Federal Practitioner

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

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.

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

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.

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

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.

In April 2022, the US Department of Veterans Affairs (VA) revised its behavioral health care eligibility policies to provide comprehensive mental and behavioral health care to former service members who received an Other Than Honorable (OTH) discharge characterization upon separation from military service.¹ This policy shift represents a marked expansion in eligibility practices (Table 1 includes amended eligibility criteria).

Since June 2017, eligibility policies allowed veterans with OTH discharges to receive “emergent mental health services” needed to stabilize acute mental health crises related to military service (eg, acute escalations in suicide risk).^2,3 Previously, veterans with OTH discharges were largely ineligible for VA-based health care; these individuals were only able to access Veterans Health Administration (VHA) mental and behavioral health care through limited channels of eligibility (eg, for treatment of military sexual trauma or psychosis or other mental illness within 2 years of discharge).^4,5 The impetus for expansions in eligibility stemmed from VA efforts to reduce the suicide rate among veterans.^6-8 Implications of such expansion extend beyond suicide prevention efforts, with notable promised effects on the care of veterans with criminal-legal involvement. This article highlights potential effects of recent eligibility expansions on veterans with criminal-legal involvement and makes specific recommendations for agencies and organizations serving these veterans.

OTHER THAN HONORABLE DISCHARGE

The US Department of Defense delineates 6 discharge characterizations provided to service members upon separation from military service: honorable, general under honorable conditions, OTH, bad conduct, dishonorable, and uncharacterized. Honorable discharge characterizations are considered to reflect general concordance between service member behavior and military standards; general discharge characterizations reflect some disparity between the service member’s behavior and military standards; OTH, bad conduct, and dishonorable discharge characterizations reflect serious disparities between the service member’s behavior and military standards; and uncharacterized discharge characterizations are given when other discharge characterizations are deemed inappropriate.^9,10 OTH discharge characterizations are typically issued under instances of misconduct, fraudulent entry, security reasons, or in lieu of trial by court martial.^9,10

Recent research suggests that about 85% of service members receive an honorable discharge characterization upon separation from military service, 8% receive general, 6% receive OTH, and 1% receive bad conduct or dishonorable discharges.11 In 2017, the VA estimated there were > 500,000 prior service members with OTH discharge characterizations, which has grown over time (1.9% during the Korean Conflict, 2.5% during the Vietnam War Era, 3.9% during the Cold War, 4.8% in the Persian Gulf War, and 5.8% in the post-9/11 era).^7,11

The OTH discharge characterization is 1 of 3 less than honorable discharges informally referred to as bad papers (ie, OTH, bad conduct, or dishonorable). Former service members receiving these discharge characterizations face significant social stigma and structural discrimination upon military discharge, including significant hurdles to employment and educational pursuits as well as notable social alienation.¹² Due to their discharge characterization, some are viewed as less deserving of the veteran title, and until recently, many did not qualify for the complex legal definition of veteran as established by the Congress.^11,13 Veterans with OTH discharge characterizations have also historically been excluded from services (eg, VHA care),³ benefits (eg, disability compensation),¹⁴ and protections (eg, Uniformed Services Employment and Reemployment Rights Act)¹⁵ offered to veterans with honorable or general discharge characterizations. However, eligibility policies have gradually expanded, providing veterans with OTH discharges with access to VHA-based mental and behavioral health services and VA supportive housing assistance.^1,3,16

Perhaps due to their historical exclusion from VA services, there is limited research available on the behavioral health and associated needs of veterans with OTH discharges. Some scholars argue that historical exclusions have exacerbated underlying difficulties faced by this population, thereby contributing to stark health and social disparities across discharge types.^14,15,17 Studies with large veteran samples, for example, reflect notable demographic and behavioral health differences across discharge types. Compared to routinely discharged veterans, veterans with OTH discharges are significantly more likely to be younger, have lower income, use substances, have a history of criminal-legal involvement, and have mental and physical health difficulties.^18,19

Substantial evidence also suggests a historical racial bias, with service members of color being disproportionately more likely to receive an OTH discharge.¹² Similarly, across all branches of military service, Black service members are significantly more likely to face general or special court martial in military justice proceedings when compared with White service members.²⁰ Service members from gender and sexual minorities are also disproportionately impacted by the OTH designation. Historically, many have been discharged with bad papers due to discriminatory policies, such as Don’t Ask Don’t Tell, which discriminated on the basis of sexual orientation between December 1993 and September 2011, and Directive-type Memorandum-19-004, which banned transgender persons from military service between April 2019 and January 2021.^21,22

There is also significant mental health bias in the provision of OTH discharges, such that OTH characterizations are disproportionately represented among individuals with mental health disorders.^18-20 Veterans discharged from military service due to behavioral misconduct are significantly more likely to meet diagnostic criteria for various behavioral health conditions and to experience homelessness, criminal-legal involvement, and suicidal ideation and behavior compared with routinely-discharged veterans.^23-28

Consistent with their comparatively higher rates of criminal-legal involvement relative to routinely discharged veterans, veterans with OTH discharges are disproportionately represented in criminal justice settings. While veterans with OTH discharges represent only 6% of discharging service members and 2.5% of community-based veterans, they represent 10% of incarcerated veterans.^11,18,23,29 Preliminary research suggests veterans with OTH discharges may be at higher risk for lifetime incarceration, though the association between OTH discharge and frequency of lifetime arrests remains unclear.^18,30

VETERANS TREATMENT COURTS

Given the overrepresentation of veterans with OTH discharges in criminal-legal settings, consideration for this subset of the veteran population and its unique needs is commonplace among problem-solving courts that service veterans. First conceptualized in 2004, Veterans Treatment Courts (VTCs) are specialized problem-solving courts that divert veterans away from traditional judicial court and penal systems and into community-based supervision and treatment (most commonly behavioral health services).^31-34 Although each VTC program is unique in structure, policies, and procedures, most VTCs can be characterized by certain key elements, including voluntary participation, plea requirements, delayed sentencing (often including reduced or dismissed charges), integration of military culture into court proceedings, a rehabilitative vs adversarial approach to decreasing risk of future criminal behavior, mandated treatment and supervision during participation, and use of veteran mentors to provide peer support.^32-35 Eligibility requirements vary; however, many restrict participation to veterans with honorable discharge types and charges for nonviolent offenses.^32,33,35-37

VTCs connect veterans within the criminal-legal system to needed behavioral health, community, and social services.^31-33,37 VTC participants are commonly connected to case management, behavioral health care, therapeutic journaling programs, and vocational rehabilitation.^38,39 Accordingly, the most common difficulties faced by veterans participating in these courts include substance use, mental health, family issues, anger management and/or aggressive behavior, and homelessness.^36,39 There is limited research on the effectiveness of VTCs. Evidence on their overall effectiveness is largely mixed, though some studies suggest VTC graduates tend to have lower recidivism rates than offenders more broadly or persons who terminate VTC programs prior to completion.^40,41 Other studies suggest that VTC participants are more likely to have jail sanctions, new arrests, and new incarcerations relative to nontreatment court participants.⁴² Notably, experimental designs (considered the gold standard in assessing effectiveness) to date have not been applied to evaluate the effectiveness of VTCs; as such, the effectiveness of these programs remains an area in need of continued empirical investigation.

Like all problem-solving courts, VTCs occasionally struggle to connect participating defendants with appropriate care, particularly when encountering structural barriers (eg, insurance, transportation) and/or complex behavioral health needs (eg, personality disorders).^34,43 As suicide rates among veterans experiencing criminal-legal involvement surge (about 150 per 100,000 in 2021, a 10% increase from 2020 to 2021 compared to about 40 per 100,000 and a 1.8% increase among other veterans), efficiency of adequate care coordination is vital.⁴⁴ Many VTCs rely on VTC-VA partnerships and collaborations to navigate these difficulties and facilitate connection of participating veterans to needed services.^32-34,45 For example, within the VHA, Veterans Justice Outreach (VJO) and Health Care for Re-Entry Veterans (HCRV) specialists assist and bridge the gap between the criminal-legal system (including, but not limited to VTCs) and VA services by engaging veterans involved in the criminal-legal system and connecting them to needed VA-based services (Table 2). Generally, VJO specialists support veterans involved with the front end of the criminallegal system (eg, arrest, pretrial incarceration, or participation in VTCs), while HCRV specialists tend to support veterans transitioning back into the community after a period of incarceration.^46,47 Specific to VTCs, VJO specialists typically serve as liaisons between the courts and VA, coordinating VA services for defendants to fulfill their terms of VTC participation.⁴⁶

The historical exclusion of veterans with OTH discharge characterizations from VA-based services has restricted many from accessing VTC programs.³² Of 17 VTC programs active in Pennsylvania in 2014, only 5 accepted veterans with OTstayH discharges, and 3 required application to and eligibility for VA benefits.³³ Similarly, in national surveys of VTC programs, about 1 in 3 report excluding veterans deemed ineligible for VA services.^35,36 When veterans with OTH discharges have accessed VTC programs, they have historically relied on non-VA, community-based programming to fulfill treatment mandates, which may be less suited to addressing the unique needs of veterans.⁴⁸

Veterans who utilize VTCs receive several benefits, namely peer support and mentorship, acceptance into a veteran-centric space, and connection with specially trained staff capable of supporting the veteran through applications for a range of VA benefits (eg, service connection, housing support).^31-33,37 Given the disparate prevalence of OTH discharge characterizations among service members from racial, sexual, and gender minorities and among service members with mental health disorders, exclusion of veterans with OTH discharges from VTCs solely based on the type of discharge likely contributes to structural inequities among these already underserved groups by restricting access to these potential benefits. Such structural inequity stands in direct conflict with VTC best practice standards, which admonish programs to adjust eligibility requirements to facilitate access to treatment court programs for historically marginalized groups.⁴⁹

ELIGIBILITY EXPANSIONS

Given the overrepresentation of veterans with OTH discharge characterizations within the criminal-legal system and historical barriers of these veterans to access needed mental and behavioral health care, expansions in VA eligibility policies could have immense implications for VTCs. First, these expansions could mitigate common barriers to connecting VTC-participating veterans with OTH discharges with needed behavioral health care by allowing these veterans to access established, VA-based services and programming. Expansion may also allow VTCs to serve as a key intercept point for identifying and engaging veterans with OTH discharges who may be unaware of their eligibility for VA-based behavioral health care.

Access to VA health care services is a major resource for VTC participants and a common requirement.³² Eligibility expansion should ease access barriers veterans with OTH discharges commonly face. By providing a potential source of treatment, expansions may also support OTH eligibility practices within VTCs, particularly practices that require participants to be eligible for VA health care.^33,35,36 Some VTCs may continue to determine eligibility on the basis of discharge status and remain inaccessible to veterans with OTH discharge characterizations without program-level policy changes.^32,36,37

Communicating changes in eligibility policies relevant to veterans with OTH discharges may be a challenge, because many of these individuals have no established channels of communication with the VA. Because veterans with OTH discharges are at increased risk for legal system involvement, VTCs may serve as a unique point of contact to help facilitate communication.¹⁸ For example, upon referral to a VTC, veterans with OTH discharges can be identified, VA health care eligibility can be verified, and veterans can connect to VA staff to facilitate enrollment in VA services and care.

VJO specialists are in a favorable position to serve a critical role in utilizing VTCs as a potential intercept point for engaging veterans with OTH discharge characterizations. As outlined in the STRONG Veterans Act of 2022, VJOs are mandated to “spread awareness and understanding of veteran eligibility for the [VJO] Program, including the eligibility of veterans who were discharged from service in the Armed Forces under conditions other than honorable.”50 The Act further requires VJOs to be annually trained in communicating eligibility changes as they arise. Accordingly, VJOs receive ongoing training in a wide variety of critical outreach topics, including changes in eligibility; while VJOs cannot make eligibility determinations, they are tasked with enrolling all veterans involved in the criminal-legal system with whom they interact into VHA services, whether through typical or special eligibility criteria (M. Stimmel, PhD, National Training Director for Veteran Justice Programming, oral communication, July 14, 2023). VJOs therefore routinely serve in this capacity of facilitating VA enrollment of veterans with OTH discharge characterizations.

Recommendations to Veteran-Servicing Judicial Programs

Considering these potential implications, professionals routinely interacting with veterans involved in the criminal-legal system should become familiarized with recent changes in VA eligibility policies. Such familiarization would support the identification of veterans previously considered ineligible for care; provision of education to these veterans regarding their new eligibility; and referral to appropriate VA-based behavioral health care options. Although conceptually simple, executing such an educational campaign may prove logistically difficult. Given their historical exclusion from VA services, veterans with OTH discharge characterizations are unlikely to seek VA-based services in times of need, instead relying on a broad swath of civilian community-based organizations and resources. Usual approaches to advertising VHA health care policy changes (eg, by notifying VA employees and/or departments providing corresponding services or by circulating information to veteran-focused mailing lists and organizations) likely would prove insufficient. Educational campaigns to disseminate information about recent OTH eligibility changes should instead consider partnering with traditionally civilian, communitybased organizations and institutions, such as state bar associations, legal aid networks, case management services, nonveteran treatment court programs (eg, drug courts, or domestic violence courts), or probation/ parole programs. Because national surveys suggest generally low military cultural competence among civilian populations, providing concurrent support in developing foundational veteran cultural competencies (eg, how to phrase questions about military service history, or understanding discharge characterizations) may be necessary to ensure effective identification and engagement of veteran clients.⁴⁸

Programs that serve veterans with criminal-legal involvement should also consider potential relevance of recent OTH eligibility changes to program operations. VTC program staff and key partners (eg, judges, case managers, district attorneys, or defense attorneys), should revisit policies and procedures surrounding the engagement of veterans with OTH discharges within VTC programs and strategies for connecting these veterans with needed services. VTC programs that have historically excluded veterans with OTH discharges due to associated difficulties in locating and connecting with needed services should consider expanding eligibility policies considering recent shifts in VA behavioral health care eligibility.^33,35,36 Within the VHA, VJO specialists can play a critical role in supporting these VTC eligibility and cultural shifts. Some evidence suggests a large proportion of VTC referrals are facilitated by VJO specialists and that many such referrals are identified when veterans involved with the criminal-legal system seek VA support and/or services.³³ Given the historical exclusion of veterans with OTH discharges from VA care, strategies used by VJO specialists to identify, connect, and engage veterans with OTH discharges with VTCs and other services may be beneficial.

Even with knowledge of VA eligibility changes and considerations of these changes on local operations, many forensic settings and programs struggle to identify veterans. These difficulties are likely amplified among veterans with OTH discharge characterizations, who may be hesitant to self-disclose their military service history due to fear of stigma and/or views of OTH discharge characterizations as undeserving of the veteran title.¹² The VA offers 2 tools to aid in identification of veterans for these settings: the Veterans Re-Entry Search Service (VRSS) and Status Query and Response Exchange System (SQUARES). For VRSS, correctional facilities, courts, and other criminal justice entities upload a simple spreadsheet that contains basic identifying information of inmates or defendants in their system. VRSS returns information about which inmates or defendants have a history of military service and alerts VA Veterans Justice Programs staff so they can conduct outreach. A pilot study conducted by the California Department of Corrections and Rehabilitation found that 2.7% of its inmate population self-identified as veterans, while VRSS identified 7.7% of inmates with a history of military service. This difference represented about 5000 previously unidentified veterans.⁵¹ Similarly, community entities that partner with the VA, such as law enforcement or homeless service programs, can be approved to become a SQUARES user and submit identifying information of individuals with whom they interact directly into the SQUARES search engine. SQUARES then directly returns information about the individual’s veteran status and eligibility for VA health care and homeless programs.

Other Eligibility Limitations

VTCs and other professionals looking to refer veterans with OTH discharge characterizations to VA-based behavioral health care should be aware of potential limitations in eligibility and access. Specifically, although veterans with OTH discharges are now broadly eligible for VA-based behavioral health care and homeless programs, they remain ineligible for other forms of health care, including primary care and nonbehavioral specialty care.1 Research has found a strong comorbidity between behavioral and nonbehavioral health concerns, particularly within historically marginalized demographic groups.^52-55 Because these historically marginalized groups are often overrepresented among persons with criminal-legal involvement, veterans with OTH discharges, and VTC participants, such comorbidities require consideration by services or programming designed to support veterans with criminal-legal involvement.^12,56-58 Connection with VA-based health care will therefore continue to fall short of addressing all health care needs of veterans with OTH discharges and effective case management will require considerable treatment coordination between VA behavioral health care practitioners (HCPs) and community-based HCPs (eg, primary care professionals or nonbehavioral HCPs).

Implications for VA Mental Health Care

Recent eligibility expansions will also have inevitable consequences for VA mental health care systems. For many years, these systems have been overburdened by high caseloads and clinician burnout.^59,60 Given the generally elevated rates of mental health and substance use concerns among veterans with OTH discharge characterizations, expansions hold the potential to further burden caseloads with clinically complex, high-risk, high-need clients. Nevertheless, these expansions are also structured in a way that forces existing systems to absorb the responsibilities of providing necessary care to these veterans. To mitigate detrimental effects of eligibility expansions on the broader VA mental health system, clinicians should be explicitly trained in identifying veterans with OTH discharge characterizations and the implications of discharge status on broader health care eligibility. Treatment of veterans with OTH discharges may also benefit from close coordination between mental health professionals and behavioral health care coordinators to ensure appropriate coordination of care between VA- and non–VA-based HCPs.

CONCLUSIONS

Recent changes to VA eligibility policies now allow comprehensive mental and behavioral health care services to be provided to veterans with OTH discharges.1 Compared to routinely discharged veterans, veterans with OTH discharges are more likely to be persons of color, sexual or gender minorities, and experiencing mental health-related difficulties. Given the disproportionate mental health burden often faced by veterans with OTH discharges and relative overrepresentation of these veterans in judicial and correctional systems, these changes have considerable implications for programs and services designed to support veterans with criminallegal involvement. Professionals within these systems, particularly VTC programs, are therefore encouraged to familiarize themselves with recent changes in VA eligibility policies and to revisit strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations. Doing so may ensure veterans with OTH discharges are effectively connected to needed behavioral health care services.

In April 2022, the US Department of Veterans Affairs (VA) revised its behavioral health care eligibility policies to provide comprehensive mental and behavioral health care to former service members who received an Other Than Honorable (OTH) discharge characterization upon separation from military service.¹ This policy shift represents a marked expansion in eligibility practices (Table 1 includes amended eligibility criteria).

Since June 2017, eligibility policies allowed veterans with OTH discharges to receive “emergent mental health services” needed to stabilize acute mental health crises related to military service (eg, acute escalations in suicide risk).^2,3 Previously, veterans with OTH discharges were largely ineligible for VA-based health care; these individuals were only able to access Veterans Health Administration (VHA) mental and behavioral health care through limited channels of eligibility (eg, for treatment of military sexual trauma or psychosis or other mental illness within 2 years of discharge).^4,5 The impetus for expansions in eligibility stemmed from VA efforts to reduce the suicide rate among veterans.^6-8 Implications of such expansion extend beyond suicide prevention efforts, with notable promised effects on the care of veterans with criminal-legal involvement. This article highlights potential effects of recent eligibility expansions on veterans with criminal-legal involvement and makes specific recommendations for agencies and organizations serving these veterans.

OTHER THAN HONORABLE DISCHARGE

The US Department of Defense delineates 6 discharge characterizations provided to service members upon separation from military service: honorable, general under honorable conditions, OTH, bad conduct, dishonorable, and uncharacterized. Honorable discharge characterizations are considered to reflect general concordance between service member behavior and military standards; general discharge characterizations reflect some disparity between the service member’s behavior and military standards; OTH, bad conduct, and dishonorable discharge characterizations reflect serious disparities between the service member’s behavior and military standards; and uncharacterized discharge characterizations are given when other discharge characterizations are deemed inappropriate.^9,10 OTH discharge characterizations are typically issued under instances of misconduct, fraudulent entry, security reasons, or in lieu of trial by court martial.^9,10

Recent research suggests that about 85% of service members receive an honorable discharge characterization upon separation from military service, 8% receive general, 6% receive OTH, and 1% receive bad conduct or dishonorable discharges.11 In 2017, the VA estimated there were > 500,000 prior service members with OTH discharge characterizations, which has grown over time (1.9% during the Korean Conflict, 2.5% during the Vietnam War Era, 3.9% during the Cold War, 4.8% in the Persian Gulf War, and 5.8% in the post-9/11 era).^7,11

The OTH discharge characterization is 1 of 3 less than honorable discharges informally referred to as bad papers (ie, OTH, bad conduct, or dishonorable). Former service members receiving these discharge characterizations face significant social stigma and structural discrimination upon military discharge, including significant hurdles to employment and educational pursuits as well as notable social alienation.¹² Due to their discharge characterization, some are viewed as less deserving of the veteran title, and until recently, many did not qualify for the complex legal definition of veteran as established by the Congress.^11,13 Veterans with OTH discharge characterizations have also historically been excluded from services (eg, VHA care),³ benefits (eg, disability compensation),¹⁴ and protections (eg, Uniformed Services Employment and Reemployment Rights Act)¹⁵ offered to veterans with honorable or general discharge characterizations. However, eligibility policies have gradually expanded, providing veterans with OTH discharges with access to VHA-based mental and behavioral health services and VA supportive housing assistance.^1,3,16

Perhaps due to their historical exclusion from VA services, there is limited research available on the behavioral health and associated needs of veterans with OTH discharges. Some scholars argue that historical exclusions have exacerbated underlying difficulties faced by this population, thereby contributing to stark health and social disparities across discharge types.^14,15,17 Studies with large veteran samples, for example, reflect notable demographic and behavioral health differences across discharge types. Compared to routinely discharged veterans, veterans with OTH discharges are significantly more likely to be younger, have lower income, use substances, have a history of criminal-legal involvement, and have mental and physical health difficulties.^18,19

Substantial evidence also suggests a historical racial bias, with service members of color being disproportionately more likely to receive an OTH discharge.¹² Similarly, across all branches of military service, Black service members are significantly more likely to face general or special court martial in military justice proceedings when compared with White service members.²⁰ Service members from gender and sexual minorities are also disproportionately impacted by the OTH designation. Historically, many have been discharged with bad papers due to discriminatory policies, such as Don’t Ask Don’t Tell, which discriminated on the basis of sexual orientation between December 1993 and September 2011, and Directive-type Memorandum-19-004, which banned transgender persons from military service between April 2019 and January 2021.^21,22

There is also significant mental health bias in the provision of OTH discharges, such that OTH characterizations are disproportionately represented among individuals with mental health disorders.^18-20 Veterans discharged from military service due to behavioral misconduct are significantly more likely to meet diagnostic criteria for various behavioral health conditions and to experience homelessness, criminal-legal involvement, and suicidal ideation and behavior compared with routinely-discharged veterans.^23-28

Consistent with their comparatively higher rates of criminal-legal involvement relative to routinely discharged veterans, veterans with OTH discharges are disproportionately represented in criminal justice settings. While veterans with OTH discharges represent only 6% of discharging service members and 2.5% of community-based veterans, they represent 10% of incarcerated veterans.^11,18,23,29 Preliminary research suggests veterans with OTH discharges may be at higher risk for lifetime incarceration, though the association between OTH discharge and frequency of lifetime arrests remains unclear.^18,30

VETERANS TREATMENT COURTS

Given the overrepresentation of veterans with OTH discharges in criminal-legal settings, consideration for this subset of the veteran population and its unique needs is commonplace among problem-solving courts that service veterans. First conceptualized in 2004, Veterans Treatment Courts (VTCs) are specialized problem-solving courts that divert veterans away from traditional judicial court and penal systems and into community-based supervision and treatment (most commonly behavioral health services).^31-34 Although each VTC program is unique in structure, policies, and procedures, most VTCs can be characterized by certain key elements, including voluntary participation, plea requirements, delayed sentencing (often including reduced or dismissed charges), integration of military culture into court proceedings, a rehabilitative vs adversarial approach to decreasing risk of future criminal behavior, mandated treatment and supervision during participation, and use of veteran mentors to provide peer support.^32-35 Eligibility requirements vary; however, many restrict participation to veterans with honorable discharge types and charges for nonviolent offenses.^32,33,35-37

VTCs connect veterans within the criminal-legal system to needed behavioral health, community, and social services.^31-33,37 VTC participants are commonly connected to case management, behavioral health care, therapeutic journaling programs, and vocational rehabilitation.^38,39 Accordingly, the most common difficulties faced by veterans participating in these courts include substance use, mental health, family issues, anger management and/or aggressive behavior, and homelessness.^36,39 There is limited research on the effectiveness of VTCs. Evidence on their overall effectiveness is largely mixed, though some studies suggest VTC graduates tend to have lower recidivism rates than offenders more broadly or persons who terminate VTC programs prior to completion.^40,41 Other studies suggest that VTC participants are more likely to have jail sanctions, new arrests, and new incarcerations relative to nontreatment court participants.⁴² Notably, experimental designs (considered the gold standard in assessing effectiveness) to date have not been applied to evaluate the effectiveness of VTCs; as such, the effectiveness of these programs remains an area in need of continued empirical investigation.

Like all problem-solving courts, VTCs occasionally struggle to connect participating defendants with appropriate care, particularly when encountering structural barriers (eg, insurance, transportation) and/or complex behavioral health needs (eg, personality disorders).^34,43 As suicide rates among veterans experiencing criminal-legal involvement surge (about 150 per 100,000 in 2021, a 10% increase from 2020 to 2021 compared to about 40 per 100,000 and a 1.8% increase among other veterans), efficiency of adequate care coordination is vital.⁴⁴ Many VTCs rely on VTC-VA partnerships and collaborations to navigate these difficulties and facilitate connection of participating veterans to needed services.^32-34,45 For example, within the VHA, Veterans Justice Outreach (VJO) and Health Care for Re-Entry Veterans (HCRV) specialists assist and bridge the gap between the criminal-legal system (including, but not limited to VTCs) and VA services by engaging veterans involved in the criminal-legal system and connecting them to needed VA-based services (Table 2). Generally, VJO specialists support veterans involved with the front end of the criminallegal system (eg, arrest, pretrial incarceration, or participation in VTCs), while HCRV specialists tend to support veterans transitioning back into the community after a period of incarceration.^46,47 Specific to VTCs, VJO specialists typically serve as liaisons between the courts and VA, coordinating VA services for defendants to fulfill their terms of VTC participation.⁴⁶

The historical exclusion of veterans with OTH discharge characterizations from VA-based services has restricted many from accessing VTC programs.³² Of 17 VTC programs active in Pennsylvania in 2014, only 5 accepted veterans with OTstayH discharges, and 3 required application to and eligibility for VA benefits.³³ Similarly, in national surveys of VTC programs, about 1 in 3 report excluding veterans deemed ineligible for VA services.^35,36 When veterans with OTH discharges have accessed VTC programs, they have historically relied on non-VA, community-based programming to fulfill treatment mandates, which may be less suited to addressing the unique needs of veterans.⁴⁸

Veterans who utilize VTCs receive several benefits, namely peer support and mentorship, acceptance into a veteran-centric space, and connection with specially trained staff capable of supporting the veteran through applications for a range of VA benefits (eg, service connection, housing support).^31-33,37 Given the disparate prevalence of OTH discharge characterizations among service members from racial, sexual, and gender minorities and among service members with mental health disorders, exclusion of veterans with OTH discharges from VTCs solely based on the type of discharge likely contributes to structural inequities among these already underserved groups by restricting access to these potential benefits. Such structural inequity stands in direct conflict with VTC best practice standards, which admonish programs to adjust eligibility requirements to facilitate access to treatment court programs for historically marginalized groups.⁴⁹

ELIGIBILITY EXPANSIONS

Given the overrepresentation of veterans with OTH discharge characterizations within the criminal-legal system and historical barriers of these veterans to access needed mental and behavioral health care, expansions in VA eligibility policies could have immense implications for VTCs. First, these expansions could mitigate common barriers to connecting VTC-participating veterans with OTH discharges with needed behavioral health care by allowing these veterans to access established, VA-based services and programming. Expansion may also allow VTCs to serve as a key intercept point for identifying and engaging veterans with OTH discharges who may be unaware of their eligibility for VA-based behavioral health care.

Access to VA health care services is a major resource for VTC participants and a common requirement.³² Eligibility expansion should ease access barriers veterans with OTH discharges commonly face. By providing a potential source of treatment, expansions may also support OTH eligibility practices within VTCs, particularly practices that require participants to be eligible for VA health care.^33,35,36 Some VTCs may continue to determine eligibility on the basis of discharge status and remain inaccessible to veterans with OTH discharge characterizations without program-level policy changes.^32,36,37

Communicating changes in eligibility policies relevant to veterans with OTH discharges may be a challenge, because many of these individuals have no established channels of communication with the VA. Because veterans with OTH discharges are at increased risk for legal system involvement, VTCs may serve as a unique point of contact to help facilitate communication.¹⁸ For example, upon referral to a VTC, veterans with OTH discharges can be identified, VA health care eligibility can be verified, and veterans can connect to VA staff to facilitate enrollment in VA services and care.

VJO specialists are in a favorable position to serve a critical role in utilizing VTCs as a potential intercept point for engaging veterans with OTH discharge characterizations. As outlined in the STRONG Veterans Act of 2022, VJOs are mandated to “spread awareness and understanding of veteran eligibility for the [VJO] Program, including the eligibility of veterans who were discharged from service in the Armed Forces under conditions other than honorable.”50 The Act further requires VJOs to be annually trained in communicating eligibility changes as they arise. Accordingly, VJOs receive ongoing training in a wide variety of critical outreach topics, including changes in eligibility; while VJOs cannot make eligibility determinations, they are tasked with enrolling all veterans involved in the criminal-legal system with whom they interact into VHA services, whether through typical or special eligibility criteria (M. Stimmel, PhD, National Training Director for Veteran Justice Programming, oral communication, July 14, 2023). VJOs therefore routinely serve in this capacity of facilitating VA enrollment of veterans with OTH discharge characterizations.

Recommendations to Veteran-Servicing Judicial Programs

Considering these potential implications, professionals routinely interacting with veterans involved in the criminal-legal system should become familiarized with recent changes in VA eligibility policies. Such familiarization would support the identification of veterans previously considered ineligible for care; provision of education to these veterans regarding their new eligibility; and referral to appropriate VA-based behavioral health care options. Although conceptually simple, executing such an educational campaign may prove logistically difficult. Given their historical exclusion from VA services, veterans with OTH discharge characterizations are unlikely to seek VA-based services in times of need, instead relying on a broad swath of civilian community-based organizations and resources. Usual approaches to advertising VHA health care policy changes (eg, by notifying VA employees and/or departments providing corresponding services or by circulating information to veteran-focused mailing lists and organizations) likely would prove insufficient. Educational campaigns to disseminate information about recent OTH eligibility changes should instead consider partnering with traditionally civilian, communitybased organizations and institutions, such as state bar associations, legal aid networks, case management services, nonveteran treatment court programs (eg, drug courts, or domestic violence courts), or probation/ parole programs. Because national surveys suggest generally low military cultural competence among civilian populations, providing concurrent support in developing foundational veteran cultural competencies (eg, how to phrase questions about military service history, or understanding discharge characterizations) may be necessary to ensure effective identification and engagement of veteran clients.⁴⁸

Programs that serve veterans with criminal-legal involvement should also consider potential relevance of recent OTH eligibility changes to program operations. VTC program staff and key partners (eg, judges, case managers, district attorneys, or defense attorneys), should revisit policies and procedures surrounding the engagement of veterans with OTH discharges within VTC programs and strategies for connecting these veterans with needed services. VTC programs that have historically excluded veterans with OTH discharges due to associated difficulties in locating and connecting with needed services should consider expanding eligibility policies considering recent shifts in VA behavioral health care eligibility.^33,35,36 Within the VHA, VJO specialists can play a critical role in supporting these VTC eligibility and cultural shifts. Some evidence suggests a large proportion of VTC referrals are facilitated by VJO specialists and that many such referrals are identified when veterans involved with the criminal-legal system seek VA support and/or services.³³ Given the historical exclusion of veterans with OTH discharges from VA care, strategies used by VJO specialists to identify, connect, and engage veterans with OTH discharges with VTCs and other services may be beneficial.

Even with knowledge of VA eligibility changes and considerations of these changes on local operations, many forensic settings and programs struggle to identify veterans. These difficulties are likely amplified among veterans with OTH discharge characterizations, who may be hesitant to self-disclose their military service history due to fear of stigma and/or views of OTH discharge characterizations as undeserving of the veteran title.¹² The VA offers 2 tools to aid in identification of veterans for these settings: the Veterans Re-Entry Search Service (VRSS) and Status Query and Response Exchange System (SQUARES). For VRSS, correctional facilities, courts, and other criminal justice entities upload a simple spreadsheet that contains basic identifying information of inmates or defendants in their system. VRSS returns information about which inmates or defendants have a history of military service and alerts VA Veterans Justice Programs staff so they can conduct outreach. A pilot study conducted by the California Department of Corrections and Rehabilitation found that 2.7% of its inmate population self-identified as veterans, while VRSS identified 7.7% of inmates with a history of military service. This difference represented about 5000 previously unidentified veterans.⁵¹ Similarly, community entities that partner with the VA, such as law enforcement or homeless service programs, can be approved to become a SQUARES user and submit identifying information of individuals with whom they interact directly into the SQUARES search engine. SQUARES then directly returns information about the individual’s veteran status and eligibility for VA health care and homeless programs.

Other Eligibility Limitations

VTCs and other professionals looking to refer veterans with OTH discharge characterizations to VA-based behavioral health care should be aware of potential limitations in eligibility and access. Specifically, although veterans with OTH discharges are now broadly eligible for VA-based behavioral health care and homeless programs, they remain ineligible for other forms of health care, including primary care and nonbehavioral specialty care.1 Research has found a strong comorbidity between behavioral and nonbehavioral health concerns, particularly within historically marginalized demographic groups.^52-55 Because these historically marginalized groups are often overrepresented among persons with criminal-legal involvement, veterans with OTH discharges, and VTC participants, such comorbidities require consideration by services or programming designed to support veterans with criminal-legal involvement.^12,56-58 Connection with VA-based health care will therefore continue to fall short of addressing all health care needs of veterans with OTH discharges and effective case management will require considerable treatment coordination between VA behavioral health care practitioners (HCPs) and community-based HCPs (eg, primary care professionals or nonbehavioral HCPs).

Implications for VA Mental Health Care

Recent eligibility expansions will also have inevitable consequences for VA mental health care systems. For many years, these systems have been overburdened by high caseloads and clinician burnout.^59,60 Given the generally elevated rates of mental health and substance use concerns among veterans with OTH discharge characterizations, expansions hold the potential to further burden caseloads with clinically complex, high-risk, high-need clients. Nevertheless, these expansions are also structured in a way that forces existing systems to absorb the responsibilities of providing necessary care to these veterans. To mitigate detrimental effects of eligibility expansions on the broader VA mental health system, clinicians should be explicitly trained in identifying veterans with OTH discharge characterizations and the implications of discharge status on broader health care eligibility. Treatment of veterans with OTH discharges may also benefit from close coordination between mental health professionals and behavioral health care coordinators to ensure appropriate coordination of care between VA- and non–VA-based HCPs.

CONCLUSIONS

Recent changes to VA eligibility policies now allow comprehensive mental and behavioral health care services to be provided to veterans with OTH discharges.1 Compared to routinely discharged veterans, veterans with OTH discharges are more likely to be persons of color, sexual or gender minorities, and experiencing mental health-related difficulties. Given the disproportionate mental health burden often faced by veterans with OTH discharges and relative overrepresentation of these veterans in judicial and correctional systems, these changes have considerable implications for programs and services designed to support veterans with criminallegal involvement. Professionals within these systems, particularly VTC programs, are therefore encouraged to familiarize themselves with recent changes in VA eligibility policies and to revisit strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations. Doing so may ensure veterans with OTH discharges are effectively connected to needed behavioral health care services.

In April 2022, the US Department of Veterans Affairs (VA) revised its behavioral health care eligibility policies to provide comprehensive mental and behavioral health care to former service members who received an Other Than Honorable (OTH) discharge characterization upon separation from military service.¹ This policy shift represents a marked expansion in eligibility practices (Table 1 includes amended eligibility criteria).

Since June 2017, eligibility policies allowed veterans with OTH discharges to receive “emergent mental health services” needed to stabilize acute mental health crises related to military service (eg, acute escalations in suicide risk).^2,3 Previously, veterans with OTH discharges were largely ineligible for VA-based health care; these individuals were only able to access Veterans Health Administration (VHA) mental and behavioral health care through limited channels of eligibility (eg, for treatment of military sexual trauma or psychosis or other mental illness within 2 years of discharge).^4,5 The impetus for expansions in eligibility stemmed from VA efforts to reduce the suicide rate among veterans.^6-8 Implications of such expansion extend beyond suicide prevention efforts, with notable promised effects on the care of veterans with criminal-legal involvement. This article highlights potential effects of recent eligibility expansions on veterans with criminal-legal involvement and makes specific recommendations for agencies and organizations serving these veterans.

OTHER THAN HONORABLE DISCHARGE

The US Department of Defense delineates 6 discharge characterizations provided to service members upon separation from military service: honorable, general under honorable conditions, OTH, bad conduct, dishonorable, and uncharacterized. Honorable discharge characterizations are considered to reflect general concordance between service member behavior and military standards; general discharge characterizations reflect some disparity between the service member’s behavior and military standards; OTH, bad conduct, and dishonorable discharge characterizations reflect serious disparities between the service member’s behavior and military standards; and uncharacterized discharge characterizations are given when other discharge characterizations are deemed inappropriate.^9,10 OTH discharge characterizations are typically issued under instances of misconduct, fraudulent entry, security reasons, or in lieu of trial by court martial.^9,10

Recent research suggests that about 85% of service members receive an honorable discharge characterization upon separation from military service, 8% receive general, 6% receive OTH, and 1% receive bad conduct or dishonorable discharges.11 In 2017, the VA estimated there were > 500,000 prior service members with OTH discharge characterizations, which has grown over time (1.9% during the Korean Conflict, 2.5% during the Vietnam War Era, 3.9% during the Cold War, 4.8% in the Persian Gulf War, and 5.8% in the post-9/11 era).^7,11

The OTH discharge characterization is 1 of 3 less than honorable discharges informally referred to as bad papers (ie, OTH, bad conduct, or dishonorable). Former service members receiving these discharge characterizations face significant social stigma and structural discrimination upon military discharge, including significant hurdles to employment and educational pursuits as well as notable social alienation.¹² Due to their discharge characterization, some are viewed as less deserving of the veteran title, and until recently, many did not qualify for the complex legal definition of veteran as established by the Congress.^11,13 Veterans with OTH discharge characterizations have also historically been excluded from services (eg, VHA care),³ benefits (eg, disability compensation),¹⁴ and protections (eg, Uniformed Services Employment and Reemployment Rights Act)¹⁵ offered to veterans with honorable or general discharge characterizations. However, eligibility policies have gradually expanded, providing veterans with OTH discharges with access to VHA-based mental and behavioral health services and VA supportive housing assistance.^1,3,16

Perhaps due to their historical exclusion from VA services, there is limited research available on the behavioral health and associated needs of veterans with OTH discharges. Some scholars argue that historical exclusions have exacerbated underlying difficulties faced by this population, thereby contributing to stark health and social disparities across discharge types.^14,15,17 Studies with large veteran samples, for example, reflect notable demographic and behavioral health differences across discharge types. Compared to routinely discharged veterans, veterans with OTH discharges are significantly more likely to be younger, have lower income, use substances, have a history of criminal-legal involvement, and have mental and physical health difficulties.^18,19

Substantial evidence also suggests a historical racial bias, with service members of color being disproportionately more likely to receive an OTH discharge.¹² Similarly, across all branches of military service, Black service members are significantly more likely to face general or special court martial in military justice proceedings when compared with White service members.²⁰ Service members from gender and sexual minorities are also disproportionately impacted by the OTH designation. Historically, many have been discharged with bad papers due to discriminatory policies, such as Don’t Ask Don’t Tell, which discriminated on the basis of sexual orientation between December 1993 and September 2011, and Directive-type Memorandum-19-004, which banned transgender persons from military service between April 2019 and January 2021.^21,22

There is also significant mental health bias in the provision of OTH discharges, such that OTH characterizations are disproportionately represented among individuals with mental health disorders.^18-20 Veterans discharged from military service due to behavioral misconduct are significantly more likely to meet diagnostic criteria for various behavioral health conditions and to experience homelessness, criminal-legal involvement, and suicidal ideation and behavior compared with routinely-discharged veterans.^23-28

Consistent with their comparatively higher rates of criminal-legal involvement relative to routinely discharged veterans, veterans with OTH discharges are disproportionately represented in criminal justice settings. While veterans with OTH discharges represent only 6% of discharging service members and 2.5% of community-based veterans, they represent 10% of incarcerated veterans.^11,18,23,29 Preliminary research suggests veterans with OTH discharges may be at higher risk for lifetime incarceration, though the association between OTH discharge and frequency of lifetime arrests remains unclear.^18,30

VETERANS TREATMENT COURTS

Given the overrepresentation of veterans with OTH discharges in criminal-legal settings, consideration for this subset of the veteran population and its unique needs is commonplace among problem-solving courts that service veterans. First conceptualized in 2004, Veterans Treatment Courts (VTCs) are specialized problem-solving courts that divert veterans away from traditional judicial court and penal systems and into community-based supervision and treatment (most commonly behavioral health services).^31-34 Although each VTC program is unique in structure, policies, and procedures, most VTCs can be characterized by certain key elements, including voluntary participation, plea requirements, delayed sentencing (often including reduced or dismissed charges), integration of military culture into court proceedings, a rehabilitative vs adversarial approach to decreasing risk of future criminal behavior, mandated treatment and supervision during participation, and use of veteran mentors to provide peer support.^32-35 Eligibility requirements vary; however, many restrict participation to veterans with honorable discharge types and charges for nonviolent offenses.^32,33,35-37

VTCs connect veterans within the criminal-legal system to needed behavioral health, community, and social services.^31-33,37 VTC participants are commonly connected to case management, behavioral health care, therapeutic journaling programs, and vocational rehabilitation.^38,39 Accordingly, the most common difficulties faced by veterans participating in these courts include substance use, mental health, family issues, anger management and/or aggressive behavior, and homelessness.^36,39 There is limited research on the effectiveness of VTCs. Evidence on their overall effectiveness is largely mixed, though some studies suggest VTC graduates tend to have lower recidivism rates than offenders more broadly or persons who terminate VTC programs prior to completion.^40,41 Other studies suggest that VTC participants are more likely to have jail sanctions, new arrests, and new incarcerations relative to nontreatment court participants.⁴² Notably, experimental designs (considered the gold standard in assessing effectiveness) to date have not been applied to evaluate the effectiveness of VTCs; as such, the effectiveness of these programs remains an area in need of continued empirical investigation.

Like all problem-solving courts, VTCs occasionally struggle to connect participating defendants with appropriate care, particularly when encountering structural barriers (eg, insurance, transportation) and/or complex behavioral health needs (eg, personality disorders).^34,43 As suicide rates among veterans experiencing criminal-legal involvement surge (about 150 per 100,000 in 2021, a 10% increase from 2020 to 2021 compared to about 40 per 100,000 and a 1.8% increase among other veterans), efficiency of adequate care coordination is vital.⁴⁴ Many VTCs rely on VTC-VA partnerships and collaborations to navigate these difficulties and facilitate connection of participating veterans to needed services.^32-34,45 For example, within the VHA, Veterans Justice Outreach (VJO) and Health Care for Re-Entry Veterans (HCRV) specialists assist and bridge the gap between the criminal-legal system (including, but not limited to VTCs) and VA services by engaging veterans involved in the criminal-legal system and connecting them to needed VA-based services (Table 2). Generally, VJO specialists support veterans involved with the front end of the criminallegal system (eg, arrest, pretrial incarceration, or participation in VTCs), while HCRV specialists tend to support veterans transitioning back into the community after a period of incarceration.^46,47 Specific to VTCs, VJO specialists typically serve as liaisons between the courts and VA, coordinating VA services for defendants to fulfill their terms of VTC participation.⁴⁶

The historical exclusion of veterans with OTH discharge characterizations from VA-based services has restricted many from accessing VTC programs.³² Of 17 VTC programs active in Pennsylvania in 2014, only 5 accepted veterans with OTstayH discharges, and 3 required application to and eligibility for VA benefits.³³ Similarly, in national surveys of VTC programs, about 1 in 3 report excluding veterans deemed ineligible for VA services.^35,36 When veterans with OTH discharges have accessed VTC programs, they have historically relied on non-VA, community-based programming to fulfill treatment mandates, which may be less suited to addressing the unique needs of veterans.⁴⁸

Veterans who utilize VTCs receive several benefits, namely peer support and mentorship, acceptance into a veteran-centric space, and connection with specially trained staff capable of supporting the veteran through applications for a range of VA benefits (eg, service connection, housing support).^31-33,37 Given the disparate prevalence of OTH discharge characterizations among service members from racial, sexual, and gender minorities and among service members with mental health disorders, exclusion of veterans with OTH discharges from VTCs solely based on the type of discharge likely contributes to structural inequities among these already underserved groups by restricting access to these potential benefits. Such structural inequity stands in direct conflict with VTC best practice standards, which admonish programs to adjust eligibility requirements to facilitate access to treatment court programs for historically marginalized groups.⁴⁹

ELIGIBILITY EXPANSIONS

Given the overrepresentation of veterans with OTH discharge characterizations within the criminal-legal system and historical barriers of these veterans to access needed mental and behavioral health care, expansions in VA eligibility policies could have immense implications for VTCs. First, these expansions could mitigate common barriers to connecting VTC-participating veterans with OTH discharges with needed behavioral health care by allowing these veterans to access established, VA-based services and programming. Expansion may also allow VTCs to serve as a key intercept point for identifying and engaging veterans with OTH discharges who may be unaware of their eligibility for VA-based behavioral health care.

Access to VA health care services is a major resource for VTC participants and a common requirement.³² Eligibility expansion should ease access barriers veterans with OTH discharges commonly face. By providing a potential source of treatment, expansions may also support OTH eligibility practices within VTCs, particularly practices that require participants to be eligible for VA health care.^33,35,36 Some VTCs may continue to determine eligibility on the basis of discharge status and remain inaccessible to veterans with OTH discharge characterizations without program-level policy changes.^32,36,37

Communicating changes in eligibility policies relevant to veterans with OTH discharges may be a challenge, because many of these individuals have no established channels of communication with the VA. Because veterans with OTH discharges are at increased risk for legal system involvement, VTCs may serve as a unique point of contact to help facilitate communication.¹⁸ For example, upon referral to a VTC, veterans with OTH discharges can be identified, VA health care eligibility can be verified, and veterans can connect to VA staff to facilitate enrollment in VA services and care.

VJO specialists are in a favorable position to serve a critical role in utilizing VTCs as a potential intercept point for engaging veterans with OTH discharge characterizations. As outlined in the STRONG Veterans Act of 2022, VJOs are mandated to “spread awareness and understanding of veteran eligibility for the [VJO] Program, including the eligibility of veterans who were discharged from service in the Armed Forces under conditions other than honorable.”50 The Act further requires VJOs to be annually trained in communicating eligibility changes as they arise. Accordingly, VJOs receive ongoing training in a wide variety of critical outreach topics, including changes in eligibility; while VJOs cannot make eligibility determinations, they are tasked with enrolling all veterans involved in the criminal-legal system with whom they interact into VHA services, whether through typical or special eligibility criteria (M. Stimmel, PhD, National Training Director for Veteran Justice Programming, oral communication, July 14, 2023). VJOs therefore routinely serve in this capacity of facilitating VA enrollment of veterans with OTH discharge characterizations.

Recommendations to Veteran-Servicing Judicial Programs

Considering these potential implications, professionals routinely interacting with veterans involved in the criminal-legal system should become familiarized with recent changes in VA eligibility policies. Such familiarization would support the identification of veterans previously considered ineligible for care; provision of education to these veterans regarding their new eligibility; and referral to appropriate VA-based behavioral health care options. Although conceptually simple, executing such an educational campaign may prove logistically difficult. Given their historical exclusion from VA services, veterans with OTH discharge characterizations are unlikely to seek VA-based services in times of need, instead relying on a broad swath of civilian community-based organizations and resources. Usual approaches to advertising VHA health care policy changes (eg, by notifying VA employees and/or departments providing corresponding services or by circulating information to veteran-focused mailing lists and organizations) likely would prove insufficient. Educational campaigns to disseminate information about recent OTH eligibility changes should instead consider partnering with traditionally civilian, communitybased organizations and institutions, such as state bar associations, legal aid networks, case management services, nonveteran treatment court programs (eg, drug courts, or domestic violence courts), or probation/ parole programs. Because national surveys suggest generally low military cultural competence among civilian populations, providing concurrent support in developing foundational veteran cultural competencies (eg, how to phrase questions about military service history, or understanding discharge characterizations) may be necessary to ensure effective identification and engagement of veteran clients.⁴⁸

Programs that serve veterans with criminal-legal involvement should also consider potential relevance of recent OTH eligibility changes to program operations. VTC program staff and key partners (eg, judges, case managers, district attorneys, or defense attorneys), should revisit policies and procedures surrounding the engagement of veterans with OTH discharges within VTC programs and strategies for connecting these veterans with needed services. VTC programs that have historically excluded veterans with OTH discharges due to associated difficulties in locating and connecting with needed services should consider expanding eligibility policies considering recent shifts in VA behavioral health care eligibility.^33,35,36 Within the VHA, VJO specialists can play a critical role in supporting these VTC eligibility and cultural shifts. Some evidence suggests a large proportion of VTC referrals are facilitated by VJO specialists and that many such referrals are identified when veterans involved with the criminal-legal system seek VA support and/or services.³³ Given the historical exclusion of veterans with OTH discharges from VA care, strategies used by VJO specialists to identify, connect, and engage veterans with OTH discharges with VTCs and other services may be beneficial.

Even with knowledge of VA eligibility changes and considerations of these changes on local operations, many forensic settings and programs struggle to identify veterans. These difficulties are likely amplified among veterans with OTH discharge characterizations, who may be hesitant to self-disclose their military service history due to fear of stigma and/or views of OTH discharge characterizations as undeserving of the veteran title.¹² The VA offers 2 tools to aid in identification of veterans for these settings: the Veterans Re-Entry Search Service (VRSS) and Status Query and Response Exchange System (SQUARES). For VRSS, correctional facilities, courts, and other criminal justice entities upload a simple spreadsheet that contains basic identifying information of inmates or defendants in their system. VRSS returns information about which inmates or defendants have a history of military service and alerts VA Veterans Justice Programs staff so they can conduct outreach. A pilot study conducted by the California Department of Corrections and Rehabilitation found that 2.7% of its inmate population self-identified as veterans, while VRSS identified 7.7% of inmates with a history of military service. This difference represented about 5000 previously unidentified veterans.⁵¹ Similarly, community entities that partner with the VA, such as law enforcement or homeless service programs, can be approved to become a SQUARES user and submit identifying information of individuals with whom they interact directly into the SQUARES search engine. SQUARES then directly returns information about the individual’s veteran status and eligibility for VA health care and homeless programs.

Other Eligibility Limitations

VTCs and other professionals looking to refer veterans with OTH discharge characterizations to VA-based behavioral health care should be aware of potential limitations in eligibility and access. Specifically, although veterans with OTH discharges are now broadly eligible for VA-based behavioral health care and homeless programs, they remain ineligible for other forms of health care, including primary care and nonbehavioral specialty care.1 Research has found a strong comorbidity between behavioral and nonbehavioral health concerns, particularly within historically marginalized demographic groups.^52-55 Because these historically marginalized groups are often overrepresented among persons with criminal-legal involvement, veterans with OTH discharges, and VTC participants, such comorbidities require consideration by services or programming designed to support veterans with criminal-legal involvement.^12,56-58 Connection with VA-based health care will therefore continue to fall short of addressing all health care needs of veterans with OTH discharges and effective case management will require considerable treatment coordination between VA behavioral health care practitioners (HCPs) and community-based HCPs (eg, primary care professionals or nonbehavioral HCPs).

Implications for VA Mental Health Care

Recent eligibility expansions will also have inevitable consequences for VA mental health care systems. For many years, these systems have been overburdened by high caseloads and clinician burnout.^59,60 Given the generally elevated rates of mental health and substance use concerns among veterans with OTH discharge characterizations, expansions hold the potential to further burden caseloads with clinically complex, high-risk, high-need clients. Nevertheless, these expansions are also structured in a way that forces existing systems to absorb the responsibilities of providing necessary care to these veterans. To mitigate detrimental effects of eligibility expansions on the broader VA mental health system, clinicians should be explicitly trained in identifying veterans with OTH discharge characterizations and the implications of discharge status on broader health care eligibility. Treatment of veterans with OTH discharges may also benefit from close coordination between mental health professionals and behavioral health care coordinators to ensure appropriate coordination of care between VA- and non–VA-based HCPs.

CONCLUSIONS

Recent changes to VA eligibility policies now allow comprehensive mental and behavioral health care services to be provided to veterans with OTH discharges.1 Compared to routinely discharged veterans, veterans with OTH discharges are more likely to be persons of color, sexual or gender minorities, and experiencing mental health-related difficulties. Given the disproportionate mental health burden often faced by veterans with OTH discharges and relative overrepresentation of these veterans in judicial and correctional systems, these changes have considerable implications for programs and services designed to support veterans with criminallegal involvement. Professionals within these systems, particularly VTC programs, are therefore encouraged to familiarize themselves with recent changes in VA eligibility policies and to revisit strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations. Doing so may ensure veterans with OTH discharges are effectively connected to needed behavioral health care services.

Acne keloidalis nuchae (AKN) is a chronic inflammatory condition commonly affecting the occipital scalp and posterior neck. It causes discrete or extensive fibrosing papules that may coalesce to form pronounced ­tumorlike masses^1,2 with scarring alopecia (Figure, A–C).³ Pustules, hair tufts, secondary bacterial infections, abscesses, and sinus tracts also may occur.¹ The pathogenesis of AKN has been characterized as varying stages of follicular inflammation at the infundibular and isthmus levels followed by fibrotic occlusion of the ­follicular lumen.⁴ Pruritus, pain, bleeding, oozing, and a feeling of scalp tightness may occur.^1,5

Umar et al⁶ performed a retrospective review of 108 men with AKN—58% of African descent, 37% Hispanic, 3% Asian, and 2% Middle Eastern—and proposed a 3-tier classification system for AKN. Tier 1 focused on the distribution and sagittal spread of AKN lesions between the clinical demarcation lines of the occipital notch and posterior hairline. Tier 2 focused on the type of lesions present—discrete papules or nodules, coalescing/abutting lesions, plaques (raised, atrophic, or indurated), or dome-shaped tumoral masses. Tier 3 focused on the presence or absence of co-existing dissecting cellulitis or folliculitis decalvans.⁶

Epidemiology

Acne keloidalis nuchae primarily manifests in adolescent and adult men of African or Afro-Caribbean descent.⁷ Among African American men, the prevalence of AKN ranges from 0.5% to 13.6%.⁸ Similar ranges have been reported among Nigerian, South African, and West African men.¹ Acne keloidalis nuchae also affects Asian and Hispanic men but rarely is seen in non-Hispanic White men or in women of any ethnicity.^9,10 The male to female ratio is 20:1.^1,11 Hair texture, hairstyling practices such as closely shaved or faded haircuts, and genetics likely contribute to development of AKN. Sports and occupations that require the use of headgear or a tight collar may increase the risk for AKN.¹²

Key clinical features in people with darker skin tones

• The lesions of AKN range in color from pink to dark brown or black. Postinflammatory hyperpigmentation or hyperchromia may be present around AKN lesions.
• Chronicity of AKN may lead to extended use of high-potency topical or intralesional corticosteroids, which causes transient or long-lasting hypopigmentation, especially in those with darker skin tones.

Worth noting

• Acne keloidalis nuchae can be disfiguring, which negatively impacts quality of life and self-esteem.¹²
• Some occupations (eg, military, police) have hair policies that may not be favorable to those with or at risk for AKN.
• Patients with AKN are 2 to 3 times more likely to present with metabolic syndrome, hypertension, type 2 diabetes mellitus, or obesity.¹³

Treatment

There are no treatments approved by the US Food and Drug Administration specifically for AKN. Treatment approaches are based on the pathophysiology, secondary impacts on the skin, and disease severity. Growing out the hair may prevent worsening and/or decrease the risk for new lesions.⁶

• Options include but are not limited to topical and systemic therapies (eg, topical corticosteroids, oral or topical antibiotics, isotretinoin, topical retinoids, imiquimod, pimecrolimus), light devices (eg, phototherapy, laser), ablative therapies (eg, laser, cryotherapy, radiotherapy), and surgery (eg, excision, follicular unit excision), often in combination.^6,14,15
• Intralesional triamcinolone injections are considered standard of care. Adotama et al found that injecting ­triamcinolone into the deep dermis in the area of flat or papular AKN yielded better control of inflammation and decreased appearance of lesions compared with injecting individual lesions.¹⁶
• For extensive AKN lesions that do not respond to ­less-invasive therapies, consider surgical techniques,^6,17 such as follicular unit excision¹⁸ and more extensive surgical excisions building on approaches from pioneers Drs. John Kenney and Harold Pierce.¹⁹ An innovative surgical approach for removal of large AKNs is the bat excision technique—wound shape resembles a bat in a spread-eagled position—with secondary intention healing with or without debridement and/or tension sutures. The resulting linear scar acts as a new posterior hair line.²⁰

Health disparity highlights

Access to a dermatologic or plastic surgeon with expertise in the surgical treatment of large AKNs may be challenging but is needed to reduce risk for recurrence and adverse events.

Close-cropped haircuts on the occipital scalp, which are particularly popular among men of African descent, increase the risk for AKN.⁵ Although this grooming style may be a personal preference, other hairstyles commonly worn by those with tightly coiled hair may be deemed “unprofessional” in society or the workplace, which leads to hairstyling practices that may increase the risk for AKN.²¹

Acne keloidalis nuchae remains an understudied entity that adversely affects patients with skin of color.

Acne keloidalis nuchae (AKN) is a chronic inflammatory condition commonly affecting the occipital scalp and posterior neck. It causes discrete or extensive fibrosing papules that may coalesce to form pronounced ­tumorlike masses^1,2 with scarring alopecia (Figure, A–C).³ Pustules, hair tufts, secondary bacterial infections, abscesses, and sinus tracts also may occur.¹ The pathogenesis of AKN has been characterized as varying stages of follicular inflammation at the infundibular and isthmus levels followed by fibrotic occlusion of the ­follicular lumen.⁴ Pruritus, pain, bleeding, oozing, and a feeling of scalp tightness may occur.^1,5

Umar et al⁶ performed a retrospective review of 108 men with AKN—58% of African descent, 37% Hispanic, 3% Asian, and 2% Middle Eastern—and proposed a 3-tier classification system for AKN. Tier 1 focused on the distribution and sagittal spread of AKN lesions between the clinical demarcation lines of the occipital notch and posterior hairline. Tier 2 focused on the type of lesions present—discrete papules or nodules, coalescing/abutting lesions, plaques (raised, atrophic, or indurated), or dome-shaped tumoral masses. Tier 3 focused on the presence or absence of co-existing dissecting cellulitis or folliculitis decalvans.⁶

Epidemiology

Acne keloidalis nuchae primarily manifests in adolescent and adult men of African or Afro-Caribbean descent.⁷ Among African American men, the prevalence of AKN ranges from 0.5% to 13.6%.⁸ Similar ranges have been reported among Nigerian, South African, and West African men.¹ Acne keloidalis nuchae also affects Asian and Hispanic men but rarely is seen in non-Hispanic White men or in women of any ethnicity.^9,10 The male to female ratio is 20:1.^1,11 Hair texture, hairstyling practices such as closely shaved or faded haircuts, and genetics likely contribute to development of AKN. Sports and occupations that require the use of headgear or a tight collar may increase the risk for AKN.¹²

Key clinical features in people with darker skin tones

• The lesions of AKN range in color from pink to dark brown or black. Postinflammatory hyperpigmentation or hyperchromia may be present around AKN lesions.
• Chronicity of AKN may lead to extended use of high-potency topical or intralesional corticosteroids, which causes transient or long-lasting hypopigmentation, especially in those with darker skin tones.

Worth noting

• Acne keloidalis nuchae can be disfiguring, which negatively impacts quality of life and self-esteem.¹²
• Some occupations (eg, military, police) have hair policies that may not be favorable to those with or at risk for AKN.
• Patients with AKN are 2 to 3 times more likely to present with metabolic syndrome, hypertension, type 2 diabetes mellitus, or obesity.¹³

Treatment

There are no treatments approved by the US Food and Drug Administration specifically for AKN. Treatment approaches are based on the pathophysiology, secondary impacts on the skin, and disease severity. Growing out the hair may prevent worsening and/or decrease the risk for new lesions.⁶

• Options include but are not limited to topical and systemic therapies (eg, topical corticosteroids, oral or topical antibiotics, isotretinoin, topical retinoids, imiquimod, pimecrolimus), light devices (eg, phototherapy, laser), ablative therapies (eg, laser, cryotherapy, radiotherapy), and surgery (eg, excision, follicular unit excision), often in combination.^6,14,15
• Intralesional triamcinolone injections are considered standard of care. Adotama et al found that injecting ­triamcinolone into the deep dermis in the area of flat or papular AKN yielded better control of inflammation and decreased appearance of lesions compared with injecting individual lesions.¹⁶
• For extensive AKN lesions that do not respond to ­less-invasive therapies, consider surgical techniques,^6,17 such as follicular unit excision¹⁸ and more extensive surgical excisions building on approaches from pioneers Drs. John Kenney and Harold Pierce.¹⁹ An innovative surgical approach for removal of large AKNs is the bat excision technique—wound shape resembles a bat in a spread-eagled position—with secondary intention healing with or without debridement and/or tension sutures. The resulting linear scar acts as a new posterior hair line.²⁰

Health disparity highlights

Access to a dermatologic or plastic surgeon with expertise in the surgical treatment of large AKNs may be challenging but is needed to reduce risk for recurrence and adverse events.

Close-cropped haircuts on the occipital scalp, which are particularly popular among men of African descent, increase the risk for AKN.⁵ Although this grooming style may be a personal preference, other hairstyles commonly worn by those with tightly coiled hair may be deemed “unprofessional” in society or the workplace, which leads to hairstyling practices that may increase the risk for AKN.²¹

Acne keloidalis nuchae remains an understudied entity that adversely affects patients with skin of color.

Acne keloidalis nuchae (AKN) is a chronic inflammatory condition commonly affecting the occipital scalp and posterior neck. It causes discrete or extensive fibrosing papules that may coalesce to form pronounced ­tumorlike masses^1,2 with scarring alopecia (Figure, A–C).³ Pustules, hair tufts, secondary bacterial infections, abscesses, and sinus tracts also may occur.¹ The pathogenesis of AKN has been characterized as varying stages of follicular inflammation at the infundibular and isthmus levels followed by fibrotic occlusion of the ­follicular lumen.⁴ Pruritus, pain, bleeding, oozing, and a feeling of scalp tightness may occur.^1,5

Umar et al⁶ performed a retrospective review of 108 men with AKN—58% of African descent, 37% Hispanic, 3% Asian, and 2% Middle Eastern—and proposed a 3-tier classification system for AKN. Tier 1 focused on the distribution and sagittal spread of AKN lesions between the clinical demarcation lines of the occipital notch and posterior hairline. Tier 2 focused on the type of lesions present—discrete papules or nodules, coalescing/abutting lesions, plaques (raised, atrophic, or indurated), or dome-shaped tumoral masses. Tier 3 focused on the presence or absence of co-existing dissecting cellulitis or folliculitis decalvans.⁶

Epidemiology

Acne keloidalis nuchae primarily manifests in adolescent and adult men of African or Afro-Caribbean descent.⁷ Among African American men, the prevalence of AKN ranges from 0.5% to 13.6%.⁸ Similar ranges have been reported among Nigerian, South African, and West African men.¹ Acne keloidalis nuchae also affects Asian and Hispanic men but rarely is seen in non-Hispanic White men or in women of any ethnicity.^9,10 The male to female ratio is 20:1.^1,11 Hair texture, hairstyling practices such as closely shaved or faded haircuts, and genetics likely contribute to development of AKN. Sports and occupations that require the use of headgear or a tight collar may increase the risk for AKN.¹²

Key clinical features in people with darker skin tones

• The lesions of AKN range in color from pink to dark brown or black. Postinflammatory hyperpigmentation or hyperchromia may be present around AKN lesions.
• Chronicity of AKN may lead to extended use of high-potency topical or intralesional corticosteroids, which causes transient or long-lasting hypopigmentation, especially in those with darker skin tones.

Worth noting

• Acne keloidalis nuchae can be disfiguring, which negatively impacts quality of life and self-esteem.¹²
• Some occupations (eg, military, police) have hair policies that may not be favorable to those with or at risk for AKN.
• Patients with AKN are 2 to 3 times more likely to present with metabolic syndrome, hypertension, type 2 diabetes mellitus, or obesity.¹³

Treatment

There are no treatments approved by the US Food and Drug Administration specifically for AKN. Treatment approaches are based on the pathophysiology, secondary impacts on the skin, and disease severity. Growing out the hair may prevent worsening and/or decrease the risk for new lesions.⁶

• Options include but are not limited to topical and systemic therapies (eg, topical corticosteroids, oral or topical antibiotics, isotretinoin, topical retinoids, imiquimod, pimecrolimus), light devices (eg, phototherapy, laser), ablative therapies (eg, laser, cryotherapy, radiotherapy), and surgery (eg, excision, follicular unit excision), often in combination.^6,14,15
• Intralesional triamcinolone injections are considered standard of care. Adotama et al found that injecting ­triamcinolone into the deep dermis in the area of flat or papular AKN yielded better control of inflammation and decreased appearance of lesions compared with injecting individual lesions.¹⁶
• For extensive AKN lesions that do not respond to ­less-invasive therapies, consider surgical techniques,^6,17 such as follicular unit excision¹⁸ and more extensive surgical excisions building on approaches from pioneers Drs. John Kenney and Harold Pierce.¹⁹ An innovative surgical approach for removal of large AKNs is the bat excision technique—wound shape resembles a bat in a spread-eagled position—with secondary intention healing with or without debridement and/or tension sutures. The resulting linear scar acts as a new posterior hair line.²⁰

Health disparity highlights

Access to a dermatologic or plastic surgeon with expertise in the surgical treatment of large AKNs may be challenging but is needed to reduce risk for recurrence and adverse events.

Close-cropped haircuts on the occipital scalp, which are particularly popular among men of African descent, increase the risk for AKN.⁵ Although this grooming style may be a personal preference, other hairstyles commonly worn by those with tightly coiled hair may be deemed “unprofessional” in society or the workplace, which leads to hairstyling practices that may increase the risk for AKN.²¹

Acne keloidalis nuchae remains an understudied entity that adversely affects patients with skin of color.

At age 57, a senior scientific researcher in Santa Barbara, California, complained of chronic erectile dysfunction (ED) in what had been a sexually active marriage. “I just couldn’t get an erection, let alone sustain one. Apart from that, I maybe felt a bit tired but generally okay,” he said. Though seemingly well otherwise, 18 months later he was dead of a hereditary right-sided colon cancer.

While not all cases of ED are associated with a dire outcome, the genitourinary signals of ED and lower urinary tract symptoms (LUTS), especially nocturia, serve as sentinel indicators of the presence of, or risk factors for, serious chronic conditions. These commonly include cardiovascular disease (CVD), diabetes, and metabolic syndrome and are associated with obesity, depression, and obstructive sleep apnea.

Sometimes these serious conditions may stay under the radar until men seek help for ED or LUTS.

“We know that among men who had a heart attack, 50% had some degree of ED within 3 years of their cardiac event,” Sam Tafari, MBBS, of the Endocrine and Metabolic Unit at Royal Adelaide Hospital in Adelaide, South Australia, said in an interview.

That’s the bad news. The good news is that these two problems may specifically incentivize men to seek timely care for serious conditions they might otherwise not get, according to Dr. Tafari. And primary care doctors are ideally positioned to get men early multifaceted care. He recently coauthored a call to action on this issue in a review appearing in the Journal of Men’s Health.

In Dr. Tafari’s experience, most patients seeking urological care are unaware of the multiple conditions linked to ED and LUTS. “Many consider these to be due to issues like low testosterone, which actually make up a very small proportion of cases of ED,” he said. Aging, obesity, inactivity, smoking, alcohol abuse, and prescription and street drugs can also contribute to the development of ED.

In most affected men, ED is of vascular etiology, with endothelial dysfunction of the inner lining of blood vessels and smooth muscle the common denominator.

This dysfunction causes inadequate blood supply to both the coronary and the penile arteries, so ED and CVD are considered different manifestations of the same systemic disorder. Because the tumescence-controlling cavernosal vessels of the penis are considerably smaller, the same level of arteriopathy causes a more severe reduction in blood in the erectile tissue. As a result, ED often precedes CVD and presents an early opportunity to screen men for CVD.

As to the mechanisms behind LUTS, Peter N. Tsambarlis, MD, a urologist at Northwestern Medicine in Chicago, subscribes to the inflammation theory. “Suboptimal health issues such as high [blood] pressure, blood lipids, and blood glucose lead to chronic widespread inflammation, which makes the bladder less flexible as a storage vessel,” he explained. “It’s not able to stretch adequately overnight to hold the urine until morning.”
 

Ask Early, Ask Often

Jeffrey P. Weiss, MD, PhD, chair of the Department of Urology at SUNY Downstate Health Sciences University in Brooklyn, New York, has done research that uncovered a relationship between structural cardiac disease and nocturia. “So if you had to ask a patient a single question that would point to a global health issue, it would be ‘Do you have frequent nighttime urination,’ ” he said.

It’s never too soon to ask men about these symptoms, said Dr. Tsambarlis. The best time to raise issues of ED and LUTS is when a man enters primary care — regardless of age or absence of symptoms. “That way you have a baseline and can watch for changes and do early intervention as needed. Men don’t usually want to bring up sexual dysfunction or urinary health, but asking doesn’t need to dominate the visit,” he said.

Dr. Tafari recommends that primary care physicians adopt a targeted approach using ED and nocturia as entry points for engaging men in their healthcare. While acknowledging that primary care physicians have an ever-growing checklist of questions to ask patients and hardly need one more thing to screen for, he suggests asking two quick, and easy “before you go” genitourinary queries:

• Are you having trouble with erections or having sex?
• Are you getting up at night to pass urine more than once?

“The men really appreciate being asked,” he said. “But what worries me is all the men we don’t see who have these symptoms but don’t know they’re important, and no one is asking about them.”

Gideon Richards, MD, a urologist at the Northwell Health Physician Partners Smith Institute for Urology at Garden City, and director of Men’s Health, Central Region, for Northwell Health in New Hyde Park, both in New York, said erectile problems should not wait for specialty care. By the time men with ED are referred to urology, they may already have failed treatment with first-line phosphodiesterase 5 inhibitor therapy, he said. “A significant proportion will have arteriogenic erectile dysfunction, a measurable decrease in the amount of blood flow into the erectile bodies.”

Addressing the Issue

Addressing genitourinary-signaled issues has the double benefit of easing ED and LUTS and improving men’s health and longevity and may help narrow the worldwide gender gap in life expectancy. As a recent global analysis found, there’s a 5-year longevity disparity favoring women over men. Biology aside, men do not access healthcare as often as women, who consult their general practitioners regularly throughout their lifespan for multiple reasons, including reproductive care, and more screening programs are aimed at women.

Added Dr. Tsambarlis, “Men should know that losing weight and switching to a healthy lifestyle can improve sexual function about half as much as phosphodiesterase 5 inhibitors such as sildenafil [Viagra] or tadalafil [Cialis].”

“Many, however, would prefer just to take drugs rather than change their lifestyle and lose weight. There are certainly effective options available, but these are not uniformly effective,” said Dr. Weiss.

Dr. Tafari’s group is designing a short, simple, culturally acceptable screening tool for use in primary care practice and will monitor its impact on physician prescribing habits and overall men’s health outcomes.

Dr. Tafari received funding from the Hospital Research Foundation and Freemasons Centre for Male Health and Wellbeing in Adelaide, South Australia. Dr. Tafari, Dr. Tsambarlis, Dr. Weiss, and Dr. Richards had no relevant conflicts of interest to declare.
 

A version of this article appeared on Medscape.com.

At age 57, a senior scientific researcher in Santa Barbara, California, complained of chronic erectile dysfunction (ED) in what had been a sexually active marriage. “I just couldn’t get an erection, let alone sustain one. Apart from that, I maybe felt a bit tired but generally okay,” he said. Though seemingly well otherwise, 18 months later he was dead of a hereditary right-sided colon cancer.

While not all cases of ED are associated with a dire outcome, the genitourinary signals of ED and lower urinary tract symptoms (LUTS), especially nocturia, serve as sentinel indicators of the presence of, or risk factors for, serious chronic conditions. These commonly include cardiovascular disease (CVD), diabetes, and metabolic syndrome and are associated with obesity, depression, and obstructive sleep apnea.

Sometimes these serious conditions may stay under the radar until men seek help for ED or LUTS.

“We know that among men who had a heart attack, 50% had some degree of ED within 3 years of their cardiac event,” Sam Tafari, MBBS, of the Endocrine and Metabolic Unit at Royal Adelaide Hospital in Adelaide, South Australia, said in an interview.

That’s the bad news. The good news is that these two problems may specifically incentivize men to seek timely care for serious conditions they might otherwise not get, according to Dr. Tafari. And primary care doctors are ideally positioned to get men early multifaceted care. He recently coauthored a call to action on this issue in a review appearing in the Journal of Men’s Health.

In Dr. Tafari’s experience, most patients seeking urological care are unaware of the multiple conditions linked to ED and LUTS. “Many consider these to be due to issues like low testosterone, which actually make up a very small proportion of cases of ED,” he said. Aging, obesity, inactivity, smoking, alcohol abuse, and prescription and street drugs can also contribute to the development of ED.

In most affected men, ED is of vascular etiology, with endothelial dysfunction of the inner lining of blood vessels and smooth muscle the common denominator.

This dysfunction causes inadequate blood supply to both the coronary and the penile arteries, so ED and CVD are considered different manifestations of the same systemic disorder. Because the tumescence-controlling cavernosal vessels of the penis are considerably smaller, the same level of arteriopathy causes a more severe reduction in blood in the erectile tissue. As a result, ED often precedes CVD and presents an early opportunity to screen men for CVD.

As to the mechanisms behind LUTS, Peter N. Tsambarlis, MD, a urologist at Northwestern Medicine in Chicago, subscribes to the inflammation theory. “Suboptimal health issues such as high [blood] pressure, blood lipids, and blood glucose lead to chronic widespread inflammation, which makes the bladder less flexible as a storage vessel,” he explained. “It’s not able to stretch adequately overnight to hold the urine until morning.”
 

Ask Early, Ask Often

Jeffrey P. Weiss, MD, PhD, chair of the Department of Urology at SUNY Downstate Health Sciences University in Brooklyn, New York, has done research that uncovered a relationship between structural cardiac disease and nocturia. “So if you had to ask a patient a single question that would point to a global health issue, it would be ‘Do you have frequent nighttime urination,’ ” he said.

It’s never too soon to ask men about these symptoms, said Dr. Tsambarlis. The best time to raise issues of ED and LUTS is when a man enters primary care — regardless of age or absence of symptoms. “That way you have a baseline and can watch for changes and do early intervention as needed. Men don’t usually want to bring up sexual dysfunction or urinary health, but asking doesn’t need to dominate the visit,” he said.

Dr. Tafari recommends that primary care physicians adopt a targeted approach using ED and nocturia as entry points for engaging men in their healthcare. While acknowledging that primary care physicians have an ever-growing checklist of questions to ask patients and hardly need one more thing to screen for, he suggests asking two quick, and easy “before you go” genitourinary queries:

• Are you having trouble with erections or having sex?
• Are you getting up at night to pass urine more than once?

“The men really appreciate being asked,” he said. “But what worries me is all the men we don’t see who have these symptoms but don’t know they’re important, and no one is asking about them.”

Gideon Richards, MD, a urologist at the Northwell Health Physician Partners Smith Institute for Urology at Garden City, and director of Men’s Health, Central Region, for Northwell Health in New Hyde Park, both in New York, said erectile problems should not wait for specialty care. By the time men with ED are referred to urology, they may already have failed treatment with first-line phosphodiesterase 5 inhibitor therapy, he said. “A significant proportion will have arteriogenic erectile dysfunction, a measurable decrease in the amount of blood flow into the erectile bodies.”

Addressing the Issue

Addressing genitourinary-signaled issues has the double benefit of easing ED and LUTS and improving men’s health and longevity and may help narrow the worldwide gender gap in life expectancy. As a recent global analysis found, there’s a 5-year longevity disparity favoring women over men. Biology aside, men do not access healthcare as often as women, who consult their general practitioners regularly throughout their lifespan for multiple reasons, including reproductive care, and more screening programs are aimed at women.

Added Dr. Tsambarlis, “Men should know that losing weight and switching to a healthy lifestyle can improve sexual function about half as much as phosphodiesterase 5 inhibitors such as sildenafil [Viagra] or tadalafil [Cialis].”

“Many, however, would prefer just to take drugs rather than change their lifestyle and lose weight. There are certainly effective options available, but these are not uniformly effective,” said Dr. Weiss.

Dr. Tafari’s group is designing a short, simple, culturally acceptable screening tool for use in primary care practice and will monitor its impact on physician prescribing habits and overall men’s health outcomes.

Dr. Tafari received funding from the Hospital Research Foundation and Freemasons Centre for Male Health and Wellbeing in Adelaide, South Australia. Dr. Tafari, Dr. Tsambarlis, Dr. Weiss, and Dr. Richards had no relevant conflicts of interest to declare.
 

A version of this article appeared on Medscape.com.

At age 57, a senior scientific researcher in Santa Barbara, California, complained of chronic erectile dysfunction (ED) in what had been a sexually active marriage. “I just couldn’t get an erection, let alone sustain one. Apart from that, I maybe felt a bit tired but generally okay,” he said. Though seemingly well otherwise, 18 months later he was dead of a hereditary right-sided colon cancer.

While not all cases of ED are associated with a dire outcome, the genitourinary signals of ED and lower urinary tract symptoms (LUTS), especially nocturia, serve as sentinel indicators of the presence of, or risk factors for, serious chronic conditions. These commonly include cardiovascular disease (CVD), diabetes, and metabolic syndrome and are associated with obesity, depression, and obstructive sleep apnea.

Sometimes these serious conditions may stay under the radar until men seek help for ED or LUTS.

“We know that among men who had a heart attack, 50% had some degree of ED within 3 years of their cardiac event,” Sam Tafari, MBBS, of the Endocrine and Metabolic Unit at Royal Adelaide Hospital in Adelaide, South Australia, said in an interview.

That’s the bad news. The good news is that these two problems may specifically incentivize men to seek timely care for serious conditions they might otherwise not get, according to Dr. Tafari. And primary care doctors are ideally positioned to get men early multifaceted care. He recently coauthored a call to action on this issue in a review appearing in the Journal of Men’s Health.

In Dr. Tafari’s experience, most patients seeking urological care are unaware of the multiple conditions linked to ED and LUTS. “Many consider these to be due to issues like low testosterone, which actually make up a very small proportion of cases of ED,” he said. Aging, obesity, inactivity, smoking, alcohol abuse, and prescription and street drugs can also contribute to the development of ED.

In most affected men, ED is of vascular etiology, with endothelial dysfunction of the inner lining of blood vessels and smooth muscle the common denominator.

This dysfunction causes inadequate blood supply to both the coronary and the penile arteries, so ED and CVD are considered different manifestations of the same systemic disorder. Because the tumescence-controlling cavernosal vessels of the penis are considerably smaller, the same level of arteriopathy causes a more severe reduction in blood in the erectile tissue. As a result, ED often precedes CVD and presents an early opportunity to screen men for CVD.

As to the mechanisms behind LUTS, Peter N. Tsambarlis, MD, a urologist at Northwestern Medicine in Chicago, subscribes to the inflammation theory. “Suboptimal health issues such as high [blood] pressure, blood lipids, and blood glucose lead to chronic widespread inflammation, which makes the bladder less flexible as a storage vessel,” he explained. “It’s not able to stretch adequately overnight to hold the urine until morning.”
 

Ask Early, Ask Often

Jeffrey P. Weiss, MD, PhD, chair of the Department of Urology at SUNY Downstate Health Sciences University in Brooklyn, New York, has done research that uncovered a relationship between structural cardiac disease and nocturia. “So if you had to ask a patient a single question that would point to a global health issue, it would be ‘Do you have frequent nighttime urination,’ ” he said.

It’s never too soon to ask men about these symptoms, said Dr. Tsambarlis. The best time to raise issues of ED and LUTS is when a man enters primary care — regardless of age or absence of symptoms. “That way you have a baseline and can watch for changes and do early intervention as needed. Men don’t usually want to bring up sexual dysfunction or urinary health, but asking doesn’t need to dominate the visit,” he said.

Dr. Tafari recommends that primary care physicians adopt a targeted approach using ED and nocturia as entry points for engaging men in their healthcare. While acknowledging that primary care physicians have an ever-growing checklist of questions to ask patients and hardly need one more thing to screen for, he suggests asking two quick, and easy “before you go” genitourinary queries:

• Are you having trouble with erections or having sex?
• Are you getting up at night to pass urine more than once?

“The men really appreciate being asked,” he said. “But what worries me is all the men we don’t see who have these symptoms but don’t know they’re important, and no one is asking about them.”

Gideon Richards, MD, a urologist at the Northwell Health Physician Partners Smith Institute for Urology at Garden City, and director of Men’s Health, Central Region, for Northwell Health in New Hyde Park, both in New York, said erectile problems should not wait for specialty care. By the time men with ED are referred to urology, they may already have failed treatment with first-line phosphodiesterase 5 inhibitor therapy, he said. “A significant proportion will have arteriogenic erectile dysfunction, a measurable decrease in the amount of blood flow into the erectile bodies.”

Addressing the Issue

Addressing genitourinary-signaled issues has the double benefit of easing ED and LUTS and improving men’s health and longevity and may help narrow the worldwide gender gap in life expectancy. As a recent global analysis found, there’s a 5-year longevity disparity favoring women over men. Biology aside, men do not access healthcare as often as women, who consult their general practitioners regularly throughout their lifespan for multiple reasons, including reproductive care, and more screening programs are aimed at women.

Added Dr. Tsambarlis, “Men should know that losing weight and switching to a healthy lifestyle can improve sexual function about half as much as phosphodiesterase 5 inhibitors such as sildenafil [Viagra] or tadalafil [Cialis].”

“Many, however, would prefer just to take drugs rather than change their lifestyle and lose weight. There are certainly effective options available, but these are not uniformly effective,” said Dr. Weiss.

Dr. Tafari’s group is designing a short, simple, culturally acceptable screening tool for use in primary care practice and will monitor its impact on physician prescribing habits and overall men’s health outcomes.

Dr. Tafari received funding from the Hospital Research Foundation and Freemasons Centre for Male Health and Wellbeing in Adelaide, South Australia. Dr. Tafari, Dr. Tsambarlis, Dr. Weiss, and Dr. Richards had no relevant conflicts of interest to declare.
 

A version of this article appeared on Medscape.com.