A Just Culture: Accountability for Patient Safety Mary Barkhymer MSN, MHA, RN, CNOR, CNO Team Lead - UPMC St. Margaret February 14, 2012
A Just Culture: Accountability for Patient Safety Today s Presenters: Mary C. Barkhymer, MSN, MHA, RN, CNOR Vice President, Patient Care Services & Chief Nursing Officer Peer Review Team Leads: Daniele Crisi-Couchenour, MHR Human Resource Manager, Human Resources Wendy Kastelic, MSN, RN Advanced Practice Nurse, Nursing Education Mary Jo Klebine, BSN, RN, CMSRN Clinician, 5A Medical/Surgical Unit Aimee K. Wilson, MSN, RN, ACM, CMSRN Manager, Care Management Karen L. Zanin, RN, CNOR IS Specialist, Surgical Services 2
Program Objectives 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 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 hospitals and/or on different units. We react because of the patient outcome. Negative perception among staff can have a chilling effect on their reporting of errors and near misses. Lack of reported information decreases the organization s ability to proactively address patient-safety issues and improve the existing work infrastructure. 4
Blame Free or Punitive? A JUST CULTURE BLAME-FREE BLAME-FREE CULTURE CULTURE PUNITIVE CULTURE PUNITIVE CULTURE 5
Evolution of A Culture of Safety and Reliability 6
Our Story of Just Culture We all want to work in a place where patients and staff are safe and treated 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 the potential for risk. THEREFORE... We are going to have rules to play by where staff are accountable to try hard 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 comfortable disclosing errors including their own while maintaining professional accountability. Recognizes that individual practitioners should not be held accountable for system failings over which they have no control. Does not tolerate reckless behavior, conscious disregard of clear risks to patients, or gross misconduct (e.g., falsifying a record, performing professional duties while intoxicated). Realizes that competent professionals make errors and acknowledges development of unhealthy norms (shortcuts, routine rule violations ). Focuses on fair, consistent, and predictable organizational responses to errors. 8
Just Culture: A Piece of the Patient Safety Puzzle PILLARS OF FOCUS Employee Leadership Patient/Family Environment 9 AHRQ patient safety survey Structured language: SBAR I need clarity Just Culture: Accountability for Patient Safety Human error At-risk behavior Careless (reckless) behavior Employee rounding Patient rounding Condition Help Speak up campaign LEARNING ORGANIZATION DIGNITY & RESPECT Safe work environment EXCELLENT CLINICAL OUTCOMES Regulatory impact on patient safety
What is Our Response to Serious Medical Error? Trouble... Trouble, trouble, trouble, trouble Trouble been doggin' my soul since the day I was born Worry... Worry, worry, worry, worry Worry just will not seem to leave my mind alone. Lyrics by Ray Lamontagne 10
Just Culture Algorithm 11
Sample Caregiver Peer Review: Magee-Womens Hospital of UPMC Peer Review Study: 50 Peer Reviews Completed Roles Peer Reviewed: RNs PCTs Pharmacy Techs Pharmacists Respiratory Therapists Laboratory Tech Types of Reviews: Medication Errors 56% Mislabeled Specimens 38% Handoff Errors 6% Behaviors Identified: Not an Error 2% Human Error 16% Risk 42% Careless 40% Processes Addressed: Verbal Orders Handoff Communication/Voicecare High Alert/Emergency Medications Alert Fatigue Allergies Specimen Labeling 12
Peer Review Process: UPMC St. Margaret Process: Peer review referral may be made by Patient Safety Officer, Department Manager or Staff Member Peer reviews not for malicious behavior, suspected staff impairment or 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 behavior 13
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
Sources California Hospital Patient Safety Organization. (2008). Just culture. California Hospital Patient Safety Organization. Retrieved October 18, 2011, from http://www.chpso.org/just/index.php Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350-383. General Electric Patient Safety Organization. (2011). The second victim. Retrieved October 18, 2011, from http://www-waaakam.thomson-webcast.net/us/dispatching/ge20110928 Hudson, P. (2001). Evolution of a culture of safety and reliability. Adapted from Safeskies 2001. Centre for Safety Science, Leiden University. 15