Just Culture: The Key To Quality And Safety

The Just CultureCommunityJust Culture: The Key toQuality and SafetyGregg S. Meyer, MD, MScEdward P. Lawrence Center for Qualityand Safety,MGH/MGPOCOESeptember 2010Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityAgenda The Need for a New Approach The Just Culture Model Applications to MGH/MGPO and SRHCommunity Questions?Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityWhy talk about “Just Culture” A Just Culture supports a “learningorganization” We all encounter issues, large and small,where a uniform and systematic approachto interpreting the situation would bevaluableCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityWhy is this important?Medical error has always been with us:Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityHow do we interpret events?Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityWhere We’re At With AccountabilityAn experienced surgeon sees a new piece ofequipment at a conference. Back at the hospital, asales representative persuades him to use theequipment for a procedure. He has never used theequipment before and accidentally punctures thepatient’s bowel. The surgeon repairs the bowel andthe patient recovers fully. The OR has a policy thatsays new equipment will be officially approved andtraining will be conducted prior to its use.Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityYour Options Take no actionWarn against doing it againEncourage different behavior/coachDiscipline/punish Does the outcome make a difference?Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityWhere We’re At With AccountabilityCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityWhere We’re At With AccountabilityThe hospital has recently revised and upgraded itsinfection control protocols. Calstat, sinks, soap, and papertowels are now available near every patient area and thereare no barriers to compliance that the staff can name. Thestaff is well educated on the risk of spreading infection andthe danger of hospital infections to their patients’ health.One month after the interventions are complete, the nursemanager observes practices in the ICU and finds thatcompliance has greatly improved, except for one nursewho routinely does not practice hand hygiene betweenpatients. When questioned, the nurse states he does nothave time to clean his hands between every patientcontact.Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityWhere We’re At With AccountabilityCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityThe Limitations of “No Harm No Foul”Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityMGH Credo As a member of the MGH community and in service of our mission, I believethat:–The first priority at MGH is the well-being of our patients, and all our work, including research, teaching andimproving the health of the community, should contribute to that goal.–Our primary focus is to give the highest quality of care to each patient delivered in a culturally sensitive,compassionate and respectful manner.–My colleagues and I are MGH’s greatest assets.–Teamwork and clear communication are essential to providing exceptional care.As a member of the MGH community and in service of our mission, I will:–Listen and respond to patients, patients’ families, my colleagues and community members.–Ensure that the MGH is safe, accessible, clean and welcoming to everyone.–Share my successes and errors with my colleagues so we can all learn from one another.–Waste no one’s time.–Make wise use of the hospital’s human, financial and environmental resources.–Be accountable for my actions.–Uphold professional and ethical standards.Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityMGH BoundariesAs a member of the MGH community and in service of ourmission, I will never:– Recklessly ignore MGH policies and procedures.– Criticize or take action against any member of the MGH community forraising or reporting a safety concern.– Speak or act disrespectfully toward anyone.– Engage in or tolerate abusive behaviors.– Look up or discuss private information about patients or staff for anypurpose outside of my specified job responsibilities.– Work while impaired by any substance or condition that compromisesmy ability to function safely and competently.Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityBo’s Law The fastest way to getyourself killed on a mannedspace flight is to not followstandard operatingprocedure The second quickest way toget yourself killed is toalways follow standardoperating procedureKarol Joseph "Bo" BobkoCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityAn Introduction to Just CultureThe single greatest impediment toerror prevention in the medical industry is“that we punish people formaking mistakes.”Dr. Lucian LeapeProfessor, Harvard School of Public HealthTestimony before Congress onHealth Care Quality ImprovementCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityAn Introduction to Just Culture“There are activities in which the degree ofprofessional skill which must be required is sohigh, and the potential consequences of thesmallest departure from that high standard are soserious, that one failure to perform in accordancewith those standards is enough to justifydismissal.”Lord DenningEnglish JudgeCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityAn Introduction to Just Culture“People make errors, which lead to accidents. Accidentslead to deaths. The standard solution is to blame thepeople involved. If we find out who made the errors andpunish them, we solve the problem, right?Wrong. The problem is seldomthe fault of an individual; it is thefault of the system. Change thepeople without changing thesystem and the problems willcontinue.”Don NormanThe Design of Everyday ThingsCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityWhat do we mean by “Just Culture”? Traditionally, health care’s culture has held individuals accountable for all errors ormishaps that befall patients under their care A just culture recognizes that individual practitioners should not be heldaccountable for system failings over which they have no control. A just culture also recognizes many errors represent predictable interactionsbetween human operators and the systems in which they work. Recognizes thatcompetent professionals make mistakes. Acknowledges that even competent professionals will develop unhealthy norms(shortcuts, “routine rule violations”). A just culture has zero tolerance for reckless behavior.Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityA Balanced AccountabilityWhat system ofaccountabilitybest supports ourvalues?Supportof SystemSafetyand OtherValuesAs applied to: Providers Managers Institutions t 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.Copyright 2007, Outcome Engineering, LLC. All rights reserved.

The Just CultureCommunityIt’s About a ProactiveLearning Culture Often, Events are Seenas Things to be Fixed Events Should Be Seenas Opportunities toInform Our Risk Model–System risk–Behavioral riskWhere management decisions arebased upon where our limitedresources can be applied tominimize the risk of harm, knowingour system is comprised ofsometimes faulty equipment,imperfect processes, and falliblehuman beingsCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.Copyright 2007, Outcome Engineering, LLC. All rights reserved.

The Just CultureCommunity3 Perspectives Creating The JustCulture Model Engineering Human Factors LegalCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityInputs and OutputsSystemDesignValues Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunitySometimes, the System Does Not Appear to WorkSystemDesignValues andExpectationsBehavioralChoicesCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityRealities of System Design Systems are never 100% reliable or “foolproof”– The space shuttle design is to have failures ofless 1/100 times (but there are tradeoffs)– Health systems are often far less reliableCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

The Just CultureCommunityThe Safety Task: Managing System ReliabilitySystem Reliability100%100%SystemFailureDesign forsystem reliability Human factorsdesign to reduce therate of errorBarriers to preventfailure Recovery to capturefailures before theybecome critical Redundancy to limitthe effects of failureSuccessfulOperation0%PoorGoodFactors Affecting System Performance knowing that systems will never be perfectCopyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.Copyright 2007, Outcome Engineering, LLC. All rights reserved.