1. Just Culture Carol Diemert, RN, MSN Minnesota Nurses Association March 2008

2. Goals Identify a common philosophy and set of principles that would be a parallel process with both front-line and management staff; shared accountability Identify a common philosophy and set of principles that would be a parallel process with both front-line and management staff; shared accountability Describe the Just Culture Model Describe the Just Culture Model Apply the concepts and principles of Just Culture to case scenarios Apply the concepts and principles of Just Culture to case scenarios

3. “To make a substantial step in patient safety, we must change the health care system. One critical element of that fundamental change is the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the health care system” “To make a substantial step in patient safety, we must change the health care system. One critical element of that fundamental change is the creation of a more open, fair, and just culture. It is through a just culture that we will begin to see, understand, and mitigate the risks within the health care system” An Introduction to a Just Culture Copyright 2005 Outcome Engineering - www.justculture.org w.justculture.org

4. What is just? What is culture?

5. Just is acting or being in conformity to what is morally upright or good, fair, impartial.

6. Culture – policies, procedures, conditions of employment, structures for decision-making and types of behaviors that are supported constitutes a culture.

7. Climate - is judged by employee perceptions of how the policies and procedures are actually carried out, and how effective they are - influences how one feels being a member of a particular organization.

8. One crucial aspect of an organization is its ethical climate – defined as how employees perceive the behaviors and practices associated with how ethical issues are handled.

9. Five conditions that promote awareness and discussion of an ethical issue 1.Power - the right to having the information needed to understand a situation, as well as to say what needs to be said 2.Trust - the confidence to disagree with others, without fear of reprisal 3.Inclusion - those with an interest in the decision are included in the process

10. 4.Role flexibility - the ability to take different points of view, and to change it based on additional information 5.Inquiry - an atmosphere of questioning and learning ANA, Guide to the Code of Ethics for Nurses, 2008

11. Just Culture - is a patient safety initiative designed to address both system issues and individual behavior. Shift from focus on errors and outcomes ----------- to system design and behavioral choices Shift from focus on errors and outcomes ----------- to system design and behavioral choices Achieve a culture where frontline staff feel comfortable disclosing errors Achieve a culture where frontline staff feel comfortable disclosing errors

12. System Issues Takes the view that most errors reflect predictable human failings in the context of poorly designed systems eg lapses in cognition in the face of too long work hours, relatively inexperienced staff faced with cognitively complex situations. Takes the view that most errors reflect predictable human failings in the context of poorly designed systems eg lapses in cognition in the face of too long work hours, relatively inexperienced staff faced with cognitively complex situations.

13. Holds the view that efforts to catch human errors before they occur or block them from causing harm will ultimately be more fruitful that ones that seek to somehow create flawless providers. Holds the view that efforts to catch human errors before they occur or block them from causing harm will ultimately be more fruitful that ones that seek to somehow create flawless providers. Example “work-arounds” – motivation lies in getting the work done (not laziness or whim) so appropriate response would be to trigger an assessment of workflow rather than repeatedly reminding staff of the policy or equipment. Example “work-arounds” – motivation lies in getting the work done (not laziness or whim) so appropriate response would be to trigger an assessment of workflow rather than repeatedly reminding staff of the policy or equipment.

14. The Swiss Cheese Model of System Accidents

15. Swiss Cheese Model of System Accidents When is the organization culpable? Blunt end refers to the many layers of the health care system not in direct contact with patients, but which influence the personnel and equipment at the sharp end who do have direct contact with patients. Blunt end refers to the many layers of the health care system not in direct contact with patients, but which influence the personnel and equipment at the sharp end who do have direct contact with patients. Lesson in this is that there are also those errors that are totally unforgiving since a single defect can cause catastrophe eg wrong-site surgery, accidental administration of potassium chloride. Lesson in this is that there are also those errors that are totally unforgiving since a single defect can cause catastrophe eg wrong-site surgery, accidental administration of potassium chloride.

16. Punitive Culture Health care organizations attempted to manage risk and errors by disciplining workers involved in errors, particularly those closest to the event. Health care organizations attempted to manage risk and errors by disciplining workers involved in errors, particularly those closest to the event. Assumption that individual workers were fully, and sometimes soley, accountable for the outcomes of patients under their care. (Prior to 1990s) Assumption that individual workers were fully, and sometimes soley, accountable for the outcomes of patients under their care. (Prior to 1990s)

17. Often the severity of disciplinary action was determined by the severity of the undesired outcome - Intended effect exactly opposite – drove errors underground and unreported. Often the severity of disciplinary action was determined by the severity of the undesired outcome - Intended effect exactly opposite – drove errors underground and unreported.

18. Blameless Culture Recognition that workers who made honest errors were not truly blameworthy, nor was there much benefit to punishing them for these unintentional acts. Recognition that workers who made honest errors were not truly blameworthy, nor was there much benefit to punishing them for these unintentional acts. Experienced, knowledgeable, vigilant and caring workers could make mistakes that could lead to patient harm. Experienced, knowledgeable, vigilant and caring workers could make mistakes that could lead to patient harm.

19. Impossible task of perfect performance. Impossible task of perfect performance. Weakness – failed to confront individuals who willfully (and often repeatedly) make unsafe behavioral choices (1990’s) Weakness – failed to confront individuals who willfully (and often repeatedly) make unsafe behavioral choices (1990’s)

20. Just Culture Move to the middle - ground Move to the middle - ground Shift in thinking Shift in thinking

21. Challenges and Questions How does this shift in thinking fit with the current system of handling errors or safety concerns? How does this shift in thinking fit with the current system of handling errors or safety concerns? How does it fit with the disciplinary process related to labor contracts? How does it fit with the disciplinary process related to labor contracts? Determining risky vs. reckless behavior is a grey area – who gets to decide? Determining risky vs. reckless behavior is a grey area – who gets to decide? How do we achieve consistency in application of this process? How do we achieve consistency in application of this process?

22. How does this become a parallel process from the beginning between front-line staff and managers vs a top-down hierarchical approach?

23. 2 Studies The Perceptions of Just Culture Across Disciplines in Health Care, Proceedings of 50 th Annual Conference of Human Factors and Ergonomics, 2006 The Perceptions of Just Culture Across Disciplines in Health Care, Proceedings of 50 th Annual Conference of Human Factors and Ergonomics, 2006 Nurse Perceptions of Medication Errors: What We Need to Know for Patient Safety, Journal of Nursing Care Quality, 2004 Nurse Perceptions of Medication Errors: What We Need to Know for Patient Safety, Journal of Nursing Care Quality, 2004

25. Reporting System (R): Does the organization have one, is it used, do people feel safe using it? Reporting System (R): Does the organization have one, is it used, do people feel safe using it? Response and Feedback (R&F): What happens to reports once they are filed? Does the organization act on the information provided? Does the organization share information and provide feedback? Response and Feedback (R&F): What happens to reports once they are filed? Does the organization act on the information provided? Does the organization share information and provide feedback? Accountability (A): Are employees held equally accountable for their actions? Is there blame or favoritism? Does the organization recognize honest mistakes? Accountability (A): Are employees held equally accountable for their actions? Is there blame or favoritism? Does the organization recognize honest mistakes? Basic Safety (BS): What is the organization's commitment to basic safety? Is it reinforced throughout? Do workers have training, tools, etc. to perform the work? Basic Safety (BS): What is the organization's commitment to basic safety? Is it reinforced throughout? Do workers have training, tools, etc. to perform the work?

26. Employees perceive that disciplinary action is adjusted according to who makes the error.

28. Nurse Perceptions of Medication Errors This study describes nurse perceptions about medication errors. Findings reveal that there are differences in the perceptions of nurses about the causes and reporting of medication errors. Causes include illegible physician handwriting and distracted, tired, and exhausted nurses. Only 45.6% of the 983 nurses believed that all drug errors are reported, and reasons for not reporting include fear of manager and peer reactions. This study describes nurse perceptions about medication errors. Findings reveal that there are differences in the perceptions of nurses about the causes and reporting of medication errors. Causes include illegible physician handwriting and distracted, tired, and exhausted nurses. Only 45.6% of the 983 nurses believed that all drug errors are reported, and reasons for not reporting include fear of manager and peer reactions.

29. Just Culture Resides within an organization’s overall safety culture Resides within an organization’s overall safety culture Addresses the shared understanding of how behavior is determined acceptable Addresses the shared understanding of how behavior is determined acceptable How accountability/culpability is evaluated How accountability/culpability is evaluated Ultimately represents a shared accountability Ultimately represents a shared accountability