A Just Culture: Accountability For Patient Safety

A Just Culture:Accountability for Patient SafetyMary Barkhymer MSN, MHA, RN, CNOR, CNOTeam Lead - UPMC St. MargaretFebruary 14, 2012

A Just Culture:Accountability for Patient SafetyToday’s Presenters:Mary C. Barkhymer, MSN, MHA, RN, CNORVice President, Patient Care Services& Chief Nursing OfficerPeer Review Team Leads:Daniele Crisi-Couchenour, MHRHuman Resource Manager, Human ResourcesWendy Kastelic, MSN, RNAdvanced Practice Nurse, Nursing EducationMary Jo Klebine, BSN, RN, CMSRNClinician, 5A Medical/Surgical UnitAimee K. Wilson, MSN, RN, ACM, CMSRNManager, Care ManagementKaren L. Zanin, RN, CNORIS Specialist, Surgical Services2

Program Objectives Describe the safety concept of A Just Culture. Introduce UPMC’s A Just Culture Algorithm as a toolfor evaluating patient-safety events. Highlight the use of A Just Culture principles in the frontlinestaff peer-review process.3

UPMC Culture of Patient Safety UPMC fosters a ―nonpunitive response to error‖: Range of ―agree‖ responses: 28%-43% Number of hospitals surveyed: 12– Perception is that same error is treated differently at different hospitalsand/or on different units.– We react because of the patient outcome.– Negative perception among staff can have a ―chilling effect‖ on theirreporting of errors and ―near misses.‖– Lack of reported information decreases the organization’s ability toproactively address patient-safety issues and improve the existing workinfrastructure.4

Blame Free or Punitive?A JUST PUNITIVECULTURECULTURE

Evolution of A Culture of Safety and Reliability6

Our Story of “Just Culture” We all want to work in a place where patients and staff are safe andtreated with dignity and respect. Nobody comes to work wanting to do the wrong thing. We know that we have the opportunity to do better every day. We know that everyone has everyday workarounds that create thepotential for risk.THEREFORE . . . We are going to have rules to play by where staff are accountable to tryhard and play by those rules. If someone plays by the rules and makes an error, they are safe. They are safe to tell us about the error. We will listen, console, and address system failures. We will share our learning to prevent future errors.7

Definition of “Just Culture”From Agency for Healthcare Research and Quality (AHRQ) Supports a culture where frontline personnel feel comfortabledisclosing errors—including their own—while maintainingprofessional accountability. Recognizes that individual practitioners should not be heldaccountable for system failings over which they have no control. Does not tolerate reckless behavior, conscious disregard of clearrisks to patients, or gross misconduct (e.g., falsifying a record,performing professional duties while intoxicated). Realizes that competent professionals make errors andacknowledges development of unhealthy norms (shortcuts, ―routinerule violations‖). Focuses on fair, consistent, and predictable organizationalresponses to errors.8

Just Culture: A Piece of the Patient Safety PuzzlePILLARS OF FOCUSEmployeeLeadershipAHRQ patientsafety surveyEmployeeroundingStructuredlanguage: SBAR “I needclarity”Patient roundingPatient/FamilyCondition HelpSpeak upcampaignEnvironmentSafe workenvironmentRegulatoryimpact onpatient safetyJust Culture:Accountabilityfor PatientSafety Human error At-riskbehavior Careless(reckless)behaviorLEARNING ORGANIZATIONDIGNITY & RESPECTEXCELLENT CLINICAL OUTCOMES9

What is Our Response to Serious Medical Error?Trouble.Trouble, trouble, trouble,troubleTrouble been doggin' my soulsince the day I was bornWorry.Worry, worry, worry, worryWorry just will not seem toleave my mind alone .Lyrics by Ray Lamontagne10

Just Culture Algorithm11

Sample Caregiver Peer Review:Magee-Womens Hospital of UPMCPeer Review Study: 50 Peer Reviews CompletedRoles Peer Reviewed: RNs PCTs Pharmacy Techs Pharmacists Respiratory Therapists Laboratory TechTypes of Reviews: Medication Errors 56% Mislabeled Specimens 38% Handoff Errors 6%12Behaviors Identified: Not an Error 2% Human Error 16% Risk 42% Careless 40%Processes Addressed: Verbal Orders HandoffCommunication/Voicecare High Alert/EmergencyMedications Alert Fatigue Allergies Specimen Labeling

Peer Review Process:UPMC St. MargaretProcess: Peer review referral may be made by Patient Safety Officer,Department Manager or Staff Member Peer reviews not for malicious behavior, suspected staff impairmentor Code of Conduct Staff and patient information are blinded Peer review meeting scheduled with Peer Review Team Behaviors are identified by review of standard algorithm questions Process and education recommendations reviewed Manager instructed to consult HR if repeated careless behavior13

In Summary:What is A Just Culture All About? It’s about raising your hand. It’s about doing the right thing. It’s about making the right choices. It’s about treating everyone fairly. It’s about creating a learning environment. It’s about prevention. It’s about doing something about it.14

SourcesCalifornia Hospital Patient Safety Organization. (2008). Justculture. California Hospital Patient Safety Organization.Retrieved October 18, 2011, fromhttp://www.chpso.org/just/index.phpEdmondson, A. (1999). Psychological safety and learning behaviorin work teams. Administrative Science Quarterly, 44(2), 350-383.General Electric Patient Safety Organization. (2011). The secondvictim. Retrieved October 18, 2011, from ing/GE20110928Hudson, P. (2001). Evolution of a culture of safety and reliability.Adapted from Safeskies 2001. Centre for Safety Science, LeidenUniversity.15

Describe the safety concept of A Just Culture. Introduce UPMC’s A Just Culture Algorithm as a tool for evaluating patient-safety events. Highlight the use of A Just Culture principles in the frontline staff peer-review pro