Transcript Just Culture

Just Culture
Carol Diemert, RN, MSN
Minnesota Nurses Association
March 2008
Goals
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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
Apply the concepts and principles of Just
Culture to case scenarios
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“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
What is just?
What is culture?
Just is acting or being in
conformity to what is morally
upright or good, fair, impartial.
Culture – policies, procedures,
conditions of employment,
structures for decision-making
and types of behaviors that are
supported constitutes a culture.
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.
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.
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
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
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
 Achieve a culture where frontline
staff feel comfortable disclosing
errors
System Issues
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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.
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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.
The Swiss Cheese Model
of System Accidents
Swiss Cheese Model of System Accidents
When is the organization culpable?
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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.
Punitive Culture
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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)
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Often the severity of disciplinary action
was determined by the severity of the
undesired outcome - Intended effect
exactly opposite – drove errors
underground and unreported.
Blameless Culture
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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.
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Impossible task of perfect performance.
Weakness – failed to confront individuals
who willfully (and often repeatedly) make
unsafe behavioral choices (1990’s)
Just Culture
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Move to the middle - ground
Shift in thinking
Challenges and Questions
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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?
Determining risky vs. reckless behavior is
a grey area – who gets to decide?
How do we achieve consistency in
application of this process?
How does this become a parallel
process from the beginning
between front-line staff and
managers vs a top-down
hierarchical approach?
2 Studies
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The Perceptions of Just Culture Across
Disciplines in Health Care, Proceedings of
50th Annual Conference of Human Factors
and Ergonomics, 2006
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Nurse Perceptions of Medication Errors:
What We Need to Know for Patient Safety,
Journal of Nursing Care Quality, 2004
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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?
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?
Employees perceive that
disciplinary action is adjusted
according to who makes the error.
Nurse Perceptions of
Medication Errors
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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.
Just Culture
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Resides within an organization’s overall
safety culture
Addresses the shared understanding of
how behavior is determined acceptable
How accountability/culpability is evaluated
Ultimately represents a shared
accountability