Transcript Quality Improvement as Part of our Nursing Practice

Just Culture
www.justculture.org
Just Culture is about:
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Creating an open, fair,
and just culture
Creating a learning
culture
Designing safe
systems
Managing behavioral
choices
Adverse
Events
Human
Errors
System
Design
Managerial
and Staff
Behaviors
Learning Culture / Just
Culture
A Model that Focuses on Three Duties
balanced against Organizational and
Individual Values
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The Three Duties
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The duty to avoid
causing unjustified risk
or harm
The duty to produce an
outcome
The duty to follow a
procedural rule
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Organizational and
Individual Values
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Safety
Cost
Effectiveness
Equity
Dignity
etc
Two Specific Classes of Duty
• Meet me at 7:00 pm at
410 Chestnut Street
The Duty to
Produce an
Outcome
• Leave the house at 6:45
pm. Go south on
Independence Ave, turn
right on Parker. At the
third light, hang a left, go
three blocks, turn right and
go to the fourth house on
the right.
The Duty to
Follow a
Procedural Rule
We know….to error is Human
But….To Drift is also Human
Managing Behavioral Choices:
Everyone Takes Risks, Every Day
RISK
SOCIAL
UTILITY
The Behaviors We Can Expect
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Human error - inadvertent action;
inadvertently doing other that what should have
been done; slip, lapse, mistake.
At-risk behavior - behavior that increases risk
where risk is not recognized, or is mistakenly
believed to be justified.
Reckless behavior - behavioral choice to
consciously disregard a substantial and
unjustifiable risk.
Accountability for our Behavioral
Choices
Human
Error
At-Risk
Behavior
Product of our current
system design
Unintentional Risk-Taking
Manage through changes in:
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Processes
Procedures
Training
Design
Environment
Console
Manage through:
• Removing incentives for
at-risk behaviors
• Creating incentives for
healthy behaviors
• Increasing situational
awareness
Coach
Reckless
Behavior
Intentional Risk-Taking
Manage through:
• Remedial action
• Disciplinary action
Punish
We need…..
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A culture that truly supports learning
A common understanding about how to treat people
when things happen
The Minnesota Agenda
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Formation of a stakeholder group - The Minnesota
Alliance for Patient Safety (MAPS)
Change state law
Developed principles of justice, learning and
accountability
Change the policies and practices of:
 The Boards
 The Dept of Health
 Delivery systems
Our Goal
The behavior of people involved in care delivery in
the state of Minnesota will be judged using a
common philosophy and a common set of
principles across healthcare organizations, the
Department of Health, the professional boards and
professional associations
Minnesota Statement of
Support
Given that:
 Medical errors and patient safety are a
national concern to all involved in health care
delivery.
 We are legally and/or ethically obligated to
hold individuals accountable for their
competency and behaviors that impact
patient care.
 A punitive environment does not fully take
into account system issues, and a blame-free
environment does not hold individuals
appropriately accountable
We resolve that our organization will:
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Strive for a culture that balances the need
for a non-punitive learning environment with
the equally important need to hold persons
accountable for their actions.
Seek to judge the behavior, not the
outcome, distinguishing between human
error, at-risk behavior, and intentional
reckless behavior.
Foster a learning environment that
encourages the identification and review of
all errors, near-misses, adverse events, and
system weaknesses.
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Promote the use of a wide range of responses to
safety-related events caused by lapses in human
behavior, including coaching, non-disciplinary
counseling, additional education or training,
demonstration of competency, additional supervision
and oversight and disciplinary action when
appropriate to address performance issues.
Support and implement systems that enable safe
behavior to prevent harm
Work to share information across organizations to
promote continuous improvement and ensure the
highest level of patient and staff safety.
Collaborate in efforts to establish a statewide culture
of learning, justice, and accountability to provide the
safest possible environment for patients.