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

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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.

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• 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.

UPMC Culture of Patient Safety

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Blame Free or Punitive?

BLAME-FREE

CULTURE PUNITIVE

CULTURE

BLAME-FREE

CULTURE

PUNITIVE

CULTURE

A JUST CULTURE

Evolution of A Culture of Safety and Reliability

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• 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.

Our Story of “Just Culture”

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• 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.

Definition of “Just Culture” From Agency for Healthcare Research and Quality (AHRQ)

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Just Culture: A Piece of the Patient Safety Puzzle

Employee

AHRQ patient

safety survey

Structured

language:

• SBAR

• “I need

clarity”

Just Culture:

Accountability

for Patient

Safety

• Human error

• At-risk

behavior

• Careless

(reckless)

behavior

PILLARS OF FOCUS Leadership

Employee

rounding

Patient rounding

Patient/Family

Condition Help

Speak up

campaign

Environment

Safe work

environment

Regulatory

impact on

patient safety

LEARNING ORGANIZATION

DIGNITY & RESPECT

EXCELLENT CLINICAL OUTCOMES 9

What is Our Response to Serious Medical Error?

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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

Just Culture Algorithm

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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

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%

Sample Caregiver Peer Review: Magee-Womens Hospital of UPMC

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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

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• 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.

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In Summary: What is A Just Culture All About?

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-waa-

akam.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.

Sources

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