Just Culture- Promoting Safety and Competence

Introduction The Past The Present The culture of health care in the past focuses on placing blame on healthcare providers whenever there was an error or bad outcomes occurred. With this kind of culture, health care providers were hesitant to report any errors due to fear of punishment. As a result, such occurrences were never reported. To improve reporting of errors, organizations moved to blameless culture, however, this type of culture did not succeed due to lack of accountability and the practice did not promote a learning environment that promoted patient safety. Today, the focus of health care is patient safety and “Just Culture.” This balances the assessment of systems, processes and human behavior when an error or event is reported.

What is “Just Culture” The term “Just Culture” refers to a safety-supportive system of shared accountability where health care organizations are accountable for the systems they have designed and for responding to the behaviors of their staff in fair and just manners. Staff, in turn, are accountable for the quality of their choices and for reporting both their errors and system vulnerabilities.

Goal of Just Culture The goal of a “Just Culture” environment is to design safe systems that will reduce the opportunity for human error and capture errors before they reach the patient. Safe systems should facilitate the staff to make good decisions and should make it more difficult to make an error. However, it is up to individuals to manage their behaviors and choices.

Just Culture Environment “Just Culture” is an environment where negligence is identified and discipline is applied appropriately after a systematic review of the error. To ensure a fair and just process, an established set of objective questions follow an algorithm to identify if the error occurred due to a system or process issue and/or due to human error. Staff is held accountable for their actions or behaviors. Staff is not at fault when there is a system or process that allowed the error to happen.

Just Culture Environment “Just Culture” environment recognizes that competent professionals make mistakes and acknowledges that even competent professionals will develop unhealthy norms (shortcuts, “routine rule violations”), but has zero tolerance for reckless behavior. “Just Culture” supports a learning culture and focuses on proactive management of system design and management of behavioral choices.

Just Culture An objective model for dealing with human errors and breaches Decision paths for allocating responsibility to either the system or the individual Based upon duty Not based upon severity of outcome

Just Culture Foundational Assumption About Risk: Humans will make errors and drift into at-risk behaviors as they become comfortable with processes Risk is managed by monitoring and measuring errors Judged using our values against what another reasonable person in a similar situation would do

Just Culture http://www.youtube.com/watch?v=2UzdKkLTphE You can embed the movie, David Marx Introduces the Just Culture, on this slide. A brief 2 minute overview of Just Culture from it’s founders.

The Just Culture Model Mission and Values Duty Breach Consequence Our reason for being… As individuals… Why do we come together as a group? Values: we must respect our values. We have 5 corporate values and many supporting values such as privacy and safety. Duty What we expect of each other and what we sign on for at hire when we agree to abide by policies, service standards, etc. We expect a lot and at times it seems like we expect perfection. However, we are inescapably fallible human beings and we live in a world of an imperfect systems. Relative to the mission Relative to values Procedures, processes Breach Failure to fulfill a duty By mistake By choice Without even knowing Consequence Our response to breach. Specific Deterrence, General deterrence, Incapacitation, Rehabilitation, Retribution. We must create realistic expectations for our organization to be successful. Consequence Days 1-3

The Just Culture Model: Mission/Values To contribute to the health of our community through the provision of quality services delivered in a compassionate and cost effective manner. We collaborate with others in the community to improve the quality of life. Dignity Collaboration Justice Stewardship Excellence Just Culture is premised upon our values. Define each value if necessary. Days 1-3

Just Culture Model: Duties Three Basic Duties Duty to produce an outcome. If an individual knows the desired outcome they should be able to produce it (e.g., safe removal of an inflamed appendix), failure to do so represents breach of this duty. Did the employee breach a duty to produce an outcome? Duty to follow a procedural rule. If the individual knows the proper procedure and it is possible to follow the rule (e.g., the procedure for inserting a central venous catheter), failure to do so represents a breach of this duty. Did the employee breach a duty to follow a procedural rule in a system designed by the employer? Duty to avoid causing unjustifiable risk or harm. Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly. Did the employee put an organizational interest or value in harm’s way?

Just Culture Expectations of Staff Look for risks in the work environment Report errors and hazards Help design safe systems Make safe choices that align with organizational mission and values Employees need to recognize that Just Culture is not a “blame-free” model, rather a model of accountability that is fair and recognizes both systems and choices. 13

Just Culture Model: Breeches Organizations must recognize that humans make mistakes. It is the behavior choices that must be managed. The behaviors that are expected when assessing an event are: Human error -inadvertent action; inadvertently doing other than what should have been done; slip, lapse, mistake. At-risk behavior –behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified. Reckless behavior -behavioral choice to consciously disregard a substantial and unjustifiable risk.

The Just Culture Model: Consequences Conscious Disregard of Substantial and Unjustifiable Risk Managed Through: Remedial action Punitive action At-Risk Behavior A Choice: Risk Believed Insignificant or Justified Remove incentives for at-risk behaviors Create incentives for good behavior Increase situational awareness Product of Current System Design and Behavioral Choices Choices Processes Procedures Training Design Environment Human Error At-Risk Behavior Reckless Behavior Punishment is reserved for reckless behavior because it is a conscious disregard of the correct choice/behavior and also reserved for repetitive errors or repetitive at-risk behaviors that cannot be controlled or managed in other ways. It is the terminal course of action after other actions with the system and the employee have been applied. Console Coach Punish 15

Example of Behaviors Here is an example of these behaviors: Human Error You are driving in your car and you are preoccupied by other things. You are driving home and suddenly realize you never stopped at the stop sign near your home. At-Risk You are running short on time and decide to drive faster to get to work. You are driving 75 miles/hour in a 65 mile/hour speed zone. Reckless You decide to go faster and switch lanes franticly to move through traffic faster.

Scenario’s: Identify the type of breach or duty the following slides indicate: Identify what type of breach or Duty each of these scenarios indicate: Human Error, At Risk, Reckless, Duty to Produce an Outcome, Duty to Follow a Procedural Rule, Duty to Avoid Unjustifiable Risk or Harm. Scenario I: An accountant working for a hospital is asked to give the lab manager a sense of how much budget they had left over at the end of the fiscal year. This extra budget would be transferred to the mobile medical office – an under- funded service to support homeless people in the city. When year-end spending was announced, the lab had overspent roughly $25,000, based in part on the accountant who incorrectly failed to account for some supply purchases made by the lab. The lab manager was told in his performance review that he needed to maintain better control of his budget. Is this: Human Error, At-Risk(Drifting)Behavior, or Reckless?

ANSWER Human Error

Scenario II A doctor removing a cyst from the arm of a teenage boy decides to take a culture while the incision in the boy’s arm is still open. To find a swab, the doctor opens a few drawers and cabinets. The doctor does this without removing his gloves or engaging in any hand hygiene between contacts with the incision. Is this Duty to produce an outcome, Duty to follow a procedural rule, or Duty to avoid causing unjustifiable risk or harm?

Duty to follow a procedural rule ANSWER Duty to follow a procedural rule

Scenario III A surgeon drops an instrument on the floor in the operating room. Upset by the delay, the surgeon reaches down to the floor, picks up the dropped instrument, and then continues with the surgery using that same instrument. The scrub nurse looks at the surgeon, horrified by the significant breach in the sterile procedure. What kind of breach is this? Human Error, At-Risk ( Drifting) Behavior, or Reckless Behavior?

ANSWER Reckless Behavior

Scenario IV The intravenous pump of a patient starts to beep signaling an occlusion in the intravenous line. A nursing assistant notices the alarm and alerts the nurse on duty. Thirty minutes later the nurse has still not come in to investigate the situation. The pump continues to beep and the patient begins to hit the call light each time the alarm rings. Repeated attempts to get the nurse in the room are unsuccessful. Frustrated, the nurse assistant shuts the pump off to keep it from beeping and to keep the patient happy (by turning off the noisy pump) until the nurse can come in and fix the problem. Forty-five minutes later the nurse comes in the room, checks the IV and notices that the catheter is unable to flush. Investigation reveals that the nurse was watching a much anticipated television episode in the break room. Which kind of breach is this? Duty to produce an outcome, Duty to follow a procedural rule, or Duty to avoid causing unjustifiable risk or harm?

Duty to avoid causing unjustifiable risk or harm ANSWER Duty to avoid causing unjustifiable risk or harm

Scenario V A medication nurse at a nursing facility was caught borrowing medication from one resident to give to another. This occurred during the midnight shift where the nursing facility did not have midnight pharmacy support. The medication nurse’s patient had run out of a pre-ordered heart medication. To get the medication to the patient, the medication nurse pulled the medication from another resident’s pre-packaged medications. The medication nurse intended to replace the borrowed medication once pharmacy restocked the resident medications. The investigation revealed that this medication nurse was taught the “borrowing” practice by a more experienced medication nurse. What type of breach is this? Human Error, At-Risk ( Drifting) Behavior, or Reckless Behavior?

At-Risk (Drifting) Behavior ANSWER At-Risk (Drifting) Behavior

Scenario VI The nurses on the night shift customarily do crossword puzzles while on duty. They reason that this helps keep them focused and awake, and can easily be set aside when needed. This has been occurring for the last several years. Recently a new manager was hired. When coming through the unit at night she stated she did not want nurses doing crosswords anymore, under any circumstances. The next week the manager found a nurse working on a crossword puzzle with a young patient who was unable to sleep. Which breach is demonstrated in this scenario? Duty to produce an outcome, Duty to follow a procedural rule, or Duty to avoid causing unjustifiable risk or harm?

Duty to Produce an Outcome ANSWER Duty to Produce an Outcome

Just Culture is a Balance Life Harm Liberty Rule Just Culture is about balancing our pursuit of these goals with the restraining influence of our duties to each other and our employer and when our choices breech this balance, then Just Culture is about applying the correct (just) response for the action. Just Culture helps us shift our focus from errors, outcomes and punitive response to good system design and wise behavioral choices. Happiness Outcome Motivation Duty

Remember: Staff are accountable for the quality of their choices and for reporting both their errors and system vulnerabilities. It’s All about safety, shared accountability and competence. Working together for our patient’s and one another makes CHSB a great place to be!