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Performance, Accountability and Safety
in a Just CultureJohn Howe, RN, BSN
Clinical Education and Professional DevelopmentDUHS
The presenter has no relationships with industry to disclose.
There will be no discussion of off-label products or the use of devices.
There is no commercial support for this program.
Disclosure
Describe the components and structure of a Just Culture that supports performance, accountability and safety
Define roles of leaders, managers and staff in this culture
Objectives
The Just Culture Community and Outcome Engineering
now OutcomEngenuity®
Credit where due
MISSIONInsert YOUR Mission here. VISION
Insert YOUR Vision here VALUESInsert YOUR Values here
Relation to Mission, Vision and Values
Leadership who are involved, direct, and demonstrate understanding of M/V/V daily
Staff who understand their role, provide quality care and service, advocate for their patients and themselves
Systems and processes that allow, facilitate, and foster the first two to occur in context of M/V/V
Maximizing Success Probability
Long, long ago in a galaxy
far, far away…
“A choice you must make, yes”…Yoda
Part of the story…..
System + Processes Design
Learning Culture/P.A.S melded culture
Human Errors
Adverse
Events
Managerial & Staff Behavior
s
With a background of a Supportive Learning Culture, we focus on proactive system design and management of behavioral choices
Relating Performance, Accountability and Safety
The term “Just Culture” refers to a safety-supportive system of shared accountability where healthcare institutions are accountable for the systems they have designed and for supporting the safe choices of patients, visitors, and staff. Staff, in turn, are accountable for the quality of their choices – knowing that we cannot will our selves to be perfect, but we can strive to make the best possible choices.
Introduction to Just Culture
Just Culture-“Culture of Safety” Brochure, 2008
Just Culture encourages discussion and reporting of errors and near misses – without fear of retribution or “getting into trouble”.
It focuses on the choices of the employee and what contributed to the choice, not merely the fact that an error occurred, nor solely on the consequences of that error.
Just Culture for Healthcare Managers, 2007
A Just Culture Defined
In a Just Culture, the institution addresses near misses, errors, and behavioral choices that may need to be investigated and addressed in a clear and equitable manner.
It also looks at the system in which the choices were made, the effect of that system on the choice, and how to maximize system use and effectiveness.
A Just Culture Defined
The steps involved in this process are defined and applied equally to all staff- clinical and non-clinical - by managers and leaders who are educated in the process and use it regularly as needed.
The same process is applied to all levels of staff – frontline employees, managers, directors, etc.
It is more than an HR tool or process
A Just Culture Defined
Just Culture is both a philosophy and a process:◦ The philosophy combines putting patients
and safety first; being open to monitoring and addressing real and potential issues and problems.
◦ The process helps to assure that our staff engage in being accountable for their actions and choices, and choices are evaluated when appropriate, and dealt with fairly and similarly across departments, services, and entities
A Just Culture Defined
System + Processes Design
Learning Culture/P.A.S melded culture
Human Errors
Adverse
Events
Managerial & Staff Behavior
s
With a background of a Supportive Learning Culture, we focus on proactive system design and management of behavioral choices
Relating Performance, Accountability and Safety
Identify the need Define the Issue and Goal Engage leadership and leader advocates: Ask “What
would this look like here?” Evaluate current systems and practices using GAP
analysis or other method Describe/develop intervention and processes to do this –
i.e. Implementation Strategies Educate leaders Identify and Educate teachers/advocates Train managers and staff Evaluation, measurement, sustainability and
communication plans
System and Process Implementation:The Steps (TeamSTEPPS or other)
DUHS wide Relationship to Mission, Vision, Values Top down and bottom up commitment Target the “Lynch Pins”
Visioning
Investigate, Reference, Benchmark Implementation Team Define expectations, Develop tools, Educate
the leaders and staff Outcomes Communicate with all
Process
Advocates/Experts/Oversight Group specialty trained
Education Sub-Committee◦ Different info for different levels/groups◦ Leadership Orientation◦ Manager Worksessions◦ Frontline Orientation – not just clinicians and HR◦ Department and Group Education◦ Physician education challenge◦ On-going efforts: on-line, class, resource, more…
Website
Education
Direct and Indirect Measures◦ Use of tools in behavioral choice evaluations◦ Staff Satisfaction Survey◦ Work Culture Survey◦ Turnover rates◦ SRS data◦ Addition to RCA documentation◦ Plans for “inter-rater reliability”, HR outcomes◦ Leadership Assessment Survey – 2013 example
Outcomes
Communication Plans In-house publications, newsletter, articles;
multi-level and media Connect to other related initiatives Communication Team Strategy
Communication
Let’s see what it really looks like…
Leadership/Manager Just Culture Orientation Work Session
How and Why Different
Unexpected results and comments
Frontline Staff presentation
“No harm, No foul” mentality The news trucks show up…… Joint Commission, regulators are coming….. A particular group that doesn’t understand,
buy-in, or feels they are exceptions “Red Rules” and Absolutes Others…….
Dealing with…….
Staff Handbook expectations Medical Staff by-laws and Peer Review
processes Just Culture Physician Algorithm “Coffee and Conversation” – a different
“algorithm”◦ – Dr. Gerald Hickson, Vanderbilt model
Duke experience
Relationship to Employee Handbook and Medical Staff By-Laws
Medical Staff Bylaws and Policies and Procedures
Bylaws and P/P = Structure
Just Culture algorithm is a tool to support investigation and evaluation of situations that may result in disciplinary action or coaching or counseling = Process
Dr. Jones has been employed with the network for 6 years. He first patient is scheduled for 8am every day. Dr. Jones arrives for work between 8:05 – 8:20 on 4 out of 5 days. This issue has been addressed numerous times by the medical director as it impacts the flow and start time in the clinic. As a result, there is no opportunity to huddle in the morning, review labs, or see the first patient in a timely fashion. Dr. Jones has had a variety of explanations (car trouble, child care, patients are not roomed promptly so there is no need to come before 8.) An adjusted template has been offered and declined.
Case Study 1
Behavioral related issues◦ Work habits – timeliness; completion of medical
records◦ Interactions with staff and colleagues
Clinical concerns◦ Basis for Peer Review – missed diagnosis, failure
to appropriately F/U, missed clinical finding◦ Systems related issues◦ Knowledge deficit
A Medical Case Study: Application and Implications
Can use the algorithm during an RCA to help tease out behavioral choices vs process issues ◦ This helps prevent revising or layering of process
that are not the issue. Flow chart the process Verify key steps Ask the questions – using appropriate algorithm
◦ Promotes partnership with the manager to achieve a successful outcome.
Using the algorithm to help differentiate behaviors and process
Leadership support Ground level understanding of importance
and benefit – more than just a tool addressing “bad behaviors”
Middle management that understands, supports and uses the process
Sustainment strategies Resources and Commitment
“Must Haves” for success…..
OutcomEngenuity: website and Just Culture resources
TeamSTEPPS
Selected Resources
Identify and then prioritize; How can make them fit within current
systems and processes – some new and some already there
Next 3 steps……
This is who we do it for….
