Just Culture Application Consoling Employees Stephanie Sobczak & Jill Hanson Quality Improvement Managers WHA

Today’s Call Guest Speaker Chris Baker, St. Mary’s Hospital Application – Consoling Case examples using the Just Culture algorithm  Next 30 days 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.

Saint Mary’s Hospital Madison Guest Presenter Chris Baker, RN, PhD, MBA Administrative Director Quality and Safety Systems Saint Mary’s Hospital Madison

Q & A with Chris Baker Could you briefly review St. Mary’s Just Culture journey for us? Perhaps the biggest shift in Just Culture is treating near misses with similar importance and attention that we give to harmful outcomes. How have you done this at St. Marys?

Q & A with Chris Baker How do you encourage front-line staff to report near misses? Can you describe your process for handling near misses?

Reviewing Past 30 Days ACTION ITEMS Modify your existing event investigation processes (if needed) Use the Just Culture Algorithm to walk through a recent employee discipline scenario Be prepared to discuss how the algorithm walk thru went during June’s webinar Sharing Your Scenario Examples (choose one): Send in a safety scenario example Schedule a Just Culture scenario interview with WHA

Group Discussion on Action Item Hands On Practice - JC Algorithm Use the algorithm to walk through a recent employee discipline scenario Share what insights you discovered as a result

Managing Human Error and Consoling Employees

The curve is a conceptual model for managing human error The curve is a conceptual model for managing human error. First, the curve shows a relationship between system design and the rate of human error. As the factors affecting human performance improve, our reliability (probability of a successful outcome) improves. As the factors affecting human performance degrade, our reliability decreases. Important to note – no task will ever have 100% reliability. Factors affecting human performance – all shape the natural rate of error for the task performed.

Human Error Inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake Just Culture Model Console the person who has made the error Address the system design Address the system design to make the human error less likely to occur.

Consoling Conversation Is one that acknowledges... The event The employee’s emotions It also… Provides an appropriate, comforting response Helps to understand why the human error occurred Identifies how it can be managed in the future.

Scenario One Group Discussion

A lab tech is running a complete blood count for an emergency department patient. When entering the values into the computer she transposes the red blood cell count value and the white blood cell count value. The emergency department physician reads the incorrect white blood cell count and orders a large dose of broad spectrum antibiotics.

Scenario One 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?

Scenario Two Group Discussion

An accountant working for a hospital is asked to give the lab manager a sense of how much budget they have 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, base 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.

Scenario Two 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?

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 Next 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.

Case Studies – High Risk Clinical Processes Thank You! Questions? July 3rd Just Culture Webinar 10-11 am Case Studies – High Risk Clinical Processes