Just Culture Is Not “Just” Culture—It’s Shifting Mindset

Health care and the Veterans Health Administration have adopted many initiatives to improve patient care, including efforts to create a “Just Culture” environment for patient safety and quality outcomes. Despite significant resources and efforts on these initiatives and some temporary improvements, we continue to struggle to make significant and sustainable improvements. At the Veterans Administration North Texas Health Care System, we see that our efforts have addressed the wrong thing. By focusing our efforts to shift the underlying mindset that drives behavior, we expect to create the foundation that will help us truly achieve a High Reliability and Just Culture organization that provides the care and outcomes our patients and staff deserve.