coach the supervisors up right and then allow them to do one-on-ones and facilitate and empower the frontline staff, and it’s just a good way of transparency and communication.”

Improved leadership sponsorship (15 responses). Participants noted that leadership buy-in is crucial for the successful implementation of just culture. Facilities should actively engage and educate leadership teams on the benefits of just culture and how it aligns with broader patient safety and organizational goals. Leaders should be visible and active champions of its principles, supporting change in their daily engagements with staff. “ELT support is absolutely necessary. Why? Because they will make it important to those in their service lines. They will make it important to those supervisors and managers. If it’s not important to that ELT member, then it’s not going to be important to that manager or that supervisor.”

Improved collaboration with patient safety and human resources (6 responses). Collaborative efforts with patient safety and human resources departments were seen as instrumental in supporting just culture, emphasizing its importance, and effectively addressing issues. Coordinating with these departments specifically contributes to consistent reinforcement and expands the bandwidth of HRO leads. These departments play integral roles in supporting just culture through effective policies, procedures, and communication. “I think it would be really helpful to have common language between what human resources teaches and what is in our decision support tool.”

DISCUSSION

This study sought to collect and synthesize the experiences of leaders across a large, integrated health care system in establishing and sustaining a just culture as part of an enterprise journey to become an HRO.²⁴ The VHA has provided enterprise-wide support (eg, training, leader coaching, and communications) for the implementation of HRO principles and practices with the goal of creating a culture of safety, which includes just culture elements. This support includes enterprise program offices, VISNs, and hospital facilities, though notably, there is variability in how HRO is implemented at the local level. The facilitators, barriers, and recommendations presented in this article are representative of the designated HRO leads at VHA hospital facilities who have direct experience with implementing and sustaining just culture. The themes presented offer specific opportunities for intervention and actionable strategies to enhance just culture initiatives, foster psychological safety and accountability, and ultimately improve the quality of care and patient outcomes.^3,25

Frequently identified facilitators such as providing training and coaching, having leaders who are available and approachable, demonstrating follow-through to address identified issues, and creating venues where errors and successes can be openly discussed.²⁶ These facilitators are aligned with enterprise HRO support strategies orchestrated by the VHA at the enterprise VISN and facility levels to support a culture of safety, continuous process improvement, and leadership commitment.

Frequently identified barriers included inadequate training, inconsistent application of just culture by middle managers vs senior leaders, a lack of accountability or corrective action when unjust corrective actions took place, time and resource constraints, and inadequate coordination across departments (eg, operational departments and human resources) and organizational levels. These factors were identified through focus groups with a limited set of HRO leads. They may reflect challenges to changing culture that may be deeply engrained in individual histories, organizational norms, and systemic practices. Improving upon these just culture initiatives requires multifaceted approaches and working through resistance to change.

VHA HRO leads identified several actionable recommendations that may be used in pursuit of a just culture. First, improvements in training involving how to apply just culture principles and, specifically, the use of the Just Culture DST were identified as an opportunity for improvement. The VHA National Center for Patient Safety developed the DST as an aid for leaders to effectively address errors in line with just culture principles, balancing individual and system accountability.²⁷ The DST specifically addresses human error as well as risky and reckless behavior, and it clarifies the delineation between individual and organizational accountability (Table).³

Scenario-based interactive training and simulations may prove especially useful for middle managers and frontline supervisors who are closest to errors. Clear and repeatable procedures for determining courses of action for accountability in response are needed, and support for their application must be coordinated across multiple departments (eg, patient safety and human resources) to ensure consistency and fairness. Coaching and consultation are also viewed as beneficial in supporting applications. Coaching is provided to senior leaders across most facilities, but the availability of specific, role-based coaching and training is more limited for middle managers and frontline supervisors who may benefit most from hands-on support.

Lastly, sponsorship from leaders was viewed as critical to success, but follow through to ensure support flows down from the executive suite to the frontline is variable across facilities and requires consistent effort over time. This is especially challenging given the frequent turnover in leadership roles evident in the VHA and other health care systems.

Limitations

This study employed qualitative methods and sampled a relatively small subset of experienced leaders with specific roles in implementing HRO in the VHA. Thus, it should not be considered representative of the perspectives of all leaders within the VHA or other health care systems. Future studies should assess facilitators and barriers beyond the facility level, including a focus incorporating both the VISN and VHA. More broadly, qualitative methods such as those employed in this study offer great depth and nuance but have limited ability to identify system-wide trends and differences. As such, it may be beneficial to specifically look at sites that are high- or low-performing on measures of patient safety culture to identify differences that may inform implementation strategies based on organizational maturity and readiness for change.

Conclusions

Successful implementation of these recommendations will require ongoing commitment, collaboration, and a sustained effort from all stakeholders involved at multiple levels of the health care system. Monitoring and evaluating progress should be conducted regularly to ensure that recommendations lead to improvements in implementing just culture principles. This quality improvement study adds to the knowledge base on factors that impact the just culture and broader efforts to realize HRO principles and practices in health care systems. The approach of this study may serve as a model for identifying opportunities to improve HRO implementation within the VHA and other settings, especially when paired with ongoing quantitative evaluation of organizational safety culture, just culture behaviors, and patient outcomes.

References

Aljabari S, Kadhim Z. Common barriers to reporting medical errors. ScientificWorldJournal. 2021;2021:6494889. doi:10.1155/2021/6494889
Arnal-Velasco D, Heras-Hernando V. Learning from errors and resilience. Curr Opin Anaesthesiol. 2023;36(3):376-381. doi:10.1097/ACO.0000000000001257
Murray JS, Clifford J, Larson S, Lee JK, Sculli GL. Implementing just culture to improve patient safety. Mil Med. doi:10.1093/milmed/usac115
Murray JS, Kelly S, Hanover C. Promoting psychological safety in healthcare organizations. Mil Med. 2022;187(7-8):808-810. doi:10.1093/milmed/usac041
van Baarle E, Hartman L, Rooijakkers S, et al. Fostering a just culture in healthcare organizations: experiences in practice. BMC Health Serv Res. 2022;22(1):1035. doi:10.1186/s12913-022-08418-z
Weenink JW, Wallenburg I, Hartman L, et al. Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care. BMJ Open. 2022;12(7):e061321. doi:10.1136/bmjopen-2022-061321
White RM, Delacroix R. Second victim phenomenon: is ‘just culture’ a reality? An integrative review. Appl Nurs Res. 2020;56:151319. doi:10.1016/j.apnr.2020.151319
Cribb A, O’Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333
Rocco C, Rodríguez AM, Noya B. Elimination of punitive outcomes and criminalization of medical errors. Curr Opin Anaesthesiol. 2022;35(6):728-732. doi:10.1097/ACO.0000000000001197
Dekker S, Rafferty J, Oates A. Restorative Just Culture in Practice: Implementation and Evaluation. Routledge; 2022.
Brattebø G, Flaatten HK. Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame. Curr Opin Anaesthesiol. 2023;36(2):240-245. doi:10.1097/ACO.0000000000001235
Shabel W, Dennis JL. Missouri’s just culture collaborative. J Healthc Risk Manag. 2012;32(2):38-43. doi:10.1002/jhrm.21093
Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. J Patient Saf. 2022;18(1):64-70. doi:10.1097/PTS.0000000000000788
Martin G, Chew S, McCarthy I, Dawson J, Dixon-Woods M. Encouraging openness in health care: policy and practice implications of a mixed-methods study in the English National Health Service. J Health Serv Res Policy. 2023;28(1):14-24. doi:10.1177/13558196221109053
Siewert B, Brook OR, Swedeen S, Eisenberg RL, Hochman M. Overcoming human barriers to safety event reporting in radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135
Barkell NP, Snyder SS. Just culture in healthcare: an integrative review. Nurs Forum. 2021;56(1):103-111. doi:10.1111/nuf.12525
Murray JS, Lee J, Larson S, Range A, Scott D, Clifford J. Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review. BMJ Open Qual. 2023;12(2)e002237. doi:10.1136/bmjoq-2022-002237
Mohr DC, Chen C, Sullivan J, Gunnar W, Damschroder L. Development and validation of the Veterans Health Administration patient safety culture survey. J Patient Saf. 2022;18(6):539-545. doi:10.1097/PTS.0000000000001027
Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th ed. SAGE Publications, Inc.; 2014.
Patton MQ. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed. SAGE Publications, Inc.; 2015.
Maxwell JA. Qualitative Research Design: An Interactive Approach. 3rd ed. SAGE Publications, Inc.; 2013.
Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47(4):2025-2047. doi:10.1007/s11135-011-9640-9
Braun V, Clarke V. Thematic Analysis: A Practical Guide. SAGE Publications, Inc; 2021.
Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68(3):151-157. doi:10.1097/JDM-D-23-00056
Dietl JE, Derksen C, Keller FM, Lippke S. Interdisciplinary and interprofessional communication intervention: how psychological safety fosters communication and increases patient safety. Front Psychol. 2023;14:1164288. doi:10.3389/fpsyg.2023.1164288
Eng DM, Schweikart SJ. Why accountability sharing in health care organizational cultures means patients are probably safer. AMA J Ethics. 2020;22(9):E779-E783. doi:10.1001/amajethics.2020.779
Veterans Health Administration National Center for Patient Safety. Just Culture Decision Support Tool. Revised May 2021. Accessed August 5, 2024.https://www.patientsafety.va.gov/docs/Just-Culture-Decision-Support-Tool-2022.pdf

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Keith Essen, PhD, MSS, RN^a; Christy Villalobos, MPP^a; Gary L. Sculli, MSN, ATP^b; Luke Steinbach, MSN^c

Author affiliations
^aCognosante, Falls Church, Virginia
^bVeterans Health Administration National Center for Patient Safety, Ann Arbor, Michigan
^cVeterans Health Administration Office of Quality and Patient Safety, Washington, DC

Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Correspondence: Keith Essen (keith.essen@cognosante.com)

Fed Pract. 2024;41(9). Published online September 18. doi:10.12788/fp.0512

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Christy Villalobos, MPP

Gary L. Sculli, MSN, ATP

Luke Steinbach, MSN

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Keith Essen, PhD, MSS, RN^a; Christy Villalobos, MPP^a; Gary L. Sculli, MSN, ATP^b; Luke Steinbach, MSN^c

Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Correspondence: Keith Essen (keith.essen@cognosante.com)

Fed Pract. 2024;41(9). Published online September 18. doi:10.12788/fp.0512

Author and Disclosure Information

Keith Essen, PhD, MSS, RN^a; Christy Villalobos, MPP^a; Gary L. Sculli, MSN, ATP^b; Luke Steinbach, MSN^c

Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Correspondence: Keith Essen (keith.essen@cognosante.com)

Fed Pract. 2024;41(9). Published online September 18. doi:10.12788/fp.0512

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METHODS

Focus Group Procedures

Analysis

Results

Facilitators

Barriers

Recommendations

DISCUSSION

Limitations

Conclusions

METHODS

Focus Group Procedures

Analysis

Results

Facilitators

Barriers

Recommendations

DISCUSSION

Limitations

Conclusions

References

Aljabari S, Kadhim Z. Common barriers to reporting medical errors. ScientificWorldJournal. 2021;2021:6494889. doi:10.1155/2021/6494889
Arnal-Velasco D, Heras-Hernando V. Learning from errors and resilience. Curr Opin Anaesthesiol. 2023;36(3):376-381. doi:10.1097/ACO.0000000000001257
Murray JS, Clifford J, Larson S, Lee JK, Sculli GL. Implementing just culture to improve patient safety. Mil Med. doi:10.1093/milmed/usac115
Murray JS, Kelly S, Hanover C. Promoting psychological safety in healthcare organizations. Mil Med. 2022;187(7-8):808-810. doi:10.1093/milmed/usac041
van Baarle E, Hartman L, Rooijakkers S, et al. Fostering a just culture in healthcare organizations: experiences in practice. BMC Health Serv Res. 2022;22(1):1035. doi:10.1186/s12913-022-08418-z
Weenink JW, Wallenburg I, Hartman L, et al. Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care. BMJ Open. 2022;12(7):e061321. doi:10.1136/bmjopen-2022-061321
White RM, Delacroix R. Second victim phenomenon: is ‘just culture’ a reality? An integrative review. Appl Nurs Res. 2020;56:151319. doi:10.1016/j.apnr.2020.151319
Cribb A, O’Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333
Rocco C, Rodríguez AM, Noya B. Elimination of punitive outcomes and criminalization of medical errors. Curr Opin Anaesthesiol. 2022;35(6):728-732. doi:10.1097/ACO.0000000000001197
Dekker S, Rafferty J, Oates A. Restorative Just Culture in Practice: Implementation and Evaluation. Routledge; 2022.
Brattebø G, Flaatten HK. Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame. Curr Opin Anaesthesiol. 2023;36(2):240-245. doi:10.1097/ACO.0000000000001235
Shabel W, Dennis JL. Missouri’s just culture collaborative. J Healthc Risk Manag. 2012;32(2):38-43. doi:10.1002/jhrm.21093
Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. J Patient Saf. 2022;18(1):64-70. doi:10.1097/PTS.0000000000000788
Martin G, Chew S, McCarthy I, Dawson J, Dixon-Woods M. Encouraging openness in health care: policy and practice implications of a mixed-methods study in the English National Health Service. J Health Serv Res Policy. 2023;28(1):14-24. doi:10.1177/13558196221109053
Siewert B, Brook OR, Swedeen S, Eisenberg RL, Hochman M. Overcoming human barriers to safety event reporting in radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135
Barkell NP, Snyder SS. Just culture in healthcare: an integrative review. Nurs Forum. 2021;56(1):103-111. doi:10.1111/nuf.12525
Murray JS, Lee J, Larson S, Range A, Scott D, Clifford J. Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review. BMJ Open Qual. 2023;12(2)e002237. doi:10.1136/bmjoq-2022-002237
Mohr DC, Chen C, Sullivan J, Gunnar W, Damschroder L. Development and validation of the Veterans Health Administration patient safety culture survey. J Patient Saf. 2022;18(6):539-545. doi:10.1097/PTS.0000000000001027
Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th ed. SAGE Publications, Inc.; 2014.
Patton MQ. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed. SAGE Publications, Inc.; 2015.
Maxwell JA. Qualitative Research Design: An Interactive Approach. 3rd ed. SAGE Publications, Inc.; 2013.
Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47(4):2025-2047. doi:10.1007/s11135-011-9640-9
Braun V, Clarke V. Thematic Analysis: A Practical Guide. SAGE Publications, Inc; 2021.
Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68(3):151-157. doi:10.1097/JDM-D-23-00056
Dietl JE, Derksen C, Keller FM, Lippke S. Interdisciplinary and interprofessional communication intervention: how psychological safety fosters communication and increases patient safety. Front Psychol. 2023;14:1164288. doi:10.3389/fpsyg.2023.1164288
Eng DM, Schweikart SJ. Why accountability sharing in health care organizational cultures means patients are probably safer. AMA J Ethics. 2020;22(9):E779-E783. doi:10.1001/amajethics.2020.779
Veterans Health Administration National Center for Patient Safety. Just Culture Decision Support Tool. Revised May 2021. Accessed August 5, 2024.https://www.patientsafety.va.gov/docs/Just-Culture-Decision-Support-Tool-2022.pdf

References

Aljabari S, Kadhim Z. Common barriers to reporting medical errors. ScientificWorldJournal. 2021;2021:6494889. doi:10.1155/2021/6494889
Arnal-Velasco D, Heras-Hernando V. Learning from errors and resilience. Curr Opin Anaesthesiol. 2023;36(3):376-381. doi:10.1097/ACO.0000000000001257
Murray JS, Clifford J, Larson S, Lee JK, Sculli GL. Implementing just culture to improve patient safety. Mil Med. doi:10.1093/milmed/usac115
Murray JS, Kelly S, Hanover C. Promoting psychological safety in healthcare organizations. Mil Med. 2022;187(7-8):808-810. doi:10.1093/milmed/usac041
van Baarle E, Hartman L, Rooijakkers S, et al. Fostering a just culture in healthcare organizations: experiences in practice. BMC Health Serv Res. 2022;22(1):1035. doi:10.1186/s12913-022-08418-z
Weenink JW, Wallenburg I, Hartman L, et al. Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care. BMJ Open. 2022;12(7):e061321. doi:10.1136/bmjopen-2022-061321
White RM, Delacroix R. Second victim phenomenon: is ‘just culture’ a reality? An integrative review. Appl Nurs Res. 2020;56:151319. doi:10.1016/j.apnr.2020.151319
Cribb A, O’Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333
Rocco C, Rodríguez AM, Noya B. Elimination of punitive outcomes and criminalization of medical errors. Curr Opin Anaesthesiol. 2022;35(6):728-732. doi:10.1097/ACO.0000000000001197
Dekker S, Rafferty J, Oates A. Restorative Just Culture in Practice: Implementation and Evaluation. Routledge; 2022.
Brattebø G, Flaatten HK. Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame. Curr Opin Anaesthesiol. 2023;36(2):240-245. doi:10.1097/ACO.0000000000001235
Shabel W, Dennis JL. Missouri’s just culture collaborative. J Healthc Risk Manag. 2012;32(2):38-43. doi:10.1002/jhrm.21093
Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. J Patient Saf. 2022;18(1):64-70. doi:10.1097/PTS.0000000000000788
Martin G, Chew S, McCarthy I, Dawson J, Dixon-Woods M. Encouraging openness in health care: policy and practice implications of a mixed-methods study in the English National Health Service. J Health Serv Res Policy. 2023;28(1):14-24. doi:10.1177/13558196221109053
Siewert B, Brook OR, Swedeen S, Eisenberg RL, Hochman M. Overcoming human barriers to safety event reporting in radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135
Barkell NP, Snyder SS. Just culture in healthcare: an integrative review. Nurs Forum. 2021;56(1):103-111. doi:10.1111/nuf.12525
Murray JS, Lee J, Larson S, Range A, Scott D, Clifford J. Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review. BMJ Open Qual. 2023;12(2)e002237. doi:10.1136/bmjoq-2022-002237
Mohr DC, Chen C, Sullivan J, Gunnar W, Damschroder L. Development and validation of the Veterans Health Administration patient safety culture survey. J Patient Saf. 2022;18(6):539-545. doi:10.1097/PTS.0000000000001027
Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th ed. SAGE Publications, Inc.; 2014.
Patton MQ. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed. SAGE Publications, Inc.; 2015.
Maxwell JA. Qualitative Research Design: An Interactive Approach. 3rd ed. SAGE Publications, Inc.; 2013.
Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47(4):2025-2047. doi:10.1007/s11135-011-9640-9
Braun V, Clarke V. Thematic Analysis: A Practical Guide. SAGE Publications, Inc; 2021.
Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68(3):151-157. doi:10.1097/JDM-D-23-00056
Dietl JE, Derksen C, Keller FM, Lippke S. Interdisciplinary and interprofessional communication intervention: how psychological safety fosters communication and increases patient safety. Front Psychol. 2023;14:1164288. doi:10.3389/fpsyg.2023.1164288
Eng DM, Schweikart SJ. Why accountability sharing in health care organizational cultures means patients are probably safer. AMA J Ethics. 2020;22(9):E779-E783. doi:10.1001/amajethics.2020.779
Veterans Health Administration National Center for Patient Safety. Just Culture Decision Support Tool. Revised May 2021. Accessed August 5, 2024.https://www.patientsafety.va.gov/docs/Just-Culture-Decision-Support-Tool-2022.pdf

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Frontline Supervisor Perspectives on Enabling High Reliability and Fostering a Just Culture at the VHA

Methods

Inclusion Criteria

Procedures

Analysis

Ethical Considerations

Results

Identified Themes

Role of Leadership

Open Communication and Transparency

Education and Training

Insufficient Resources and Funding

Resistance to Change and Entrenched Attitudes

Synthesis and Integration of Findings

Discussion

Limitations

Conclusions

Methods

Inclusion Criteria

Procedures

Analysis

Ethical Considerations

Results

Identified Themes

Role of Leadership

Open Communication and Transparency

Education and Training

Insufficient Resources and Funding

Resistance to Change and Entrenched Attitudes

Synthesis and Integration of Findings

Discussion

Limitations

Conclusions

Methods

Inclusion Criteria

Procedures

Analysis

Ethical Considerations

Results

Identified Themes

Role of Leadership

Open Communication and Transparency

Education and Training

Insufficient Resources and Funding

Resistance to Change and Entrenched Attitudes

Synthesis and Integration of Findings

Discussion

Limitations

Conclusions

Establishing a Just Culture: Implications for the Veterans Health Administration Journey to High Reliability

METHODS

Focus Group Procedures

Analysis

Results

Facilitators

Barriers

Recommendations

DISCUSSION

Limitations

Conclusions

METHODS

Focus Group Procedures

Analysis

Results

Facilitators

Barriers

Recommendations

DISCUSSION

Limitations

Conclusions

METHODS

Focus Group Procedures

Analysis

Results

Facilitators

Barriers

Recommendations

DISCUSSION

Limitations