Just Culture Implementation – Phase 2 Using the Just Culture Algorithm Stephanie Sobczak and Jill Hanson WHA Quality Improvement Managers

Today’s Call Implementation –Phase 3 Event Investigation Using the Just Culture Algorithm Case Scenarios

Past 30 Days ACTION ITEMS Review current incident reporting process and how the data is used Continue working on your implementation plan Request Just Culture Algorithms from WHA, if you haven’t done so already

The Purpose of the Algorithm

by Alison H. Page, MS, MHA October 2007 “We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition.” http://webmm.ahrq.gov/perspective.aspx?perspectiveID=50 This narrative by Alison Page (who is the current CEO at Baldwin) says it the best.

by Alison H. Page, MS, MHA October 2007 “Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership.” http://webmm.ahrq.gov/perspective.aspx?perspectiveID=50

by Alison H. Page, MS, MHA October 2007 “The Just Culture concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.” http://webmm.ahrq.gov/perspective.aspx?perspectiveID=50

Purpose of the Algorithm To consistently determine the actions taken as a result an investigation. To provide a mechanism to better understand “near misses” and degree of risk (dissociated from outcome). To clearly distinguish between Human Error, At-risk Behavior, and Reckless Behavior.

Event Investigation Gathering essential information about an event or situation prior to using the algorithm is key. Managers must be trained to conduct a good investigation of an event. For learning the Just Culture™ Algorithm, scenarios will provide the basic elements from an event investigation. Create tool for assessment

(much more on this next month – Training Managers) Common Traps Guessing or assuming “I’ve seen this before.” Not doing an investigation Not talking to the people involved Not listening “actively” during discussions Arriving at a conclusion early (much more on this next month – Training Managers)

We need to understand the details about these two elements Identifying Events Mortality and morbidity We need to understand the details about these two elements

Algorithm Steps 1. Obtain basic event investigation information. 2. Apply Duty to Avoid Causing Unjustifiable Risk or Harm and apply corresponding actions. 3. Apply either: a. Duty to Follow a Procedural Rule and apply corresponding actions. b. Duty to Produce an Outcome and apply corresponding actions. 4. Is the event repetitive? Use Repetitive Human Errors or Repetitive At-Risk Behaviors.

Algorithm Steps 1. Obtain basic event investigation information. 2. Apply Duty to Avoid Causing Unjustifiable Risk or Harm and apply corresponding actions. 3. Apply either: a. Duty to Follow a Procedural Rule and apply corresponding actions. b. Duty to Produce an Outcome and apply corresponding actions. 4. Is the event repetitive? Use Repetitive Human Errors or Repetitive At-Risk Behaviors. Staff Safety Assessment – Ask if individuals would like to share their findings – any great observations by your co-workers 1. Please describe how you think the next patient in your unit/clinical area will be harmed. 2. Please describe what you think can be done to prevent or minimize this harm POTENTIAL FOR WEBEX SURVEY

The Three Duties Putting the organizational interest or value in harms way: Potential or actual harm to persons Potential or actual harm to property

Algorithm Steps 1. Obtain basic event investigation information. 2. Apply Duty to Avoid Causing Unjustifiable Risk or Harm and apply corresponding actions. 3. Apply either: a. Duty to Follow a Procedural Rule and apply corresponding actions. b. Duty to Produce an Outcome and apply corresponding actions. 4. Is the event repetitive? Use Repetitive Human Errors or Repetitive At-Risk Behaviors. Staff Safety Assessment – Ask if individuals would like to share their findings – any great observations by your co-workers 1. Please describe how you think the next patient in your unit/clinical area will be harmed. 2. Please describe what you think can be done to prevent or minimize this harm POTENTIAL FOR WEBEX SURVEY

Determine duty A rule, process, or procedure is in place specifying how to perform the job. (The system is largely controlled by the employer) The employee knows what the goal is (or the outcome expected) but is not told how to reach the goal or achieve the outcome. (The system is largely controlled by the employee.)

Algorithm Steps 1. Obtain basic event investigation information. 2. Apply Duty to Avoid Causing Unjustifiable Risk or Harm and apply corresponding actions. 3. Apply either: a. Duty to Follow a Procedural Rule and apply corresponding actions. b. Duty to Produce an Outcome and apply corresponding actions. 4. Is the event repetitive? Use Repetitive Human Errors or Repetitive At-Risk Behaviors. Staff Safety Assessment – Ask if individuals would like to share their findings – any great observations by your co-workers 1. Please describe how you think the next patient in your unit/clinical area will be harmed. 2. Please describe what you think can be done to prevent or minimize this harm POTENTIAL FOR WEBEX SURVEY

Case Applications using the Just Culture Algorithm

Hand Hygiene

Repetitive At-risk Behaviors

Using the algorithm You core team should be comfortable using the algorithm: To learn, consider using your hospital’s previously encountered cases to learn the algorithm. Try it with your colleagues stories/scenarios Trial it with new situations.

We can learn from each other Do you have a case the group can learn from? How? Write up a paragraph similar to those we used today Email it to Jill Hanson We prefer that you do not identify your facility in the case description, and we will not disclose your facility. If you wish to speak to the case yourself on a call, please let us know.

Upcoming Months February – Training Managers and Staff March - Event Investigation April – Coaching at risk behaviors * Please contribute your cases

The Next 30 Days ACTION ITEMS Request Just Culture Algorithms from WHA, if you haven’t done so already In your core team, practice using the Just Culture Algorithm with your hospital cases Related to your implementation plan, discuss how you will introduce the algorithm to your management staff. Who will use the algorithm? In what circumstances?

Questions? Stephanie Sobczak Jill Hanson Thank You! Questions? Stephanie Sobczak Jill Hanson