John Howe, RN, BSN Clinical Education and Professional Development DUHS

 The presenter has no relationships with industry to disclose.  There will be no discussion of off-label products or the use of devices.  There is no commercial support for this program.

 Describe the components and structure of a Just Culture that supports performance, accountability and safety  Define roles of leaders, managers and staff in this culture

The Just Culture Community and Outcome Engineering now OutcomEngenuity®

 MISSION Insert YOUR Mission here.  VISION Insert YOUR Vision here  VALUES Insert YOUR Values here

 Leadership who are involved, direct, and demonstrate understanding of M/V/V daily  Staff who understand their role, provide quality care and service, advocate for their patients and themselves  Systems and processes that allow, facilitate, and foster the first two to occur in context of M/V/V

Long, long ago in a galaxy far, far away… “A choice you must make, yes”… Yoda

System + Processes Design Learning Culture/P.A.S melded culture Human Errors Adverse Events Managerial & Staff Behaviors With a background of a Supportive Learning Culture, we focus on proactive system design and management of behavioral choices Relating Performance, Accountability and Safety

 The term “Just Culture” refers to a safety- supportive system of shared accountability where healthcare institutions are accountable for the systems they have designed and for supporting the safe choices of patients, visitors, and staff. Staff, in turn, are accountable for the quality of their choices – knowing that we cannot will our selves to be perfect, but we can strive to make the best possible choices. Just Culture-“Culture of Safety” Brochure, 2008

 Just Culture encourages discussion and reporting of errors and near misses – without fear of retribution or “getting into trouble”.  It focuses on the choices of the employee and what contributed to the choice, not merely the fact that an error occurred, nor solely on the consequences of that error. Just Culture for Healthcare Managers, 2007

 In a Just Culture, the institution addresses near misses, errors, and behavioral choices that may need to be investigated and addressed in a clear and equitable manner.  It also looks at the system in which the choices were made, the effect of that system on the choice, and how to maximize system use and effectiveness.

 The steps involved in this process are defined and applied equally to all staff- clinical and non-clinical - by managers and leaders who are educated in the process and use it regularly as needed.  The same process is applied to all levels of staff – frontline employees, managers, directors, etc.  It is more than an HR tool or process

 Just Culture is both a philosophy and a process: ◦ The philosophy combines putting patients and safety first; being open to monitoring and addressing real and potential issues and problems. ◦ The process helps to assure that our staff engage in being accountable for their actions and choices, and choices are evaluated when appropriate, and dealt with fairly and similarly across departments, services, and entities

System + Processes Design Learning Culture/P.A.S melded culture Human Errors Adverse Events Managerial & Staff Behaviors With a background of a Supportive Learning Culture, we focus on proactive system design and management of behavioral choices Relating Performance, Accountability and Safety

 Identify the need  Define the Issue and Goal  Engage leadership and leader advocates: Ask “What would this look like here?”  Evaluate current systems and practices using GAP analysis or other method  Describe/develop intervention and processes to do this – i.e. Implementation Strategies  Educate leaders  Identify and Educate teachers/advocates  Train managers and staff  Evaluation, measurement, sustainability and communication plans

 DUHS wide  Relationship to Mission, Vision, Values  Top down and bottom up commitment  Target the “Lynch Pins”

 Investigate, Reference, Benchmark  Implementation Team  Define expectations, Develop tools, Educate the leaders and staff  Outcomes  Communicate with all

 Advocates/Experts/Oversight Group specialty trained  Education Sub-Committee ◦ Different info for different levels/groups ◦ Leadership Orientation ◦ Manager Worksessions ◦ Frontline Orientation – not just clinicians and HR ◦ Department and Group Education ◦ Physician education challenge ◦ On-going efforts: on-line, class, resource, more…  Website

 Direct and Indirect Measures ◦ Use of tools in behavioral choice evaluations ◦ Staff Satisfaction Survey ◦ Work Culture Survey ◦ Turnover rates ◦ SRS data ◦ Addition to RCA documentation ◦ Plans for “inter-rater reliability”, HR outcomes ◦ Leadership Assessment Survey – 2013 example

 Communication Plans  In-house publications, newsletter, articles; multi-level and media  Connect to other related initiatives  Communication Team Strategy

 Let’s see what it really looks like… Leadership/Manager Just Culture Orientation Work Session

 How and Why Different  Unexpected results and comments

 “No harm, No foul” mentality  The news trucks show up……  Joint Commission, regulators are coming…..  A particular group that doesn’t understand, buy-in, or feels they are exceptions  “Red Rules” and Absolutes  Others…….

 Staff Handbook expectations  Medical Staff by-laws and Peer Review processes  Just Culture Physician Algorithm  “Coffee and Conversation” – a different “algorithm” ◦ – Dr. Gerald Hickson, Vanderbilt model  Duke experience

 Bylaws and P/P = Structure  Just Culture algorithm is a tool to support investigation and evaluation of situations that may result in disciplinary action or coaching or counseling = Process

 Dr. Jones has been employed with the network for 6 years. He first patient is scheduled for 8am every day. Dr. Jones arrives for work between 8:05 – 8:20 on 4 out of 5 days. This issue has been addressed numerous times by the medical director as it impacts the flow and start time in the clinic. As a result, there is no opportunity to huddle in the morning, review labs, or see the first patient in a timely fashion. Dr. Jones has had a variety of explanations (car trouble, child care, patients are not roomed promptly so there is no need to come before 8.) An adjusted template has been offered and declined.

 Behavioral related issues ◦ Work habits – timeliness; completion of medical records ◦ Interactions with staff and colleagues  Clinical concerns ◦ Basis for Peer Review – missed diagnosis, failure to appropriately F/U, missed clinical finding ◦ Systems related issues ◦ Knowledge deficit

 Can use the algorithm during an RCA to help tease out behavioral choices vs process issues ◦ This helps prevent revising or layering of process that are not the issue.  Flow chart the process  Verify key steps  Ask the questions – using appropriate algorithm ◦ Promotes partnership with the manager to achieve a successful outcome.

 Leadership support  Ground level understanding of importance and benefit – more than just a tool addressing “bad behaviors”  Middle management that understands, supports and uses the process  Sustainment strategies  Resources and Commitment

 OutcomEngenuity: website and Just Culture resources  TeamSTEPPS

 Identify and then prioritize;  How can make them fit within current systems and processes – some new and some already there