Interventions
The intervention used multiple complementary strategies to strengthen Just Culture and patient safety across the region:
- Conducted a regional multidisciplinary Surgical Safety Summit focused on non-technical skills, psychological safety, and Just Culture.
- Facilitated development of site-specific driver diagrams to support locally owned improvement priorities.
- Developed a Just Culture educational video that evolved into an interactive on-demand learning module based on participant feedback.
- Integrated Just Culture and patient safety principles into the Fraser Health Quality Improvement Essentials training program.
- Delivered a 10-part Patient Safety Lunch and Learn series for staff and physicians covering key patient safety concepts, tools, and practices.
- Embedded educational resources within the Fraser Health intranet to provide ongoing access for all staff.
Reinforced learning through Patient Safety Week activities and continued organizational messaging.
Implementation Strategy
Implementation focused on creating sustainable organizational change rather than delivering a single educational intervention. Executive sponsorship provided visible leadership support throughout the initiative, while multidisciplinary engagement promoted shared accountability for patient safety across professional groups.
Interactive summit activities encouraged each surgical site to identify local challenges and develop site-specific driver diagrams, allowing improvement work to be tailored to local context while maintaining alignment with regional objectives. Participant feedback following the Surgical Safety Summit informed iterative refinement of the initial Just Culture video into an interactive on-demand learning module. This adaptation improved usability, expanded organizational reach, and provided a sustainable resource that could be incorporated into ongoing staff education. Educational resources were intentionally reinforced through multiple organizational platforms, including Patient Safety Week, Quality Improvement Essentials training, Lunch and Learn sessions, and online learning resources, providing repeated opportunities for learning and engagement.
Measurement and feedback were incorporated throughout implementation to reinforce learning and support culture change. Regional Never Event trends and patient safety learning data were shared with participating sites to promote transparency, stimulate discussion, and guide local improvement activities. In keeping with Just Culture principles, balancing measures included monitoring trends in Patient Safety Learning System (PSLS) reporting, with an anticipated increase in reporting reflecting improved psychological safety and a reduction in reliance on anonymous reporting over time.
The initiative subsequently expanded beyond surgical services, demonstrating successful spread of the implementation approach across Fraser Health.
Costs and Funding Sources
No dedicated project funding was required. The initiative was developed and implemented using existing organizational resources and staff time.
Overall Results and Analysis
More than 200 Fraser Health staff participated in the regional Surgical Safety Summit, including executive leaders, surgeons, anesthesiologists, nurses, educators, and quality improvement professionals. Participant evaluation demonstrated high acceptability, with 98% indicating they would recommend the training to colleagues.
The initiative resulted in development of site-specific driver diagrams that informed local improvement activities and supported implementation across multiple surgical sites. Just Culture principles were subsequently incorporated into organizational education programs, Patient Safety Week activities, Quality Improvement Essentials, and region-wide online learning resources, demonstrating successful spread and sustainability beyond the initial project.
Ongoing monitoring included both outcome measures (days between Never Events) and balancing measures related to safety reporting culture, including PSLS reporting trends and anonymous reporting. These measures continue to inform implementation and evaluation as the initiative matures.
Following implementation of the broader surgical safety initiative, the average number of days between reported Never Events increased from 21 days to 62 days across all sites. While this multifaceted initiative was not designed to attribute improvement to any single intervention, the findings are consistent with sustained organizational efforts to strengthen surgical safety culture and reduce preventable harm.
The driver diagrams also helped translate regional safety priorities into site-level action. For example, some sites implemented targeted workflow changes, such as lowering music volume during the Surgical Safety Checklist and other key communication moments, to support clearer team communication and improve reliability during critical safety processes. These local changes demonstrate how the initiative encouraged teams to identify practical barriers and implement interventions tailored to their clinical environments.
