1. The Role of Just Culture in a Culture of Safety Katherine J. Jones, PT, PhD University of Nebraska Medical Center August 14, 2012 1

2. Define Just Culture Explain the role of Just Culture in establishing a Culture of Safety Define Disruptive Behavior Explain the importance of managing disruptive behavior in an overall patient safety program 2 Objectives

3. What is a Culture of Safety? Enduring, shared, LEARNED 1 beliefs and behaviors that reflect an organization’s willingness to learn from errors 2 Four beliefs present in a safe, informed culture 3 – Our processes are designed to prevent failure – We are committed to detect and learn from error – We have a just culture that disciplines based on risk – People who work in teams make fewer errors 2. Wiegmann. A synthesis of safety culture and safety climate research; 2002. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf 3. Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004. 1. Schein, E. Organizational Culture and Leadership. 4 th ed. San Francisco, CA: John Wiley & Sons; 2010. 3

4. Four Components of Safety Culture SENSEMAKINGSENSEMAKING TRUSTTRUST A culture of safety is informed. It never forgets to be afraid… Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited. Battles et al. (2006). Sensemaking of patient safety risks and hazards. HSR, 41(4 Pt 2), 1555-1575. 4

5. Reason’s Components HSOPS Dimension or Outcome Measure Just Culture - management will support and reward reporting; discipline occurs based on risk-taking Nonpunitive Response to Error (U) O = Outcome measure U = Measured at level of unit/department H = Measured at level of hospital 5

6. If Item labeled with “R” then it is positive to DISAGREE Bigger numbers always better Positive is positive for patient safety Reverse-Worded Items * Green Bar = % DISAGREE/STRONGLY DISAGREE for REVERSE-WORDED ITEMS * * *

7. JUST CULTURE… the attitudes and practices within health care organizations that support a system of shared accountability in determining the root causes of medical errors and adverse events. Personal Communication, David Marx, outcomengenuity http://www.outcome-eng.com/

8. Role of Just Culture…Build Trust Questioning attitude Resistance to complacency Commitment to excellence Individual accountability for behavior Management accountability for systems Replaces a culture of silence with a culture of learning Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited.

9. Inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. Behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified. Behavioral choice to consciously disregard a substantial and unjustifiable risk Human Behavior Source: Outcome Engenuity Reckless Behavior At-Risk Behavior Human Error

10. Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through: Remedial action Punitive action At-Risk Behavior A Choice: Risk Believed Insignificant or Justified Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Human Error Product of Our Current System Design and Behavioral Choices Manage through changes in: Choices Processes Procedures Training Design Environment ConsoleCoachPunish The Three Behaviors Source: Outcome Engenuity

11. Current State Non punitive approach – Does not factor in individual accountability and behavioral choices Culture of Shame and Blame in which fear of discipline – Limits reporting – Inhibits learning – Often unfair or unjust – Severity bias (outcomes dependent)

12. Implementing Just Culture = transformational change – Clearly define the change – Ensure support: management, board, medical staff – Champion to overcome barriers – Change is a priority – Resources to train managers – Hardwire change Policies/procedures modified to sustain the change Job descriptions/performance evaluations changed Evaluate effectiveness of change 12 Organizational Strategy Helfrich CD, et.al. (2007). Determinants of implementation effectiveness: Adapting a framework for complex innovations. Medical Care Research and Review;64(3):279-303.

13. Statewide Strategy Adoption of the principles of Just Culture at all levels of healthcare across a state Public Providers/ Facilities Professional Organizations Regulatory Bodies

14. Action Planning: A Just culture is engineered… Practices/Tools Understanding human error (Reason 2003, 2006) – Active errors (sharp end) – Latent errors Just Culture principles and behavior (Marx, 2001) – Conduct: human error, negligence, reckless, intentional rule violation – Shared accountability: managers & individuals/systems & individual behavior – Disciplinary decision-making: outcome-based, rule-based, risk-based Unsafe Acts Algorithm Disruptive Behavior Policy/Standards Human Factors

15. Known medical condition? NO YES NO YES NO YES NO CulpableGray AreaBlameless NO YES NO Adapted from James Reason. (1997). Managing the Risks of Organizational Accidents. UNSAFE ACTS ALGORITHM Were the actions as intended? Evidence of illness or substance use? Knowingly violated safe procedures? Pass substitution test? (Could someone else have done the same thing)? History of unsafe acts? Were the consequences as intended? Were procedures available, workable, intelligible, correct and routinely used? Deficiencies in training, selection, or inexperienced? Substance abuse without mitigation Sabotage, malevolent damage Substance use with mitigation Possible reckless violation System induced violation Possible negligent behavior System induced error Blameless error, corrective training, counseling indicated Blameless error NO

16. Just Culture Action Plan 1.A consistent approach to operationalizing a just and fair culture across the hospital regardless of profession or hierarchy. a.Goal: Improve aggregate perceptions of Nonpunitive Response to Error by 5% or more at the next HSOPS reassessment b.We will do this by implementing the following interventions: i.Providing training about human factors and active vs. latent causes of errors ii.Training managers to use Algorithms to balance individual and systems accountability iii.Training managers to collaborate with human resources and discipline individuals based on at-risk and reckless behavior and not on outcomes iv.Implement a policy/procedure to manage disruptive behavior. c.Identify where this change will occur…hospital-wide or a specific work area? d.Identify when this change will occur

17. Definition of Disruptive Behavior Disruptive behavior is any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or sexual harassment. Disruptive behavior causes strong psychological and emotional feelings, which can adversely affect patient care. Rosenstein A, O’Daniel M. (2008). Managing disruptive physician behavior: Impact on staff relationships. Neurology, 70, 1564-1570.

18. Example of Disruptive Behavior from AHRQ HSOPS “A lot depends on who you work with. Communication is poor. You walk on egg shells whenever you go to work. I think everyone should have to work all shifts and maybe they wouldn't cut down the ones that work all shifts.”

19. Change the Frame of Reference Disruptive Behavior: Old frame of reference – Tolerate the behavior as a way of doing business – Shrug off problem; minor occurrence, no ill effects to patients or staff Disruptive Behavior: New frame of reference – Disruptive behaviors have profound effect on safety and quality – Not unique to physicians or healthcare – Consequences permeate the organization Affect staff morale, patient and family Community perceptions and hospital reputation. – Hospitals can no longer take a passive approach to disruptive behaviors Rosenstein A, O’Daniel M. (2008). Managing disruptive physician behavior: Impact on staff relationships. Neurology, 70, 1564-1570.

20. Strategy to Address Disruptive Behavior Raise awareness – conduct survey Develop policies/procedures – Code of behavior – Confidential reporting system – Enforcement—interdisciplinary staff relations committee – Follow-up and feedback to reporters and all staff Education – Link behavior to adverse events – Communication and teamwork using TeamSTEPPS tools Rosenstein A, O’Daniel M. (2008). Managing disruptive physician behavior: Impact on staff relationships. Neurology, 70, 1564-1570.

21. Leaders Engineer Culture “…it is the unique function of leadership to perceive the functional and dysfunctional elements and to manage cultural evolution and change.” 21 Schein, E.H. Organizational Leadership and Culture 4 th ed. San Francisco: John Wiley & Sons; 2010.

22. Contact Information Katherine Jones, PT, PhD kjonesj@unmc.edu Anne Skinner askinner@unmc.edu Web site where tools are posted www.unmc.edu/rural/patient-safety 22