Just CultureJust CultureCarol Diemert, RN, MSNCarol Diemert, RN, MSN

Minnesota Nurses AssociationMinnesota Nurses Association

March March 20082008

GoalsGoals

Identify a common philosophy and Identify a common philosophy and set of principles that would be a set of principles that would be a parallel process with both front-line parallel process with both front-line and management staff; shared and management staff; shared accountability accountability

Describe the Just Culture ModelDescribe the Just Culture Model Apply the concepts and principles of Apply the concepts and principles of

Just Culture to case scenariosJust Culture to case scenarios

““To make a substantial step in patient To make a substantial step in patient safety, we must change the health safety, we must change the health care system. One critical element of care system. One critical element of that fundamental change is the that fundamental change is the creation of a more open, fair, and just creation of a more open, fair, and just culture. It is through a just culture culture. It is through a just culture that we will begin to see, understand, that we will begin to see, understand, and mitigate the risks within the and mitigate the risks within the health care system”health care system”

An Introduction to a Just CultureAn Introduction to a Just CultureCopyright 2005 Outcome Engineering - Copyright 2005 Outcome Engineering - wwwww.justculture.orgw.justculture.org

What is just?What is just?

What is What is culture?culture?

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

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

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

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

Five conditions that promote Five conditions that promote awareness and discussionawareness and discussion of an of an

ethical issueethical issue 1.1. PowerPower - the right to having the - the right to having the

information needed to understand a information needed to understand a situation, as well as to say what situation, as well as to say what needs to be said needs to be said

2.2. TrustTrust - the confidence to disagree - the confidence to disagree with others, without fear of reprisal with others, without fear of reprisal

3.3. InclusionInclusion - those with an interest in - those with an interest in the decision are included in the the decision are included in the process process

4.4. Role flexibilityRole flexibility - the ability to - the ability to take different points of view, and take different points of view, and to change it based on additional to change it based on additional informationinformation

5.5. InquiryInquiry - an atmosphere of - an atmosphere of questioning and learning questioning and learning

ANA, Guide to the Code of Ethics for Nurses, 2008ANA, Guide to the Code of Ethics for Nurses, 2008

Just Culture -Just Culture - is a patient safety is a patient safetyinitiative designed to addressinitiative designed to addressboth system issues and both system issues and

individualindividualbehavior.behavior.

Shift from focus on errors and Shift from focus on errors and outcomes ----------- to system outcomes ----------- to system design and behavioral choicesdesign and behavioral choices

Achieve a culture where frontline Achieve a culture where frontline staff feel comfortable disclosing staff feel comfortable disclosing errorserrors

System IssuesSystem Issues

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

Holds the view that efforts to catch Holds the view that efforts to catch human errors before they occur or block human errors before they occur or block them from causing harm will ultimately them from causing harm will ultimately be more fruitful that ones that seek to be more fruitful that ones that seek to somehow create flawless providers. somehow create flawless providers.

Example “work-arounds” – motivation Example “work-arounds” – motivation lies in getting the work done (not lies in getting the work done (not laziness or whim) so appropriate laziness or whim) so appropriate response would be to trigger an response would be to trigger an assessment of workflow rather than assessment of workflow rather than repeatedly reminding staff of the policy repeatedly reminding staff of the policy or equipment. or equipment.

The Swiss Cheese ModelThe Swiss Cheese Modelof System Accidentsof System Accidents

Swiss Cheese Model of System Swiss Cheese Model of System AccidentsAccidents

When is the organization culpable?When is the organization culpable? Blunt endBlunt end refers to the many layers of the refers to the many layers of the

health care system not in direct contact with health care system not in direct contact with patients, but which influence the personnel patients, but which influence the personnel and equipment at the and equipment at the sharp endsharp end who do have who do have direct contact with patients.direct contact with patients.

Lesson in this is that there are also those Lesson in this is that there are also those errors that are totally unforgiving since a errors that are totally unforgiving since a single defect can cause catastrophe eg wrong-single defect can cause catastrophe eg wrong-site surgery, accidental administration of site surgery, accidental administration of potassium chloride. potassium chloride.

Punitive CulturePunitive Culture Health care organizations attempted to Health care organizations attempted to

manage risk and errors by disciplining manage risk and errors by disciplining workers involved in errors, particularly workers involved in errors, particularly those closest to the event.those closest to the event.

Assumption that individual workers were Assumption that individual workers were fully, and sometimes soley, accountable fully, and sometimes soley, accountable for the outcomes of patients under their for the outcomes of patients under their care. (Prior to 1990s)care. (Prior to 1990s)

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

Blameless CultureBlameless Culture

Recognition that workers who made Recognition that workers who made honest errors were not truly honest errors were not truly blameworthy, nor was there much blameworthy, nor was there much benefit to punishing them for these benefit to punishing them for these unintentional acts. unintentional acts.

Experienced, knowledgeable, vigilant Experienced, knowledgeable, vigilant and caring workers could make and caring workers could make mistakes that could lead to patient mistakes that could lead to patient harm. harm.

Impossible task of perfect Impossible task of perfect performance. performance.

Weakness – failed to confront Weakness – failed to confront individuals who willfully (and often individuals who willfully (and often repeatedly) make unsafe behavioral repeatedly) make unsafe behavioral choices (1990’s)choices (1990’s)

Just CultureJust Culture

Move to the middle - groundMove to the middle - ground Shift in thinkingShift in thinking

Challenges and Challenges and QuestionsQuestions

How does this shift in thinking fit with How does this shift in thinking fit with the current system of handling errors the current system of handling errors or safety concerns?or safety concerns?

How does it fit with the disciplinary How does it fit with the disciplinary process related to labor contracts?process related to labor contracts?

Determining risky vs. reckless Determining risky vs. reckless behavior is a grey area – who gets to behavior is a grey area – who gets to decide?decide?

How do we achieve consistency in How do we achieve consistency in application of this process?application of this process?

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

2 Studies2 Studies

The Perceptions of Just Culture Across The Perceptions of Just Culture Across Disciplines in Health Care,Disciplines in Health Care, Proceedings Proceedings of 50of 50thth Annual Conference of Human Annual Conference of Human Factors and ErgonomicsFactors and Ergonomics, 2006, 2006

Nurse Perceptions of Medication Nurse Perceptions of Medication Errors: What We Need to Know for Errors: What We Need to Know for Patient SafetyPatient Safety, , Journal of Nursing Care Journal of Nursing Care QualityQuality, 2004, 2004

Reporting System (R):Reporting System (R): Does the Does the organization have one, is it used, do people organization have one, is it used, do people feel safe using it? feel safe using it?

Response and Feedback (R&F):Response and Feedback (R&F): What What happens to reports once they are filed? happens to reports once they are filed? Does the organization act on the Does the organization act on the information provided? Does the organization information provided? Does the organization share information and provide feedback? share information and provide feedback?

Accountability (A):Accountability (A): Are employees held Are employees held equally accountable for their actions? Is equally accountable for their actions? Is there blame or favoritism? Does the there blame or favoritism? Does the organization recognize honest mistakes? organization recognize honest mistakes?

Basic Safety (BS):Basic Safety (BS): What is the What is the organization's commitment to basic safety? organization's commitment to basic safety? Is it reinforced throughout? Do workers have Is it reinforced throughout? Do workers have training, tools, etc. to perform the work? training, tools, etc. to perform the work?

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

Nurse Perceptions of Nurse Perceptions of Medication ErrorsMedication Errors

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

Just CultureJust Culture

Resides within an organization’s Resides within an organization’s overall safety cultureoverall safety culture

Addresses the shared understanding Addresses the shared understanding of how behavior is determined of how behavior is determined acceptableacceptable

How accountability/culpability is How accountability/culpability is evaluatedevaluated

Ultimately represents a shared Ultimately represents a shared accountabilityaccountability