Transcript Protecting the Public through Disciplinary Action

Protecting the Public
through Disciplinary
Action
Maryann Alexander, PhD, RN, FAAN
Kathleen Russell, JD, RN
The Board’s Duty Is To
Protect The Public
Not
Punish The Licensee
Criminal Justice System
 Punishment does not improve behavior
 Emphasis is needed on examining what
happened and how can we prevent you
from doing this again.
 Support and resources lessen the chance of
recidivating.
TERCAP Data
Individuals disciplined by their employer
have a much higher chance of being
disciplined by the board of nursing at
sometime in the future
2012
 200,000 people die from medical errors a year (Andel, et al, 2012)
 More than 130,000 Medicare beneficiaries experienced one or
more adverse events in hospitals in a single month. (HHS, OIG,
2012).
 When quality life adjusted years (QALYs) are applied to
patients that die, the errors committed on an annual basis
translates into $1 trillion dollars a year (Andel, et al, 2012)
What does all this mean?
 Regulation and health care facilities need to
work together.
 We need to effectively prevent errors.
 Examine system as well as individual errors.
 Punishment may not be the best option for
preventing future errors or poor
performance.
 Remediation, counseling, supervision are
tools that need to be considered as part of
disciplinary action.
Punishment
 People tend to hide errors
 Prevents fixing the system
 Risk to patient
 Focus is on punishment
 Effective when used in the right way.
Questions
 When do we take no action?
 When do we counsel, remediate and
supervise?
 When do we punish/remove from practice?
Just Culture
a system of justice (disciplinary and
enforcement action) that reflects what
we now know of socio-technical
system design, human free will and our
inescapable human fallibility.
The Just Culture Model (simplified)
Human
Error
At-Risk
Behavior
Product of Our Current
System Design and
Behavioral Choices
A Choice: Risk Believed
Insignificant or Justified
Manage through
changes in:
•
•
•
•
•
•
Choices
Processes
Procedures
Training
Design
Environment
Console
© 2012
Manage through:
• Removing incentives
•
•
for at-risk behaviors
Creating incentives
for healthy behaviors
Increasing situational
awareness
Coach
Reckless
Behavior
Conscious Disregard of
Substantial and
Unjustifiable Risk
Manage through:
• Remedial action
• Punitive action
Punish
System versus Individual Errors
© 2012
System Errors
 May be due to a deficit in the institution’s
policies and/or procedures
 May be due to other providers in the health
care system
 Often a combination of factors
Human Error
Human Error
 Can happen to high performers with no
history of past error
 Discipline may not prevent
 Remediation may not be needed
Risk-Taking Behavior
“Justifiable Risk”
Risk-Taking Behavior
 May need remediation/counseling
 May need discipline/supervision
Reckless
the police.
Reckless
 Discipline
 Remediation/supervision/counseling/job
transfer
The Just Culture Model (simplified)
Human
Error
At-Risk
Behavior
Product of Our Current
System Design and
Behavioral Choices
A Choice: Risk Believed
Insignificant or Justified
Manage through
changes in:
•
•
•
•
•
•
Choices
Processes
Procedures
Training
Design
Environment
Console
© 2012
Manage through:
• Removing incentives
•
•
for at-risk behaviors
Creating incentives
for healthy behaviors
Increasing situational
awareness
Coach
Reckless
Behavior
Conscious Disregard of
Substantial and
Unjustifiable Risk
Manage through:
• Remedial action
• Punitive action
Punish
The Just Culture Model
A Single Event
Repetitive Events
 Repetitive errors – yes,
there is a process
 Repetitive at-risk
behaviors – yes, there is
a process
 Both may lead to
disciplinary action…
Remediation
 Alternative to Discipline Programs
 Only effective if the remediation is truly
directed towards preventing future
occurrence.
 Monitoring and mentoring.
 Institution must be aware and involved.
Deliberate Behavior
 Discipline
 May warrant permanent revocation of
license
Regulatory Action Pathway
 Consistent way of evaluating BON cases
 Based on principles of James Reason, Just
Culture, patient safety movement
 Transparent
 Patient centered
 Relies on remediation
 Partnership with hospitals
Regulatory Action Pathway
 Encourage good choices beginning with
reporting and identification of errors that
might lead to better systems
 Identify the difference between errors that
are caused by human fallibility, risk-taking
behaviors and recklessness
 Direct discipline according to the type of
error.
Regulatory Action Pathway
 Patient centered
 Examines intention and distinguishes
between types of errors
 Encourages reporting of errors
 Encourages partnership between BON and
institution
 Emphasis on corrective activities
 Accounts for system related issues
 Looks at repeated occurrences
 Discipline when needed