Just Culture Case Studies – High Risk Scenarios Stephanie Sobczak Mgr, Quality Improvement WHA

Today’s Call Case Studies about a High Risk Scenarios High Risk Clinical Processes

Past 30 Days ACTION ITEMS Assess current risk/event reporting system as it relates to Just Culture. Does it allow for reporting of good catches/near misses? Determine if event reporting/near miss process is sufficient Develop/modify process to routinely assess risk as it relates to a fair and just culture, if not done currently.

Discussion Would anyone share their experience with looking at their current risk/event reporting system? Does it account for easy reporting of good catches/near misses? If not…what is your plan? Mortality and morbidity Courtesy Reminders: Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) Please do not take calls and place the phone on HOLD during the presentation.

High Risk Processes in a Just Culture

The Three Duties The Duty to Avoid Causing Unjustifiable Risk or Harm Risk Based Quality of Choices Organization’s Mgt of Risk Society sets the expectation for the result Organization assesses how we were managing the risk Employee is assessed for their behavior and quality of their choices (HE, ARB, RB) Objective standard (reasonable person standard) is applied Investigate, Analyze, Review, Interview, Assess Substantial and Unjustifiable Risk? If there is no rate of failure you are prepared to accept – one breach is too many Process Based System Based Compliance Check Task Based Outcome Based Rate Based The Duty to Produce an Outcome The Duty to Follow a Procedural Rule OR Imposer sets the expectation for the result Employee owns the system for the result i.e “How you do that is up to you…we just judge if you did it or not” Don’t assess HE, ARB or RB Rate based expectation Imposer sets the expectation for the result Employer owns the system for the result, i.e “Do it our way, as defined, every time for reliable results” Can assess HE, ARB or RB Be a reliable component in our system

To Review Not uncommonly, we turn a blind eye (often by assumption that staff are following the rules) to noncompliance as long as patients are taken care of and no one is hurt. When an adverse event occurs (such as a mislabeled specimen), we then use disciplinary sanction against the nurse or lab technician because we assume they must not have complied with the rule. It is this outcome-based disciplinary process (“no harm, no foul”) that is antithetical to patient safety.

Duty to Avoid Unjustifiable Risk or Harm High Risk Tasks Always there is the Duty to Avoid Unjustifiable Risk or Harm (When might a high risk task be a Duty to Produce and Outcome vs. a Duty to Follow a Procedural Rule?)

I’ve hired a company to provide the Internet feed in my apartment I’ve hired a company to provide the Internet feed in my apartment. Well, I don’t know much about the Internet. This is an instance where I cannot ‘’the duty – I rely on the experts to provide the Internet feed into my apartment. Now, I’d like to think that if I took the time and the energy, I could learn about the Internet and I could get to the point where I can ‘proceduralize’ the process. However, now it comes into play that this is where I won’t look into the behavior – I elect to not use my time and my resources to do that. I am going to leave it as Duty to Produce an Outcome because I won’t look into that behavior. So again, the phrase I like to use to help me decide whether to articulate a duty as a Duty to Produce an Outcome or a Duty to Follow a Procedural Rule, is that a Duty to Produce an Outcome is when I can’t or won’t look into the behavior. In healthcare, there are certain processes that we cannot leave as a duty to produce an Outcome. We might identify processes that become a Duty to Follow a procedural Rule. Look at the changes in handwashing over the past 15 years.

VS. High Risk Tasks Duty to Produce an Outcome: Employee owns the system for the result i.e, “How you do that is up to you…we just judge if you did it or not” Duty to Follow a Procedural Rule: Employer owns the system for the result, i.e, “Do it our way, as defined, every time for reliable results”

Case Study Palmetto Health Richland – South Carolina worked closely with David Marx and Outcome Engenuity. Palmetto had a Red Rule in place to prevent staff from not following the blood administration procedures. However, on occasion, patients were still getting the wrong blood, despite the training and disciplinary process in place.

The Red Rule Red Rules trigger an automatic disciplinary action if they are violated – even once. The idea is to ensure staff follow a procedure related to a high-risk practice.

Doesn’t account for system failure The Root Cause Analysis showed there were variations in process by all staff…but also mistakes in blood labeling in the lab. In practice, Red Rules did not hold staff accountable for following the procedure, but instead waited for a mislabeled specimen, and then in response to a mislabeled specimen, inferred noncompliance with the Red Rule and took disciplinary action.

The Final Check Where a high-risk clinical process meets Just Culture Create tool for assessment

What is “The Final Check”? A post-labeling verbal confirmation of the last three digits of the medical record number Staff should ‘out loud ‘ confirm the digits as read from each specimen label and the patients arm band.  The single reason for a 98% reduction in administering a mislabeled specimen

In effect, the original Red Rule held staff accountable for an incorrectly labeled specimen, not for failure to comply with the specimen labeling procedure. In a Just Culture, there are places where staff are accountable for a Duty to Produce an Outcome – such as time and attendance. Specimen labeling is one area where outcome-based duties will not be effective for the line nurse or lab technician.

Implementing The Final Check Early in the process – console the error of giving mislabeled blood. Once the Final Check is taught, a decision by a staff person to skip the final check can be coached. Effectively implemented – staff should see the decision to skip the Final Check as a reckless choice because they are aware and see the risks of non-compliance, and as responsible professionals will choose to comply.

The Final Check The Final Check Toolkit is available free on the web Toolkit Booklet http://www.thefinalcheck.org/final-check/ Q & A Videos with Nursing Staff If you haven’t examined your blood administration procedures in awhile OR you have a Red Rule in place. Consider taking a look at this in a Just Culture framework. http://www.thefinalcheck.org/faq-videos-2/

Scenario Three Group Discussion

The nurse goes to the medication room to retrieve Demerol for her patient. She reaches into the bin and grabs the vial in the bottom right corner of the drawer. Next, she draws up the medication and administers it to the patient. The pharmacy had made a change and placed Morphine in the slot where the Demerol used to be kept. The nurse actually gave the patient Morphine. The patient had an allergic reaction and coded. Although they were able to revive him, he suffered anoxic injuries that resulted in right-sided paralysis.

Scenario Three Questions What would you need to know from the event investigation? Were any duties breached in this scenario? If yes, which? Now walk this scenario through the Just Culture Algorithm: What is you assessment using the algorithm? What action would you take based on your assessment?

The August 7th Just Culture Webinar The Next 30 Days ACTION ITEMS Assess one of your hospital’s high-risk processes, such as blood administration, or review tasks that have a “red rule” approach, for alignment with Just Culture Principles. The August 7th Just Culture Webinar Guest Speaker: Dr. Steven Kulick from ProHealth, a Just Culture Champion will share a physicians perspective on Just Culture. Dr. Kulick and his colleagues Dr. Timothy Westlake and Dr. James Gardner recently presented Just Culture to the State Medical Examining Board.

A note about Coaching Calls and Webinars On the WHA Quality Center Calendar of Events some Just Culture monthly webinars may be labeled “Coaching Calls”. These will still occur on the first Wednesday of the month at 10:00 am. We may take a “Coaching Call” approach occasionally , (which means a phone conference only / no webinar) when we do not have a guest speaker. We will keep you informed if there is not a webinar.

Questions? Please answer the brief 3 question survey at the conclusion of the webinar. Thank You!