Session 49AB Examining the Just Culture Model: 20 Years Later

Transcription

1 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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3 Examining the Just Culture Model: 20 Years Later Disclosure of Relevant Financial 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 2 1

4 Faculty Joanne L. Sorensen DNP, RN, FACHE CNO, VP Patient Care Services UPMC Northwest Anne Pedersen MSN, RN, NEA-BC Director of Nursing UPMC Hamot 3 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. 4 2

5 Agenda 1. Thought leaders: a historical perspective Reason, Marx, Donabedian, & Leape 20 Year challenges and learning The impact of a limited focus 2. Current research 3. A Model for the Future Culture is local Concepts which support Just Culture 4. Case Studies 5. Outcomes 6. Conclusions 5 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) 6 3

6 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) 7 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 8 4

7 James Reason Swiss Cheese Model Worked with 3 Risk Industries Military Air Traffic Control Nuclear 9 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 10 5

8 Avedis Donabedian The Father of Quality Assurance The Donabedian Model Structures of Care Processes of Care Outcomes 11 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. 12 6

9 Lucian Leape MD Punishment of Individuals instead of changing systems provides strong incentives for under-reporting. 13 Lucian Leape Professional 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 14 7

10 Lucian Leape Professional 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 15 Lucian Leape Human Factors Research-Health Care Industry Mental functioning is automatic-schematic mode Skill-based efforts Attentional Control Modeconscious, used in problemsolving, takes effort Rule and Knowledge-based 16 8

11 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 17 In Fact.. The IOM has identified safety as a property of a health care system rather than of an individual, noting that moving from a culture of blame to one of learning and improving is one of the major challenges in creating a safer health care system. 18 9

12 Punitive culture creates fear, destroys creativity, builds barriers, and DRIVES ERROR UNDERGROUND. 19 The Second Victim 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. Institute for Safe Medication Practice accessed on January 2, 2015 at

13 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 21 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

14 Blame-Free vs. Punitive Cultures ORGANIZATIONAL CULTURES Blame-Free Punitive All errors are faults of the system, not individuals All errors are blamed on mistakes made by individuals A Just Culture finds the middle ground between a blame-free culture and an overly punitive culture 23 Just Culture Simplified Human Error Product of our current system design and behavioral choices Manage through: Choices Processes Procedures Training Design Environment Risk Behavior A Choice: Risk believed insignificant or justified Manage through : Removing incentives for at risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Careless Behavior Conscious disregard of substantial and unjustifiable risk Manage through : Remedial action Punitive action Console Coach Punish 24 12

15 Barriers to a Safety Culture Organizational commitment Poor teamwork Communication Culture of low expectations Pronounced authority gradients 25 Just Culture Current Research Efforts to develop a strong safety culture produce spillover effects. Abrahamson, et al

16 Just Culture Current Research 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 27 Just Culture Current Research: Key Relationships Patient Experience Open Communication Collaboration Commitment Patient Outcomes Mortality Readmissions AHRQ PSI HAPU 28 14

17 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 J Patient Safety 29 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 30 15

18 Current Research Summary Emerging recognition that a Safety Culture is LOCAL 31 Definitions: ANA Position Statement Just Culture Human Error Inadvertently doing other than what should have been done. System Risk Identification of system risk is critically important. It is about designing safe systems, structures, and processes of care

19 Definitions: ANA Position Statement Just Culture Reckless Reckless behavior is action taken with conscious disregard for a substantial and unjustifiable risk. Risk Behavior 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

20 Let s Give It a Try! Small Group Application Exercise 35 1: Case of the Expired Tubing System Situational Awareness: Policies & Procedures in place Dedicated Vascular Access Team Active CLABSI Champions HWST Zero CLABSI x 5 months 36 18

21 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:???

22 Audience Polling Select the outcome category of this case from the options listed below:... Answer Now 1. Human Error 2. Risky Behavior 3. Careless Behavior 4. System Error 5. Human Error + System Error 6. Risky Behavior + System Error 39 Case 2: It s Raining Pills! 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 40 20

23 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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25 Audience Polling Select the outcome category of this case from the options listed below:... Answer Now 1. Human Error 2. Risky Behavior 3. Careless Behavior 4. System Error 5. Human Error + System Error 6. Risky Behavior + System Error 45 3: Case of the Missing Screw 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 46 23

26 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:???

27 Audience Polling Select the outcome category of this case from the options listed below:... Answer Now 1. Human Error 2. Risky Behavior 3. Careless Behavior 4. System Error 5. Human Error + System Error 6. Risky Behavior + System Error 49 HOW DOES THE OUTCOME IMPACT OUR PERCEPTION OF THE EVENT? 50 25

28 Strategic Implications: 20 years later A comprehensive patient safety strategy is multifaceted: It depends on a fair and just response to errorleadership 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 51 Strategic Implications 5 Local Culture with Patient Safety Focus Just Culture Response to Error 1 Superior Outcomes 4 Local Leadership Safety Culture Simulation Practice Communication & Teamwork CRM Standardize Systems Focus

29 Outcomes 53 Tools & Concepts JCAT JC Concepts AHRQ COS Tool Magnet NDNQI My Voice Survey Feedback & Communication Openness of Communication Quality of eventreporting Continuous improvement Trust Balance Open Communication Error Feedback Reporting Frequency Support for Safety Non punitive Response Org Learning Overall Perception of Safety Staffing Supervisor Actions Teamwork Across Teamwork Within Facility Handoffs Foundations for quality of care Nurse manager ability, leadership & support Perceived quality Staffing & resource adequacy Collegial Nurse MD relationships Last shift description Recommend hospital, orientation, in services I can speak openly The people I work with help each other We deliver quality care & services A commitment to patient care is clear My supervisor acknowledges me for doing good work My leaders treats me with dignity & respect 6 Concepts 12 Domains Scales 42 Questions 54 27

30 Outcomes UPMC Hamot AHRQ COS MAGNET NDNQI Staffing Overall Perception of Safety Nonpunitive Response to Error Facility Management Support for Safety Frequency of Event Reporting Nurse Participation Hospital Affairs Nursing Foundations for Quality of Care Nurse Manager Ability, Leadership, and Support Staffing and Resource Adequacy Collegial Nurse- Physician Relationship Mean PES 55 Outcomes: Unit A vs B AHRQ Culture of Safety Overall Perception of Safety Management Support For Safety Unit A v Unit B: 2014 Communication Openness COS is local Unit A & B are next door Report up to the same leaders Different managers, issues & challenges Unit A Unit B

31 Outcomes: PACU My Voice Magnet NDNQI ARHQ Survey Teamwork within Hospital Unit Teamwork Across Hospital Units Supervisor Actions Promoting Safety Frequency of Event Reporting Communication Openness % 50% 60% 70% 80% 90% 100% 57 Outcomes: The OR My Voice Survey Magnet NDNQI Survey Large unit Tenured staff Leadership changes New leader, new values OR changed greatly between the 2 surveys Structure, staffing, leadership 58 29

32 NICU: An Exemplar AHRQ COS Director in role for 15 years hospital 43 years Deep commitment to patients and staff Exciting culture, evidence based, and research oriented 100.0% NICU AHRQ COS Overall Results 80.0% % 40.0% 20.0% % AHRQ 50% 59 The NICU: An Exemplar Magnet Magnet NDNQI Practice Environment Scale Nurse Participation Hospital Affairs Nursing Foundations for Quality of Care Nurse Manager Ability, Leadership, and Support Staffing and Resource Adequacy Collegial Nurse-Physician Relationship NICU Mean of Hospitals Bedsize

33 The NICU: An Exemplar My Voice My Voice Survey NICU Hospital System 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 61 Strategic Implications 5 Local Culture with Patient Safety Focus Just Culture response to error 1 Superior Outcomes 4 Local Leadership Safety Culture Simulation Practice Communication and Teamwork CRM Standardize Systems Focus

34 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 63 Data and Analysis: The System ORs 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 AHRQ COS Tool Open Communication Error Feedback Reporting Frequency Support for Safety Non punitive Response Org Learning Overall Perception of Safety Staffing Supervisor Actions Teamwork Across Teamwork Within Facility Handoffs My Voice Survey I can speak openly The people I work with help each other We deliver quality care & services A commitment to patient care is clear My supervisor acknowledges me for doing good work My leaders treats me with dignity & respect 12 Domains 42 Questions 64 32

35 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 Bolded correlations are statistically significant As the proportion of engagement increases in a unit, the culture of safety domains tend to improve as well 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 65 Conclusions Must Have C-Suite Backing May Have Physician buy in HR Alignment Staff Readiness Internal vs. External Resources Shared Governance Model 66 33

36 Conclusions 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! 67 Presenters Joanne L. Sorensen DNP, RN, FACHE Anne Pedersen MSN, RN, NEA-BC Chief Nursing Officer and Vice President of Patient Care Services at UPMC Northwest sorensenjl@upmc.edu Director of Nursing, Emergency, Critical, and Operative Services at UPMC Hamot pedersena@upmc.edu

37 Joanne Sorensen Biography Joanne Sorensen has been a nurse leader for 33 years in a variety of settings and roles and is currently the VP of Patient Care Services/CNO at UPMC Northwest. Previously she served as Clinical Director: Regulatory Readiness/ Women s Hospital at UPMC Hamot. She earned her DNP from Waynesburg University in 2011 where she is adjunct faculty. She was a member of the Pennsylvania State Board of Nursing from , chairing the board in Sorensen co-chaired the UPMC Health System implementation of a Just Culture. She is also a certified LifeWings instructor teaching the principles of CRM. Sorensen, the recipient of the 2015 Cameos of Caring Quality and Safety Nursing Award, has extensive process improvement experience and has developed and implemented nursing peer review incorporating a Just Culture. Sorensen has presented nationally and internationally on the concepts of Patient Safety and Safety Cultures. Joanne L. Sorensen DNP, RN, FACHE CNO, VP Patient Services UPMC Northwest 100 Fairfield Drive Seneca, PA Office: sorensenjl@upmc.edu 69 Anne Pedersen Biography Anne Pedersen MSN, RN, NEA-BC has been a nurse leader in a variety of settings for over 20 years. She earned her BSN at the University of Pittsburgh and MSN at UNC-Chapel Hill. She has published extensively in journals ranging from Nursing Management to the Journal of Nursing Administration. She has spoken nationally and internationally on a variety of topics including patient satisfaction, peer review, and the qualities of effective leadership. She is currently the Director of Nursing at UPMC Hamot in Erie, Pennsylvania. She has nurse executive oversight of implementing crew resource management in the ICUs, ED and trauma service lines. Anne Pedersen MSN, RN, NEA-BC Director of Nursing, UPMC Hamot 201 State Street Erie, PA Office: pedersena@upmc.edu 70 35

38 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), Agency for Healthcare Research and Quality. (2004) Safety culture dimensions and reliabilities: user s guide: hospital survey on patient safety culture. Accessed January 2, Albrecht, R. M. (2015). Patient safety: the what, how, and when. American Journal Of Surgery, 210(6), doi: /j.amjsurg Bashaw, E. S., & Lounsbury, K. (2012). Forging a new culture: blending Magnet principles with Just Culture. Nursing Management, 43(10), Best, M., & Neuhauser, D. (2004). Avedis Donabedian: father of quality assurance and poet. Quality & Safety In Health Care, 13(6), Bibliography/References Boysen II, P. G. (2013). Just Culture: A Foundation for Balanced Accountability and Patient Safety. Ochsner Journal, 13(3), DiCuccio, M. H. (2015). The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic Review. Journal Of Patient Safety, 11(3), doi: /pts Helbling, N., & Huve, J. (2015). Finding the balance for a culture of safety. Nursing2015, 45(12). Pp doi: /01.NURSE Leape L. (1994) Error in Medicine. JAMA, 272(23): doi: /jama 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), doi: /pts.0b013e31828fff