Building a Just Culture

Transcription

1 Approved by: Building a Just Culture President and Chief Executive Officer Corporate Policy & Procedures Manual Policy No. III-35 Date Approved September 13, 2011 Next Review October 2014 Purpose The purpose of this policy is to outline Covenant Health s commitment to a just culture which guides the organization s approach to reporting, response to, and management of adverse events, close calls and hazards. A just culture improves safety of care and services as it encourages the reporting and discussion of adverse events, close calls and hazards. A just culture acknowledges error as fact, and does not punish individuals for system failures of which they have no control over but reinforces the need for professional accountability. This policy is aligned with the Covenant Health Board of Directors Just Culture policy. Policy Statement Applicability Responsibility Principles Covenant Health supports a just culture approach to the reporting, response to, and management of adverse events, close calls and hazards. Healthcare providers and staff are to feel supported, safe and comfortable in sharing event details for the purpose of wider learning and system improvement. This policy and procedure applies to all Covenant Health facilities, staff, physicians, volunteers, students and any other persons acting on behalf of Covenant Health. All Covenant Health staff, physicians, volunteers, students and any other persons acting on behalf of Covenant Health will support a just culture by providing appropriate care and support to patients, residents and/or families and to healthcare providers involved, demonstrating a commitment to system improvement, and maintaining professional accountability. The guiding principles of a just culture are: 1. Errors do occur Despite the dedication, training, education and best intentions of professionals, errors do occur and unhealthy norms may develop (eg. shortcuts, routine rule violations ). Most errors, whether or not they cause harm, are due to breakdown in organizational systems (eg. environmental, communication, human factors), and not individual performance. 2. Non-punitive reporting Healthcare providers and staff shall not incur repercussion (eg. discipline, suspension, coercion, dismissal) from colleagues or the organization for identifying and reporting adverse events, close calls and hazards. 3. Recognition of appropriate system and professional accountability A just culture does not mean the absence of culpability in appropriate circumstances (see Appendix 1). Healthcare providers and staff are accountable for their own performance in accordance with their job responsibilities and Covenant Health values. However, individuals shall not be held accountable for system failures over which they have little or no control over (see Appendix 1). Individuals are often blamed when system errors do occur, which creates a culture of fear and defensiveness that diminishes both the learning opportunity and the capacity to

2 Building a Just Culture Policy No. III-35 Page 2 of 6 continuously improve quality and patient/resident safety. Refer to Covenant Health Corporate Policy and Procedure #III-45 Responding to Adverse Events, Close Calls and Hazards. 4. Safe and supportive environment Covenant Health is committed to providing a safe environment that allows and encourages openness and frankness in identifying and reporting adverse events, close calls and hazards. Healthcare providers and staff should feel safe and supported in sharing details for the purpose of wider learning and system improvement. When adverse events, close calls and hazards occur, healthcare providers and staff will be provided with full support in the management of, and recovery from these events. This includes services such as Critical Incident Stress Management (CISM), Employee and Family Assistance Program (EFAP), Spiritual Care, Human Resources, Quality and Patient Safety Office, and others. 5. Interdisciplinary learning and system improvement - A just culture focuses on discovery, learning and sharing in a multi-disciplinary and collaborative environment in order to identify system improvements that will reduce the likelihood of similar occurrence in the future. 6. Disclosure Prompt and transparent disclosure is an important element of a just culture. Relationships between healthcare providers and patients/residents should be built on trust and open communication. By sharing information in an open, honest and timely manner, collaborative relationships with patients, residents and their families is promoted and developed. Refer to Covenant Health Corporate Policy and Procedure #III-40 Disclosure of Adverse Events, Close Calls and Hazards. 7. Zero tolerance for reckless behavior While a just culture acknowledges that mistakes will be made, there is zero tolerance for conscious disregard of risk to patients/residents or recklessness. Covenant Health will not tolerate any reckless behavior, and/or willful violations that puts patients, residents, healthcare providers and staff at risk or results in abuse. Incidences involving such behavior will result in disciplinary action and/or termination. EXCEPTIONS Exceptions to just culture are: 1. Deliberate and intentional acts to harm or deceive 2. Evidence of criminal activity 3. When an individual knew or reasonably ought to have known harm would result 4. Recklessness (action without care or thought of consequences) 5. Deviations from approved practices without justification 6. Demonstrated lack of competency 7. Unprofessional conduct as defined by the Health Professions Act (HPA) Definitions Adverse Event An unexpected/unplanned event that reaches the patient/resident and results in no harm, harm (minimal to severe) or death.

3 Building a Just Culture Policy No. III-35 Page 3 of 6 Apology Close Call Disclosure Harm Hazard Healthcare Provider Just Culture Nonpunitive Reporting Patient or Resident Reckless Behaviour Staff Substitute Decision Makers (SDMs) An expression of sympathy or regret. As per the Apology Act (Alberta Evidence Amendment Act, 2008), an apology is not an admission of fault or liability. An event that could have caused harm but was prevented from reaching the patient/resident The process of communicating an adverse event, and where appropriate close call or hazard, to a patient/resident or substitute decision maker (SDM) by healthcare providers. An outcome for the patient/resident, resulting from the care and/or services provided, that negatively affects the patient s/resident s health and/or quality of life. A situation or circumstances that could escalate into an adverse event or close call (eg. equipment malfunction) Those involved with the delivery of healthcare services to patients/ residents on behalf of Covenant Health. An atmosphere of trust in which people are encouraged to report adverse events, close calls and hazards. Individuals will not be punished for reporting adverse events, close calls and hazards, and shall not incur repercussions for sharing details of an event. An individual who receives treatment or services including provision of health information from a healthcare provider on behalf of Covenant Health. Involves an individual taking a reckless and unjustifiable risk knowing, or ought to have known, that there is a potential that harm would result from the action. An Individual employed by Covenant Health including contracted service providers. Substitute decision makers (SDMs) include agents pursuant to a personal directive, legal guardians, co-decision makers, and specific decision makers. SDMs include the following: 1. Agent pursuant to a personal directive 2. Legal guardian pursuant to Adult Guardian and Trusteeship Act (AGTA) the and Child, Youth, Family Enhancement Act or court order 3. Co-decision makers pursuant to AGTA 4. Specific decision maker pursuant to AGTA which may include family members in the following order: i. Spouse or interdependent partner

4 Building a Just Culture Policy No. III-35 Page 4 of 6 ii. adult son or daughter iii. father or mother iv. adult brother or sister v. grandfather or grandmother vi. adult grandson or granddaughter vii. adult uncle or aunt viii. adult nephew or niece In the absence of any of the above, the substitute decision maker will be the Public Guardian. Willful Violations When an individual knew or foresaw the result of the action, but went ahead and did the action anyway. Related Documents References Revisions 1. #III-40 Disclosure of Adverse Events, Close Calls and Hazards 2. #III-45 Responding to Adverse Events, Close Calls and Hazards 3. Our Commitment to Ethical Integrity, Covenant Health Code of Conduct, Adult Guardian and Trusteeship Act. RSA 2009, Chapter A-4.2. Available online at 2. Child, Youth, Family Enhancement Act. RSA 2000, Chapter C-12. Available online at 3. Health Professions Act. RSA 2000, Chapter H-7. Available online at 4. Marx, David. Patient Safety and a Just Culture : A Primer for Healthcare Executives. New York: Columbia University, National Health Service. National Patient Safety Agency. Incident Decision Tree Reason, James. Human Error: Models in Management. British Medical Journal 320 (2000): Reason, James. Managing the risks of organizational accidents. Aldershot: Ashgate Publishing Limited, NA

5 APPENDIX 1 INCIDENT DECISION TREE Based on James Reason s culpability model. National Patient Safety Agency

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