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Introduction To Creating Just Culture
Presented by [Marie Dotseth] (53-minute Webinar) [date e.g., 02-12-2014]
Kristi Wergin: Hello everyone, this is Kristi Wergin with Stratis Health, the Quality Improvement Organization in Minnesota. I’d like to welcome you to this educational session entitled Introduction to Creating a Just Culture.
Nursing Homes in the United States will soon be required to develop quality assurance performance improvement or QAPI. QAPI will take many nursing homes into a new realm in quality. A systematic, comprehensive, data driven, proactive approach to performance management and improvement.
One important component of QAPI is that the governing body ensures that while staff are held accountable, there exists an atmosphere in which staff are encouraged to identify and report quality problems, as well as opportunities for improvement. Leadership should be working on creating a climate of open communication and respect, where caregivers feel free to bring quality concerns forward without fear of punishment. This is sometimes referred to as a ‘just culture’.
We’re pleased to have Marie Dotseth as our guest speaker this afternoon, to help us get a better understanding of what a just culture is and how we can work to create it. Marie is the Executive Director for the Minnesota Alliance for Patient Safety (MAPS). This is Minnesota’s public and private patient safety coalition. She’s been in this role since July 2012. Marie was instrumental in helping organize MAPS in 2000, while working for the Minnesota Commissioner of Health at the State Health Department, and she’s been active in various MAPS committees and work group throughout its history.
Welcome Marie, and thank you for being with us today. Let me turn the presentation over to you.
Marie Dotseth: Thank you very much for inviting me to do this. I’m looking forward to giving the presentation and answering any questions you may have about just culture. It’s an interesting topic area and it’s challenging, but also very rewarding.
I’m going to talk to you briefly about MAPS, our rule in this whole thing and then I’ll talk a little about why a just culture and then we’ll go through an overview. It’s high level and won’t be a comprehensive presentation. One of the things Kristi didn’t mention is that prior to my work at MAPS I did consulting and worked with an organization called Outcome Engineering. I used to teach just culture across the country at different healthcare organizations, including long-term care organizations and this was a two-day introductory course.
Therefore, we’re only skimming the surface here, but hopefully I can leave you with enough to get started and point you in the direction of some other resources.
MAPS- some of you are familiar with this, and I wish we were all here in one room so I could get a better sense of who’s knows about this. We were established in 2000 by the Health Department, Medical Association and the Hospital Association.
A few years ago the group decided it was going on a bold new strategy to redefine itself, so five organizations, including Stratis Health came together to commit significant time and resources to basically recreate MAPS, hire staff, myself and a project manager and then we more actively recruited members from across the community and part of that active recruitment was going and seeking long-term care organizations, those being Care Providers and Aging Services of Minnesota have a seat on the MAPS board, and we’re now a 501(c)3 organization. That’s just a couple words about MAPS.
Now I’ll try to answer the question of why you should care about a just culture.
The simplest reason is that QAPI requires it, as Kristi just mentioned. From the overview, leaders need to create an environment where caregivers feel free to bring quality concerns without fear of punishment. In the self assessment for QAPI, the question is… has an organization established a culture in which caregivers are held accountable for their performance, but not punished for errors and do not fear retaliation for reporting quality concerns.
There is mention throughout the QAPI materials about the need to create a culture that has quality assurance and performance improvement built into it. So, one reason to do this is because it’s required by the new regulations. Another reason is that we like the concept of having a place to work and being an employer that is fair and just. We appreciate those values and who wouldn’t want to be fair, who wouldn’t want to treat folks in a fair way? I would argue, the reason we would want to work in an environment that was a just culture environment is because that’s the place where we can achieve constant learning and improvement.
It’s because we open ourselves up to learn about the risks in our environment. We won’t be able to understand what’s going on if every time someone raises their hand with a question or concern they get punished “to inform our risk model”… which is to get a better understanding of the risks around it. We aren’t going to get where we need to go by simply reacting to errors in advance. We really need to figure out what is going on with our humans and the systems they’re working in, before an adverse event occurs.
So this framework is a way for us to understand things before the bad things happen and to really redesign the way we provide the service, both the human and technical systems that support those outcomes. To circle back to the first reason you’d want to implement a just culture, is the reason QAPI is requiring it in the first place.
We all know that our adverse events, the things that result in a bad thing happening to the residents, to patients, to consumers, are just the tip of the iceberg.
§ They are really other things we sometimes call ‘near misses’. They are a lot more frequent that don’t result in any harm and they are at the tip of the pyramid.
§ Below that, we have to live with those adverse effects and human errors. Those are outcomes of whatever the system is that we designed to get those results.
§ Below that we have systems, for example, medication and administration systems or dietary systems or lifting systems, whatever they are in order to accomplish a task.
§ Then there is staff choices, behaviors or our managers and staff, which combined give us the adverse events and errors.
Now, what we’re hoping to achieve and why we have a just culture to get that feedback loop going, so we base everything on a culture that learns and that is just. A just culture really is all about supporting that learning culture and it focuses on the management of the system and behavioral choices and hopefully provides an objective and fair response to events that will ultimately happen.
Back in 2000, when the Institute of Medicine produced its report To Err is Human there was a lot of confusion about patient safety and resident safety. There was a leader that stepped forward with testimony to Congress over a decade ago. No physician or nurse/nursing assistant or administrator, wants to hurt our patients or residents. Everyone we work with is highly trained. They hold themselves to very high standards, but paradoxically it’s that focus on individual responsibility and our question to not make mistakes that we reinforce the punishment and makes healthcare so terribly unsafe.
The person that said that is Dr. Lucien Leep and in his testimony before Congress, he said the single greatest impediment to error prevention in the healthcare industry is that we punish people for making mistakes. Isn’t it ironic that we punish people for making mistakes and that’s actually impeding us from having safer healthcare? What he meant is that by having a blame/shame culture, we squash our ability to learn and prevent the next bad thing from happening.
With that as background, I’m going to talk about a scenario. Think about this. An experienced nurse manager sees a piece of resident lifting equipment at a conference. Back at the nursing home the sales rep persuades them to use the equipment for a lift. You’ve never used the equipment before and you accidentally drops a resident while positioning them. Other staff are present during this incident. The nursing home has a policy that says new equipment will be officially approved and training will be conducted prior to its use.
So, there are a couple things I want to point out about this scenario. First, is that on the far right hand side there is the box that says increased risk of resident harm. Notice in the scenario I didn’t say whether or not the resident got hurt seriously or otherwise, or whether there was no harmful outcome, because in a just culture model we try to approach things and the risk without regard to outcome. We try not to have an outcome bias.
If you were doing an event investigation, we have a couple things going on here. The error that happened was that the resident was dropped. That was something other than what was intended. We also had a manager using equipment without any training. Why? Usually we don’t go back far enough and ask why. We also had something else going on, in that the staff didn’t speak up and stop the action of the manager.
Therefore, where we find ourselves is that a lot of what’s going on goes unexplained and part of the just culture model is to be able to explain more of what’s going on and to understand more of what’s giving us the results that we’re getting. If you’re thinking about the best system you can design to support safety, you want it somewhere along that line of between blame free and punitive. There are a couple myths that I hope I can dispel as I go through this and hopefully one of them is that somehow a just culture is about being blame-free.
In some of the QAPI materials they talk about a blame-free reporting culture and while reporting is blame-free, having a blame-free culture isn’t the same as having a just culture. A just culture is an accountable culture that requires accountability at all levels, but we don’t blame the human error and you certainly wouldn’t blame reporting. So, we’re looking for that place between punitive and blame-free where we can get a maximum support for patient and/or resident safety.
What are the cornerstones of a just culture? We create an open fair and accountable culture, so systems and humans share the accountability, and all members are held to the same standards. We create a learning culture and I talked about that and the reason why we would want a just culture. We spend a lot of time in a just culture looking at safe system designs and thinking about those we have designed and the unintended consequences and the work-arounds that are created from our policies and procedures and think about better ways to design those systems. It focuses on managing behavioral choices of the human component of the system.
Just culture is all about shared accountability, it’s not blame free or overly punitive, but it’s about shared accountability and again the things we can control are system design and management of human behavior, which are the things we work on. We have to base it on a just culture, to help us to learn. Another way to look at it is where you start on the left with your value and expectation and today we’re talking about safety, quality and safety, but this would work around other values that an organization has.
For example, you could say we have expectations around customer satisfaction and there really is only two things we can do to affect our errors and outcomes, and we have to live with those, but we can design a system and manage behavioral choices, and those two combined will give us our errors and outcomes.
Now I’ll talk about safe system design and managing behavior, giving you some of the key components of a just culture in each of those areas. Those two things are key when talking about just culture.
Managing behavior – we have an example of sub-optimal behavior of Brittney Spears back in the day when she was driving with a small child on her lap. That’s obviously not the kind of behavior… that falls under reckless behavior and we’ll talk about the different categories soon. We can expect these three human behaviors to occur.
- Human error – inadvertent and doing other than what should have been done that we call it a slip, lapse or mistake.
- At risk behavior – defined is it’s a behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified.
I like using driving examples because it’s outside our healthcare world, but is something we all do daily and that we’re familiar with. In that risk behavior is that driving 5-7 miles over the speed limit. We’re making the choice to do it. We think it’s okay and most of the time it is, except on a day when there is black ice on the road or when suddenly we’re in a residential area and didn’t expect to be.
- Reckless behavior – that is a behavioral choice to consciously disregard a substantial and unjustifiable risk.
Again, an example of that would be drunk driving or not driving 5-10 miles over the speed limit, but 75 miles over the speed limit, like when you see people weaving in and out of traffic going clearly at a dangerous speed.
So those are the three kinds of behaviors and again, if we were in a room together I would ask you to give me your assessment on which type of behavior we see most often in work or other settings. I will tell you, pure human error is predictable, but fairly uncommon. Reckless behavior is also fairly uncommon and the one that’s tricky and is our most common behavior is the at-risk behavior. You’ll find that most often when you do event investigations. You will find that folks have figured out some type of work-around or some cutting corners and that’s where you’ll have your trickiest behavior.