Prepared for the Foundation of the American College of Healthcare Executives
Session 49AB Examining the Just Culture Model:
20 Years Later
Presented by: Anne Pedersen, MSN, RN, NEA-BC
Joanne L. Sorensen, DNP, RN, FACHE
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Examining the Just Culture Model: 20 Years Later
Disclosure of RelevantFinancial Relationships
The following faculty of this continuing education activity has no relevant financial relationships with commercial interests to disclose:
• Joanne Sorensen, DNP, RN, FACHE
• Anne Pedersen, MSN, RN, NEA-BC
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FacultyJoanne L. Sorensen DNP, RN, FACHE
CNO, VP Patient Care Services
UPMC Northwest
Anne Pedersen MSN, RN, NEA-BC
Director of Nursing
UPMC Hamot
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Learning Objectives
#1 Following this session, attendees will be able to discuss the concept of Just Culture and application of a structured Just Culture Decision-Tree.
#2 Following this session, attendees will be able to assess their organization for challenges, barriers and strategies to overcome obstacles related to enhancing and strengthening a Just Culture.
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Agenda 1.Thought leaders: a historical perspective
• Reason, Marx, Donabedian, & Leape• 20 Year challenges and learning• The impact of a limited focus
2. Current research3. A Model for the Future
• Culture is local• Concepts which support Just Culture
4. Case Studies5. Outcomes6. Conclusions
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Patient Safety in America
• 200,000 people die from medical errors/year (Andel, et al, 2012)
• OVER 130,000 Medicare beneficiaries experienced 1 or more adverse events in hospitals in a single month (HHS, OIC, 2012)
• In 2014, 56% of hospital employees did not report any medical errors over a 12 month period (AHRQ, 2014)
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A Just Culture Historical Underpinnings
• James Reason-seminal work 1990’s in human factors and safe environments of care - author of Human Error
• Avedis Donabedian-Links Quality Outcomes to Structure, Process, and Love
• David Marx-thought leader and author of Patient Safety and the Just Culture: A Primer for Health Care Executives (2001)
• Lucian Leape-Applied Human Factors research within the Medical Model- author of Error in Medicine (1994)
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A Just Culture Historical Underpinnings
AHRQ Culture of Safety recognizes essentials:
– High risk nature of the work being done
– Determination to achieve consistent safe operations
– A safe and fair environment for reporting error that is blame-free
– Collaboration across ranks and disciplines
– Organizational commitment of resources toward the elimination of safety concerns
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James Reason
“Swiss Cheese Model”Worked with 3 Risk Industries
• Military• Air Traffic Control• Nuclear
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David Marx“Just Culture” was first used in a 2001 report by David Marx the report which popularized the term in the patient safety lexicon
The Three Duties
• 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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Avedis Donabedian
The Father of Quality AssuranceThe Donabedian Model
Structures of Care
Processesof Care
Outcomes
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Donabedian understood health care as a system…
“Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system”.
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Lucian Leape MD
Punishment of Individuals instead
of changing systems provides
strong incentives for under-reporting.
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Lucian LeapeProfessional Response to Human Error
Physician Values
• Physicians are socialized to strive for error-free
• Error is viewed as a failure of character
• Medical responsibility= infallibility
• Emotional devastation
• Learn from error in a vacuum
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Lucian LeapeProfessional Response to Human Error
Nursing Values• Rigid adherence to
protocols
• Social and peer disapproval is viewed as punishment
• Emotional devastation
• Learn from error in a vacuum
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Lucian Leape Human Factors Research-Health Care Industry
• Mental functioning is automatic-Schematic mode
• Skill-based efforts
• Attentional Control Mode-conscious, used in problem-solving, takes effort
• Rule and Knowledge-based
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Just Culture
Single greatest impediment to error prevention in the medical industry is
“that we punish people for making mistakes”
Lucian Leape, Professor, Harvard School of Public Health
Testimony before Congress on Health Care Quality Improvement
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In Fact …..The IOM has identifiedsafety as a property of ahealth care system ratherthan of an individual,noting that moving from aculture of blame to one oflearning and improving isone of the majorchallenges in creating asafer health care system.
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Punitive culture creates fear, destroys creativity, builds barriers, and DRIVES ERROR UNDERGROUND.
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TOO MANY ABANDON THE “SECOND VICTIMS” OF MEDICAL ERRORS
July 14, 2011 issue
It was with immeasurable sadness that we learned a veteran pediatric nurse had taken her own life in the aftermath of a fatal medication error. The nurse, Kimberly, 50, committed suicide on April 3, 2011, just 7 months after making a mathematical error that led to an overdose of calcium chloride and the subsequent death of a critically ill infant.
The Second Victim
Institute for Safe Medication Practice accessed on January 2, 2015 at https://www.ismp.org/newsletters/acutecare/articles/20110714.asp
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Just Culture Theoretical Underpinnings
• Believing that a culture is fair and just is a lived reality– Dignity and Respect
– Psychological Safety
• The system has effective structures and processes
• Safety is institutionalized
• Values: Honesty and Integrity
• Communication openness
• Understanding of human factors
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Just Culture: Giving Staff a Voice
An environment of trust and fairness where:
– it is safe to report and learn from mistakes and system flaws to ensure patient safety;
– consistent clarity and distinction exist between human error in unreliable systems and intentional unsafe acts;
– leaders, physicians, and staff work collaboratively to build a thriving healthcare culture.
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Blame-Free vs. Punitive Cultures
A Just Culture finds the middle ground between a blame-free culture and an overly punitive culture
ORGANIZATIONAL CULTURES
All errors are faults of the ‘system,’ not individuals
All errors are blamed on mistakes made by individuals
PunitiveBlame-Free
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Just Culture Simplified
Product of our current system design and behavioral choices
Manage through:
• Choices• Processes• Procedures• Training• Design• Environment
Human Error
Risk Behavior
Careless Behavior
A Choice: Risk believed insignificant or justified
Manage through :
• Removing incentives for at‐risk behaviors
• Creating incentives for healthy behaviors
• Increasing situational awareness
Conscious disregard of substantial and unjustifiable risk
Manage through :
• Remedial action• Punitive action
Console Coach Punish
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• Organizational commitment
• Poor teamwork
• Communication
• Culture of low expectations
• Pronounced authority gradients
Barriers to a Safety Culture
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Just Culture Current Research
Efforts to develop a strong safety culture produce spillover effects. Abrahamson, et al. 2016
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ANCC Magnet
• Structural Empowerment • Exemplary Professional
Practice• Transformational
Leadership• New Knowledge,
Innovation • Empirical Outcomes
Engagement
• Local culture drives safety culture
• Synergy -- employee engagement & safety
• Link to unit culture, LOS, morbidity & mortality
• Clear safety policies, safety training
Just Culture Current Research
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Patient Experience
• Open Communication
• Collaboration
• Commitment
Patient Outcomes
Mortality
Readmissions
AHRQ PSI
HAPU
Just Culture Current Research:Key Relationships
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Just Culture Current Research: Systematic Review of Safety Culture Associations
• Hospital level versus unit level research
• Composite score for AHRQ Patient Safety Indicators
• Mortality
• Patient outcomes
• Patient experience
Margaret DiCuccio. 2015 J Patient Safety
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What if we could measure how “Just” a Culture really is …..
The Development of the JCAT
1. Feedback and communication
2. Openness of communication
3. Balance
4. Quality of event-reporting process
5. Continuous improvement
6. Trust
Petschonek, S. et. Al (2013) J. of Patient Safety
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Current Research Summary
Emerging recognition that
a Safety Culture is
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• “Inadvertently doing other than what should have been done.”
• Identification of system risk is critically important. It is about designing safe systems, structures, and processes of care.
Definitions: ANA Position Statement Just Culture
Human Error
System Risk
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• “Reckless behavior is action taken with conscious disregard for a substantial and unjustifiable risk.”
• “At-risk behavior occurs when a behavioral choice is made that increases risk where risk is not recognized or is mistakenly believed to be justified.”
Definitions: ANA Position Statement Just Culture
Reckless
Risk Behavior
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Let’s Give It a Try!
Small Group Application Exercise
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System Situational Awareness:
• Policies & Procedures in place
• Dedicated Vascular Access Team
• Active CLABSI Champions
• HWST
• Zero CLABSI x 5 months
1: Case of the Expired Tubing
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Case 1: Evaluate the care by the nursing staff
• Situation: Patient went to Interventional Radiology to have a PICC (Peripherally Inserted Central Catheter) line inserted.
• Background: A 38-year-old female was admitted with multiple comorbidities. After three days in hospital, she went to Interventional Radiology for PICC line placement related to multiple IV antibiotics ordered.
• Assessment: Upon return to her room, the nurse connected the old tubing to the new PICC line. For the next 3 days and over the course of 5 assigned nurses, no one changed the tubing.
• Recommendation: ???
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Select the outcome category of this case from the options listed below:......
1. Human Error
2. Risky Behavior
3. Careless Behavior
4. System Error
5. Human Error + System Error
6. Risky Behavior + System Error
Answer Now
Audience Polling
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System Situational Awareness
• Suicide Precautions and Psyche Care Attendants part of Mandatory Madness Fairs
• Nursing M&Ms
• 18 inservices offered
• Bright green sitters placed on name tags, to identify staff as “Psych Care Attendants"
• The "Safe Room Checklist" revised
• Unit Directors engaged in oversight of Suicide Precautions – incorporated into all nursing unit shift huddles
Case 2: It’s Raining Pills!
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Case 2: Evaluate care provided by the staff
• Situation: A patient was admitted for fractured long bones. She was placed under suicide watch for her hospital stay per comments she made to staff and Psychiatrist.
• Background: A 59 year old female fell off a ladder at home. She sustained a broken tib/fib requiring surgery to repair the fracture; an external fixator was applied. Several days into her hospitalization, she began to voice suicidal ideations (with a plan). The Psyche eval was completed with the recommendation to petition for involuntary commitment. Psych Care Attendants (PCAs) were ordered until discharge
• Assessment: It came to the attention of leaders that the PCAs and RNs were departing from policy (allowing luggage and belongings in the room. Upon search found over 100 different pills (Oxycodone, etc.), 5 fentanyl patches, razor, cell phone w/charger cord etc.
• Recommendation: ???
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Select the outcome category of this case from the options listed below:......
1. Human Error
2. Risky Behavior
3. Careless Behavior
4. System Error
5. Human Error + System Error
6. Risky Behavior + System Error
Answer Now
Audience Polling
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System Situational Awareness
– Policy & Procedure
• Counts
• Critical moments
• Role clarity
– Sophisticated OR Safety Triad
• Measured and monitored Safety Triad
• Practiced in Sim Lab
– Tenured team
– Strong working relationships
3: Case of the Missing Screw
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Case 1: Evaluate the care by the Surgical Team
• Situation: Patient went to OR for removal of hardware in knee. Six of seven screws removed.
• Background: A 59 year-old female was admitted fore removal of surgical hardware in her knew related to infection. The attending surgeon started the case removing the plate and then went to a second procedure. The chief resident to removed six screws, closed the incision, dressed the wound as the patient was awakened. The surgeon returned to the room and asked if all seven screws were removed. Upon confirming that one screw remained, the patient was re-sedated, re-opened and the final screw removed.
• Assessment: Only the attending surgeon knew that 7 screws were to be removed.
• Recommendation: ???
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Select the outcome category of this case from the options listed below:......
1. Human Error
2. Risky Behavior
3. Careless Behavior
4. System Error
5. Human Error + System Error
6. Risky Behavior + System Error
Answer Now
Audience Polling
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HOW DOES THE OUTCOME IMPACT OUR PERCEPTION OF
THE EVENT?
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Strategic Implications: 20 years later
A comprehensive patient safety strategy is multifaceted:
• It depends on a fair and just response to error-leadership matters
• Recognizes the local nature of safety culture and the benefit of front-line staff engagement
• Incorporates the creation of safer systems of care
• Psychological safety matters
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Just Culture Response to
Error
Just Culture Response to
Error
Just Culture Response to
Error
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CRMStandardize
Systems Focus
CRMStandardize
Systems Focus
CRMStandardize
Systems Focus
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SimulationPractice
Communication & Teamwork
SimulationPractice
Communication & Teamwork
SimulationPractice
Communication & Teamwork
3Superior Outcomes
StrategicImplications
Safety Culture
Local Culture with Patient Safety Focus
Local Culture with Patient Safety Focus
Local Culture with Patient Safety Focus
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Local Leadership
Local Leadership
Local Leadership
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Outcomes
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Tools & Concepts
Magnet NDNQIJCAT JC Concepts My Voice Survey
12 Domains6 Concepts 42 Questions
Feedback & CommunicationOpenness of CommunicationQuality of event‐reporting Continuous improvementTrustBalance
Open Communication Error Feedback Reporting FrequencySupport for SafetyNon‐punitive ResponseOrg Learning Overall Perception of SafetyStaffingSupervisor ActionsTeamwork AcrossTeamwork WithinFacility Handoffs
I can speak openlyThe people I work with help each otherWe deliver quality care & servicesA commitment to patient care is clearMy supervisor acknowledges me for doing good workMy leaders treats me with dignity & respect
AHRQ COS Tool
Foundations for quality of care Nurse manager ability, leadership & supportPerceived qualityStaffing & resource adequacyCollegial Nurse MD relationshipsLast shift descriptionRecommend hospital, orientation, in‐services
Scales
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Outcomes UPMC Hamot
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63
37
64
55
56
54
30
58
43
20 30 40 50 60 70
Frequency of EventReporting
Facility Management Supportfor Safety
Nonpunitive Response toError
Overall Perception of Safety
Staffing
20122014
1.00
1.50
2.00
2.50
3.00
3.50
2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 2015 2016
NurseParticipation
Hospital Affairs
NursingFoundations forQuality of Care
Nurse ManagerAbility,
Leadership, andSupport
Staffing andResourceAdequacy
Collegial Nurse-Physician
Relationship
Mean PES
AHRQ COS MAGNET NDNQI
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Outcomes: Unit A vs B AHRQ Culture of Safety
63
70
76
43
52
45
40 50 60 70 80
CommunicationOpenness
Management SupportFor Safety
Overall Perception ofSafety
Unit A v Unit B: 2014
Unit A Unit B
• COS is local
• Unit A & B are next door
• Report up to the same leaders
• Different managers, issues & challenges
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Outcomes: PACU
40% 50% 60% 70% 80% 90% 100%
Communication Openness
Frequency of Event Reporting
Supervisor Actions Promoting Safety
Teamwork Across Hospital Units
Teamwork within Hospital Unit
2012 2014
ARHQ Survey
My Voice
Magnet NDNQI
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Outcomes: The OR
• Large unit
• Tenured staff
• Leadership changes
• New leader, new values
• OR changed greatly between the 2 surveys
• Structure, staffing, leadership
My Voice Survey
Magnet NDNQI Survey
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NICU: An Exemplar → AHRQ COS
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%NICU AHRQ COS Overall Results
2012
2014
AHRQ 50%
Director in role for 15 years – hospital 43 yearsDeep commitment to patients and staffExciting culture, evidence based, and research oriented
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The NICU: An Exemplar → Magnet
2012 2013 2015 2012 2013 2015 2012 2013 2015 2012 2013 2015 2012 2013 2015
Nurse ParticipationHospital Affairs
Nursing Foundations forQuality of Care
Nurse Manager Ability,Leadership, and Support
Staffing and ResourceAdequacy
Collegial Nurse-PhysicianRelationship
NICU 3.2 3.17 3.26 3.41 3.4 3.45 3.4 3.44 3.38 3.27 2.84 3.15 3.35 3.37 3.36
Mean of Hospitals Bedsize 300-399 2.89 2.87 2.87 3.14 3.11 3.08 2.92 2.91 2.9 2.92 2.91 2.87 3.17 3.14 3.18
1
1.5
2
2.5
3
3.5
Magnet NDNQI Practice Environment Scale
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COMMENTS
• Strong leadership at all levels
• Commitment to patient safety and quality
• Drive to succeed to provide the best care in the region
• Caring, compassion
• Teamwork
• Allowing nurses to be part of making the changes
• I am lucky to work here
• Commitment to quality care
• Great people who work here
• The staff of the hospital are wonderful
My Voice Survey █ NICU █ Hospital █ System
The NICU: An Exemplar → My Voice
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Just Culture response to
error
Just Culture response to
error
Just Culture response to
error
1
CRMStandardize
Systems Focus
CRMStandardize
Systems Focus
CRMStandardize
Systems Focus
2
SimulationPractice
Communication and Teamwork
SimulationPractice
Communication and Teamwork
SimulationPractice
Communication and Teamwork
3Superior Outcomes
StrategicImplications
Safety Culture
Local Culture with Patient Safety Focus
Local Culture with Patient Safety Focus
Local Culture with Patient Safety Focus
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Local Leadership
Local Leadership
Local Leadership
4
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The NICU: An Exemplar → Outcomes
Beating Benchmarks on:
– Mortality
– Morbidity
– Readmission Rates
– Complications
• Retinopathy of prematurity
• Necrotizing enterocolitis
• Intraventricular hemorrhage
• Nosocomial infections
• Chronic lung disease
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My Voice Survey
12 Domains 42 Questions
Open Communication Error Feedback Reporting FrequencySupport for SafetyNon‐punitive ResponseOrg Learning Overall Perception of SafetyStaffingSupervisor ActionsTeamwork AcrossTeamwork WithinFacility Handoffs
I can speak openlyThe people I work with help each otherWe deliver quality care & servicesA commitment to patient care is clearMy supervisor acknowledges me for doing good workMy leaders treats me with dignity & respect
AHRQ COS Tool
Data• Sample: surgical units across
the system• Sources:
– 2016 MyVoice Engagement Index (≥ 10 respondents per unit)
– 2015 Culture of Safety (≥ 10 respondents per unit)
Analysis• Calculated Spearman rank
correlations between the Engagement Index and 12 Culture of Safety Domains
Data and Analysis: The System ORs
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• Bolded correlations are statistically significant
• As the proportion of engagement increases in a unit, the culture of safety domains tend to improve as well
Culture of Safety Domain Engagement Index
Communication Openness .40*
Feedback & Communication About Error .33*
Frequency of Event Reporting .15
Facility Management Support For Safety .44*
Nonpunitive Response to Error .18
Organizational Learning & Continuous
Improvement .45*
Overall Perceptions of Safety .53*
Staffing .27
Supervisor Actions Promoting Safety .48*
Teamwork Across Facility Units .65*
Teamwork Within Hospital Units .66*
Facility Handoffs & Transitions .35*
*p<.05, Spearman’s rank correlation
Data
• Sample: surgical units across system
Sources:
• 2016 My Voice Engagement Index (≥ 10 respondents per unit)
• 2015 Culture of Safety (≥ 10 respondents per unit)
Analysis
• Calculated Spearman rank correlations between the Engagement Index and 12 Culture of Safety Domains
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Conclusions
C-Suite Backing
HR Alignment
Internal vs. External Resources
Must Have Physician
buy in
Staff Readiness
Shared Governance Model
May Have
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• Consider that culture is a local phenomena and engage front-line staff in owning their safety culture
• Incorporate principles of CRM and Simulation Training to identify local risk behaviors
• Celebrate success with stories and data!
Conclusions
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PresentersJoanne L. Sorensen DNP, RN, FACHE Anne Pedersen MSN, RN, NEA-BC
Chief Nursing Officer and Vice President of Patient Care Services at UPMC Northwest
814-877-6875
Director of Nursing, Emergency,
Critical, and Operative Services at UPMC Hamot
814-877-2928
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Joanne Sorensen BiographyJoanne Sorensen has been a nurse leader for 33years in a variety of settings and roles and is currentlythe VP of Patient Care Services/CNO at UPMCNorthwest. Previously she served as Clinical Director:Regulatory Readiness/ Women’s Hospital at UPMCHamot. She earned her DNP from WaynesburgUniversity in 2011 where she is adjunct faculty. Shewas a member of the Pennsylvania State Board ofNursing from 2003-2015, chairing the board in 2006.Sorensen co-chaired the UPMC Health Systemimplementation of a Just Culture. She is also acertified LifeWings instructor teaching the principlesof CRM. Sorensen, the recipient of the 2015 Cameosof Caring Quality and Safety Nursing Award, hasextensive process improvement experience and hasdeveloped and implemented nursing peer reviewincorporating a “Just Culture”. Sorensen haspresented nationally and internationally on theconcepts of Patient Safety and Safety Cultures.
Joanne L. Sorensen DNP, RN, FACHECNO, VP Patient ServicesUPMC Northwest100 Fairfield DriveSeneca, PA 16346
Office: 814-676-7147Email: [email protected]
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Anne Pedersen Biography
Anne Pedersen MSN, RN, NEA-BC has been anurse leader in a variety of settings for over 20years. She earned her BSN at the University ofPittsburgh and MSN at UNC-Chapel Hill. Shehas published extensively in journals rangingfrom Nursing Management to the Journal ofNursing Administration. She has spokennationally and internationally on a variety oftopics including patient satisfaction, peer review,and the qualities of effective leadership. She iscurrently the Director of Nursing at UPMCHamot in Erie, Pennsylvania. She has nurseexecutive oversight of implementing crewresource management in the ICUs, ED andtrauma service lines.
Anne Pedersen MSN, RN, NEA-BCDirector of Nursing, UPMC Hamot201 State StreetErie, PA 16550
Office: 814-877-2928Email: [email protected]
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Bibliography/References• Abrahamson, K., Hass, Z., Morgan, K., Fulton, B., & Ramanujam, R.
(2016). The Relationship Between Nurse-Reported Safety Culture and the Patient Experience. The Journal Of Nursing Administration, 46(12), 662-668.
• Agency for Healthcare Research and Quality. (2004) Safety culture dimensions and reliabilities: user’s guide: hospital survey on patient safety culture. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html. Accessed January 2, 2017.
• Albrecht, R. M. (2015). Patient safety: the what, how, and when. American Journal Of Surgery, 210(6), 978-982. doi:10.1016/j.amjsurg.2015.09.003
• Bashaw, E. S., & Lounsbury, K. (2012). Forging a new culture: blending Magnet® principles with Just Culture. Nursing Management, 43(10), 49-53.
• Best, M., & Neuhauser, D. (2004). Avedis Donabedian: father of quality assurance and poet. Quality & Safety In Health Care, 13(6), 472-473.
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Bibliography/References• Boysen II, P. G. (2013). Just Culture: A Foundation for Balanced Accountability
and Patient Safety. Ochsner Journal, 13(3), 400-406.
• DiCuccio, M. H. (2015). The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic Review. Journal Of Patient Safety, 11(3), 135-142. doi:10.1097/PTS.0000000000000058
• Helbling, N., & Huve, J. (2015). Finding the balance for a culture of safety. Nursing2015, 45(12). Pp. 56-68 doi: 10.1097/01.NURSE.0000473405.04919.10
• Leape L. (1994) Error in Medicine. JAMA, 272(23):1851-1857. doi:10.1001/jama.1994.03520230061039
• Marx, D. (2001). Patient Safety and the Just Culture: A Primer for Health Care Executives, New York: Columbia University
• Miranda, S. J., & Olexa, G. A. (2013). Creating a just culture: recalibrating our culture of patient safety. The Pennsylvania Nurse, 68(4), 4-9.
• Petschonek, S., Burlison, J., Cross, C., Martin, K., Laver, J., Landis, R. S., & Hoffman, J. M. (2013). Development of the just culture assessment tool: measuring the perceptions of health-care professionals in hospitals. Journal Of Patient Safety, 9(4), 190-197. doi:10.1097/PTS.0b013e31828fff34
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