Moving the Needle on Patient Safety: Implementing the Just Culture Model at Rochester Regional Health

By Renee Demski , EVP for Quality, Patient Safety, and Performance Excellence

At Rochester Regional Health (RRH), patient safety starts with protecting our caregivers. When healthcare workers experience blame and fear instead of support and learning, it leads to stress, burnout, and ultimately more risk for patients. That’s why we are embedding Just Culture into our strategic plan—to ensure our team members are not unfairly blamed for system failures but instead supported in preventing them.

Just Culture is a structured framework for safety, accountability, fairness, and learning that shifts the focus from punishment to problem-solving. Instead of asking who made the mistake, we ask why it happened and learn how to prevent it in the future. This approach creates a more open, resilient healthcare environment where safety is truly a shared responsibility.

Why This Matters Now

The 2022 and 2024 Safety Culture Surveys made it clear that team members were hesitant to report safety concerns—not because they didn’t care, but because they feared unfair consequences. The result? Unaddressed risks, emotional stress, and a heavier burden on the healthcare system. 

When caregivers feel unsupported, the impact extends beyond their own well-being. Burnout, fear, and stress can affect focus, decision-making, and teamwork—directly impacting patient safety. At RRH, we recognize that by fostering psychological safety among caregivers, we improve the quality and reliability of care for patients.

By embedding Just Culture into our leadership approach, we are making it clear:

1. We trust our caregivers.
2. We want them to feel safe.
3. We are committed to doing better—for them and for our patients.

A Thoughtful, Fair Approach to Accountability

Just Culture is not about eliminating accountability. It is about ensuring that consequences are appropriate and effective in preventing future harm.

Instead of immediately assigning blame, Just Culture encourages leaders to ask:

• Was this a process failure rather than an individual mistake?
• Were caregivers set up for success, or were they working within broken systems?
• How can we fix the issue so no one else is put in this position?

Just Culture recognizes different types of actions and responds accordingly:

• Human error, for example an accidental slip or oversight, requires support and system improvements.
• At-risk behavior like taking shortcuts requires coaching and education to reinforce best practices.
• Reckless behavior such as willfully disregarding safety rules requires corrective action, including discipline when necessary.

RRH partnered with The Just Culture Company, led by David Marx and Barbara Olson, MS, RN, CPPS, FISMP , to bring this framework to life. Managers and senior leaders have already been trained to apply a consistent, fair approach to safety events. Instead of reacting with discipline first, leadership is now focused on understanding, learning, and making meaningful improvements.

By shifting how we respond to errors, we are not just improving patient safety—we are protecting the well-being of our caregivers. 

Living Our Values: Care Like Family & Rooted in Community

At Rochester Regional, we are more than a healthcare system—we are a community of caregivers. Just Culture is a direct reflection of what it means to Care Like Family.

Caring like family means supporting one another, especially in moments of difficulty. When a team member makes an honest mistake, they should not be met with fear or blame but with understanding and a commitment to improvement. This approach builds trust, ensures that safety is a shared responsibility, and helps prevent emotional harm that comes with working in an unsafe culture.

 Just Culture also reflects what it means to be Rooted in Community. At RRH, we don’t just serve the community—we are the community. Our caregivers are our neighbors, family members, and friends. We are deeply invested in making sure our caregivers feel supported, safe, and empowered because when we take care of them, they can take better care of our patients.

What We’ve Learned So Far

Since launching Just Culture, the response from leadership has been overwhelmingly positive:

• Managers have craved this level of guidance. Many have expressed relief in having a structured, fair way to approach difficult situations.
• Training in Just Culture has been particularly meaningful for newer managers who previously struggled with tough decisions—whether to coach a team member, intervene with training, or escalate a concern.
• Leaders now have a clear framework that provides consistency, support, and the tools to navigate complex challenges.

One key takeaway? Leaders and caregivers alike want fairness. They want an environment where they can safely report concerns, improve systems, and focus on delivering the best care possible.

Where We’re Headed

Rochester Regional Health is committed to embedding Just Culture across the entire organization. Next steps include:

• Expanding training to all leaders and staff so that every team member understands Just Culture principles.
• Providing scenario-based learning to strengthen leaders’ confidence in applying Just Culture to real-world situations.
• Continuing to refine safety processes so that reporting concerns leads to improvement—not fear.

A Call to Action for Healthcare Leaders

We encourage other healthcare organizations to take bold steps toward a Just Culture model and ask the following questions:

• Is your organization’s response to safety events preventing harm—or simply punishing individuals?
• Do your caregivers feel psychologically safe reporting concerns?
• Are your teams able to learn from mistakes and improve, rather than fear repercussions?

Rochester Regional has committed to a new standard of safety, fairness, and accountability—and we invite others to join us.

Patient safety should not be reactive. It should be proactive, systematic, and grounded in fairness.

By embracing Just Culture, we are leading the way in making healthcare safer—not just for patients, but for the people who care for them every day.