Leadership is crucial to establishing safety culture, reducing adverse events

Safety culture is the sum of what an organization does to provide optimal patient care. The Patient Safety Systems (PS) chapter of The Joint Commission accreditation manuals defines safety culture as the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.1

The PS chapter asserts that organizations with a robust safety culture are characterized by the following:

  • Communication based in mutual trust
  • Shared perceptions of the importance of safety
  • Confidence in the efficacy of preventive measures

The Joint Commission described behaviors that undermine a culture of safety in a July 2008 issue of Sentinel Event Alert, which was followed by another Alert published the following year emphasizing the benefits of a leadership standard that requires leaders to create and maintain a culture of safety.2,3 In January 2017, the PS chapter was expanded to include critical access hospitals, ambulatory care, and office-based surgery settings. And most recently, in March of this year The Joint Commission released a new Sentinel Event Alert that updates the 2009 Alert, and which clarifies the essential role of leadership in developing a safety culture.4

Surgeon leaders play a fundamental role in ingraining safety culture strategies into the core of an organization. The Joint Commission’s accreditation manual glossary defines a leader as “an individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization’s governance, management, and clinical and support functions and processes.”4

The board and chief executive officer (CEO)—key leadership roles in any organization—must emphasize with their every action that communication of unsafe conditions is an obligation of every person working in the organization. According to the Sentinel Event Alert published March 1, 2017, strong leaders understand that “systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.” These human errors, sometimes referred to as “latent” holes or weaknesses, may be present in any culture of safety.4

The best way to communicate these unsafe conditions is to develop mechanisms that allow identification of safety threats, correction of those threats, and recognition that the threat has been adequately addressed. These actions convey to those working in a health care organization that safety is important in the minds of their leaders.

Preventing future harm

Developing a culture of safety begins with incorporating lessons learned from adverse events and near misses in order to prevent future harm. This environment does not rely on a punishment model to correct these unsafe conditions or behaviors because most adverse events are related to unintended systems or human failures. This approach does not mean that individuals are not being held accountable for their behaviors, but the focus is on preventing future adverse events rather than punishment.

Failure on the part of leadership to create an effective culture of safety has been identified as a contributing factor to adverse events, such as wrong site surgery and delays in treatment. The March Sentinel Event Alert emphasizes the commitment to a culture of safety as equally important to the resources devoted to financial stability, system integration, and productivity, according to Ana Pujols McKee, MD, executive vice-president and chief medical officer of The Joint Commission.4,5

In addition to contributing to adverse events, an underdeveloped culture of safety leads to adverse outcomes, according to the Joint Commission Center for Transforming Healthcare, including the following:4

  • Insufficient support of patient safety event reporting
  • Lack of feedback or response to staff and others who report safety vulnerabilities
  • Allowing intimidation of staff who report events
  • Refusing to consistently prioritize and implement safety recommendations

Promoting everyday safety

Competent and thoughtful leaders contribute to improvements in safety and organizational culture because they understand that systemic flaws can lead to latent threats to safety and that humans make mistakes. Preventing those mistakes by reinforcing the system and developing ways to recognize and address failures when they happen is the key to a safety culture.

According to a Health Foundation report published in May 2012, a safety culture is supported by leaders who “consistently and visibly support and promote everyday safety measures.”4,6 An enduring commitment to a culture of safety is the “product of what is done on a consistent daily basis.”4 An organization’s commitment to culture should be determined “by what leaders do, rather than what they say should be done.”4

To promote consistent, everyday safety measures, The Joint Commission recommends that leaders take specific actions to establish and continuously improve safety culture. These 11 action items, defined by Mark R. Chassin, MD, FACP, MPP, MPH, president and CEO of The Joint Commission, and Jerod M. Loeb, PhD, are described in the March 2017 Sentinel Event Alert (see Figure 1). These actions include establishing a transparent, nonpunitive approach to reporting adverse events and incorporating safety culture team training into quality improvement projects.4,7

Figure 1. 11 tenets of a safety culture

Figure 1. 11 tenets of a safety culture


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.


  1. The Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Patient Safety Systems Chapter, Update 2. January 2016. Available at: www.jointcommission.org/assets/1/18/PSC_for_Web.pdf. Accessed March 30, 2017.
  2. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. July 9, 2008. Issue 40. Available at: www.jointcommission.org/assets/1/18/SEA_40.PDF. Accessed March 30, 2017.
  3. The Joint Commission. Leadership committed to safety. Sentinel Event Alert. Revised September 8, 2009. Issue 43. Available at: www.jointcommission.org/assets/1/18/SEA_43.PDF. Accessed March 30, 2017.
  4. The Joint Commission. The essential role of leadership in developing a safety culture. Sentinel Event Alert. March 1, 2017. Issue 57. Available at: www.jointcommission.org/assets/1/18/sea_57_safety_culture_leadership_0317.pdf. Accessed March 30, 2017.
  5. The Joint Commission. Sentinel Event Alert focuses on leadership’s role in establishing safety culture. Joint Commission Online. Available at: bit.ly/2oGrnmg. Accessed April 3, 2017.
  6. Frankel M, Frankel A. How can leaders influence a safety culture? The Health Foundation Thought Paper. May 2012. Available at: www.health.org.uk/sites/health/files/CanLeadersInfluenceASafetyCulture.pdf. Accessed March 30, 2017.
  7. Chassin MR, Loeb JM. High-reliability health care: Getting there from here. The Milbank Quarterly. 2013;91(3):459-490.

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