The Role of Just Culture in a Culture of Safety

Katherine J. Jones, PT, PhD

University of Nebraska Medical CenterAugust 14, 2012

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• Define Just Culture• Explain the role of Just Culture

in establishing a Culture of Safety

• Define Disruptive Behavior• Explain the importance of

managing disruptive behavior in an overall patient safety program

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Objectives

What is a Culture of Safety?

• Enduring, shared, LEARNED1 beliefs and behaviors that reflect an organization’s willingness to learn from errors2

• Four beliefs present in a safe, informed culture3

– Our processes are designed to prevent failure– We are committed to detect and learn from error– We have a just culture that disciplines based on risk– People who work in teams make fewer errors

2. Wiegmann. A synthesis of safety culture and safety climate research; 2002. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf 3. Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004.

1. Schein, E. Organizational Culture and Leadership. 4th ed. San Francisco, CA: John Wiley & Sons; 2010.

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Four Components of Safety Culture

SENSEMAKING

TRUST

A culture of safety is informed. It never forgets to be afraid…

Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited.

Battles et al. (2006). Sensemaking of patient safety risks and hazards. HSR, 41(4 Pt 2), 1555-1575.

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Reason’s Components HSOPS Dimension or Outcome Measure

Just Culture - management will support and reward reporting; discipline occurs based on risk-taking

•Nonpunitive Response to Error (U)

O = Outcome measureU = Measured at level of unit/departmentH = Measured at level of hospital 5

12. Nonpunitive Response to Error

1. Staff feel like their mistakes are held against them. (A8R)

2. When an event is reported, it feels like the person is being written up, not the problem. (A12R)

3. Staff worry that mistakes they make are kept in their personnel file. (A16R)

Weakness

56% 24% 21%

40% 31% 29%

49% 30% 21%

Positive Neutral Negative

• If Item labeled with “R” then it is positive to DISAGREE

• Bigger numbers always better• Positive is positive for patient safety

Reverse-Worded Items

*Green Bar = % DISAGREE/STRONGLY DISAGREE for REVERSE-WORDED ITEMS

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*

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JUST CULTURE…the attitudes and practices within

health care organizations that support a system of shared

accountability in determining the root causes of medical errors and

adverse events. Personal Communication, David Marx, outcomengenuity http://www.outcome-eng.com/

Role of Just Culture…Build Trust• Questioning attitude

• Resistance to complacency

• Commitment to excellence

• Individual accountability for behavior

• Management accountability for systems

• Replaces a culture of silence with a culture of learning

Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited.

• Inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.

• Behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.

• Behavioral choice to consciously disregard a substantial and unjustifiable risk

Human BehaviorSource: Outcome Engenuity

Reckless Behavior

At-Risk Behavior

Human Error

RecklessBehavior

Conscious Disregard of Substantial and Unjustifiable

Risk

Manage through: • Remedial action• Punitive action

At-RiskBehavior

A Choice: Risk Believed Insignificant or Justified

Manage through:

• Removing incentives for at-risk behaviors

• Creating incentives for healthy behaviors

• Increasing situational awareness

HumanError

Product of Our Current System Design and Behavioral Choices

Manage through changes in:

• Choices• Processes• Procedures• Training• Design• Environment

Console Coach Punish

The Three BehaviorsSource: Outcome Engenuity

Current State

• Non punitive approach– Does not factor in individual accountability

and behavioral choices

• Culture of Shame and Blame in which fear of discipline– Limits reporting– Inhibits learning– Often unfair or unjust– Severity bias (outcomes dependent)

• Implementing Just Culture = transformational change– Clearly define the change– Ensure support: management, board, medical staff– Champion to overcome barriers– Change is a priority– Resources to train managers – Hardwire change

• Policies/procedures modified to sustain the change• Job descriptions/performance evaluations changed• Evaluate effectiveness of change

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Organizational Strategy

Helfrich CD, et.al. (2007). Determinants of implementation effectiveness: Adapting a framework for complex innovations. Medical Care Research and Review;64(3):279-303.

Statewide StrategyAdoption of the principles of Just Culture at all levels of healthcare across a state

Public

Providers/ Facilities

Professional Organizations

Regulatory Bodies

Action Planning: A Just culture is engineered…

Practices/Tools• Understanding human error (Reason 2003, 2006)

– Active errors (sharp end)– Latent errors

• Just Culture principles and behavior (Marx, 2001)

– Conduct: human error, negligence, reckless, intentional rule violation

– Shared accountability: managers & individuals/systems & individual behavior

– Disciplinary decision-making: outcome-based, rule-based, risk-based

• Unsafe Acts Algorithm • Disruptive Behavior Policy/Standards

Human Factors

Known medicalcondition?

NO NO NO YES

NOYES

YES

YES

YESNO

YES

YES NO

Culpable Gray Area Blameless

NOYES

YESNO

Adapted from James Reason. (1997). Managing the Risks of Organizational Accidents.

UNSAFE ACTS ALGORITHM

Were the actions as intended?

Evidence of illness or substance use?

Knowingly violated safe procedures?

Pass substitutiontest? (Could someone else have done the same thing)?

History of unsafe acts?

Were the consequencesas intended?

Were proceduresavailable, workable, intelligible, correct and routinely used?

Deficiencies in training, selection, or inexperienced?

Substance abusewithout mitigation

Sabotage, malevolent damage

Substance usewith mitigation

Possible recklessviolation

System inducedviolation

Possible negligentbehavior

System inducederror

Blameless error, corrective training, counseling indicated

Blameless error

NO

Just Culture Action Plan

1. A consistent approach to operationalizing a just and fair culture across the hospital regardless of profession or hierarchy. a. Goal: Improve aggregate perceptions of Nonpunitive Response to

Error by 5% or more at the next HSOPS reassessment b. We will do this by implementing the following interventions:

i. Providing training about human factors and active vs. latent causes of errorsii. Training managers to use Algorithms to balance individual and systems

accountabilityiii. Training managers to collaborate with human resources and discipline individuals

based on at-risk and reckless behavior and not on outcomesiv. Implement a policy/procedure to manage disruptive behavior.

c. Identify where this change will occur…hospital-wide or a specific work area?

d. Identify when this change will occur

Definition of Disruptive Behavior

Disruptive behavior is any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or sexual harassment. Disruptive behavior causes strong psychological and emotional feelings, which can adversely affect patient care. Rosenstein A, O’Daniel M. (2008). Managing disruptive

physician behavior: Impact on staff relationships. Neurology, 70, 1564-1570.

Example of Disruptive Behavior from AHRQ HSOPS

“A lot depends on who you work with. Communication is poor. You walk on egg shells whenever you go to work. I think everyone should have to work all shifts and maybe they wouldn't cut down the ones that work all shifts.”

Change the Frame of Reference• Disruptive Behavior: Old frame of reference

– Tolerate the behavior as a way of doing business– Shrug off problem; minor occurrence, no ill effects to patients or

staff• Disruptive Behavior: New frame of reference

– Disruptive behaviors have profound effect on safety and quality – Not unique to physicians or healthcare– Consequences permeate the organization

• Affect staff morale, patient and family• Community perceptions and hospital reputation.

– Hospitals can no longer take a passive approach to disruptive behaviors

Rosenstein A, O’Daniel M. (2008). Managing disruptive physician behavior: Impact on staff relationships. Neurology, 70, 1564-1570.

Strategy to Address Disruptive Behavior• Raise awareness – conduct survey • Develop policies/procedures

– Code of behavior– Confidential reporting system– Enforcement—interdisciplinary staff relations

committee– Follow-up and feedback to reporters and all staff

• Education – Link behavior to adverse events– Communication and teamwork using TeamSTEPPS

toolsRosenstein A, O’Daniel M. (2008). Managing disruptive physician behavior: Impact on staff relationships. Neurology, 70, 1564-1570.

Leaders Engineer Culture

“…it is the unique function of leadership to perceive the functional and dysfunctional elements and to manage cultural evolution and change.”

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Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco: John Wiley & Sons; 2010.

Contact Information

Katherine Jones, PT, PhD kjonesj@unmc.edu

Anne Skinneraskinner@unmc.edu

Web site where tools are posted www.unmc.edu/rural/patient-safety

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