(C20) Just Culture: The Critical Paradigm · PDF file Just Culture- Balancing safety and...

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Transcript of (C20) Just Culture: The Critical Paradigm · PDF file Just Culture- Balancing safety and...

  • 11/19/2019

    1

    (C20) Just Culture:

    The Critical Paradigm Shift Megan Anders, MD, MS, CPPS

    Assoc. Chair for Anesthesiology Safety and Quality, Univ. of Maryland School of Medicine

    Rebekah Friedrich, MS, RN, CCRN, CPPS Sr. Performance Improvement Leader, University of Maryland Medical Center

    Mangla Gulati, MD, CPPS, FACP, SFHM Chief Quality Officer, Associate CMO VP of Patient Safety & Clinical Effectiveness,

    University of Maryland Medical Center

    Nothing to Disclose

    Dr. Megan Anders, Rebekah Friedrich, and Dr. Mangla Gulati have no relevant financial or nonfinancial relationship(s) within the services

    described, reviewed, evaluated or compared in this presentation.

    Session Objectives

    After attending this session, you will be able to:

    1. Explain why a Just Culture is an essential precursor to High Reliability

    2. Identify key steps in sustaining cultural change

    3. Integrate lessons from our model into an implementation strategy for your organization

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    • Academic Medical Center • Two campuses in Baltimore • Home of Shock Trauma Center

    • 900 licensed beds • 10,400 staff • > 900 residents & fellows • 1,100 clinical faculty physicians

    • Annual encounters: • 32,200 inpatient • 441,500 outpatient

    University of Maryland Medical Center

    How can we be consistently excellent?

    High Reliability Organizations

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    MidtownDowntown

    50

    40

    30

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    0 MidtownDowntown

    50

    40

    30

    20

    10

    0

    2015/2016

    % P

    os iti

    ve R

    es po

    ns e 44%

    2018 47%

    Nonpunit ive Response to Er ror Domain

    AHRQ Safety Culture Survey: UMMC

    = AHRQ 50% benchmark

    47

    48 53

    62 66 66 67 69

    72 72

    80 82Teamwork

    Within Units

    Nonpunitive Response to Error

    2018 National Data* % Positive Response

    * Based on 2018 AHRQ Nationally-Reported Data

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    UMMC Just Culture Journey

    Readiness Train Sustain

    • Began December ’17 • Event reporting:

     62.7% from CY15 CY17 • Concern rates may decline

    without intervention 0 2000

    4000

    6000

    8000

    10000

    12000

    14000

    16000

    CY 15 CY 16 CY 17 CY 18

    # of event reports submitted at UMMC

    7,509 reports

    12,214 reports

    3-Phase Approach

    Readiness Train Sustain

    1.Establish core team 2.Perform Stakeholder Analysis 3.Form Steering Committee 4.Collect baseline data 5.Perform Policy review

    3. Form Steering Committee

    Exec. Sponsor President of Med. Staff Org. Process Owner (driver) VP of Human Resources Physician Champion VP of Operations CMO Hospital President CNO Risk Management Director of Patient Safety Legal VP of Ambulatory Services Director of PI & Quality GME Leader (DIO) VP of Professional Development

    Readiness Train Sustain

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    Readiness Train Sustain

    6. Create curriculum 7. Identify & train Instructors & Facilitators 8. Train leaders

    • Plan future training for new leaders

    9. Train frontline staff • Embed frontline training into orientation

    8. Train Leaders • 3-hour workshop • Required participants:

    Perform safety event follow-up

    Manage Staff Behavior

    CEO Supervisor SOM Dean, Assoc. Deans Unit/Department Medical Director

    SVPs, VP Lead NP/PA Department Chair Residency/FellowshipProgram Director

    Director HR Business Partner Division/Section Chief Chief Resident

    Manager Unit-Based Safety Clinician Service Line Quality Champion

    Readiness Train Sustain

    Human Error Product of our current system design and human tendencies

    Manage by changing: • Choices • Processes • Procedures • Training • Design • Environment

    At-Risk Behavior A choice: risk believed to be insignificant or justified

    Manage through: • Removing incentives

    for at-risk behaviors • Creating incentives

    for appropriate behaviors

    • Increasing situational awareness

    Reckless Behavior Conscious disregard of substantial and unjustifiable risk

    Manage through: • Remedial action • Punitive discipline

    Console Coach Discipline

    Behaviors in Just Culture

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    • Response is fair, considers: • System failures • THIS situation, context • THIS person’s knowledge • THIS person’s perception of risk

    • Response is more fair & consistent • Builds staff trust • Response is more fair & consistent

    • Reverse side is “toolkit” (next steps)

    Just Culture Algorithm

    A Case

    Case

    Step 1: Determine the action to evaluate

    • RN: 1 year experience in ICU

    • Sick patient • 4th dose of

    rocuronium this shift • Grabbed medication

    from wrong bin • Assumed had

    selected correct medication

    • Didn’t scan or check the med prior to administration

    • Administered insulin instead of roc.

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    Case • RN: 1 year

    experience in ICU • Sick patient • 4th dose of

    rocuronium this shift • Grabbed medication

    from wrong bin • Assumed had

    selected correct medication

    • Didn’t scan or check the med prior to administration

    • Administered insulin instead of roc.

    Case • RN: 1 year

    experience in ICU • Sick patient • 4th dose of

    rocuronium this shift • Grabbed medication

    from wrong bin • Assumed had

    selected correct medication

    • Didn’t scan or check the med prior to administration

    • Administered insulin instead of roc.

    At-Risk Behavior Coach

    • Referral to care for caregiver program • Recalibrate perception of risk • How prevalent is this behavior in larger

    group? • Manage through increasing situational

    awareness

    Case • RN: 1 year

    experience in ICU • Sick patient • 4th dose of

    rocuronium this shift • Grabbed medication

    from wrong bin • Assumed had

    selected correct medication

    • Didn’t scan or check the med prior to administration

    • Administered insulin instead of roc.

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    • How can someone accidentally administer insulin IV?

    Use the 5 Why’s • Insulin Aspart vial shouldn’t have been

    stocked in Pyxis  Removed all Insulin Aspart vials  Added to “do-not-load” list  Queried all other Pyxis machines

    Case

    Also assess for System Failure

    • RN: 1 year experience in ICU

    • Sick patient • 4th dose of

    rocuronium this shift • Grabbed medication

    from wrong bin • Assumed had

    selected correct medication

    • Didn’t scan or check the med prior to administration

    • Administered insulin instead of roc.

    Leader Training

    >1,300 leaders trained since January ‘19

    Leader Role Number Attended Vice President 32 Director 140 Manager 276 Supervisor 121 Lead NP/PA 29 Department Chair 27 Division Chief 110 Service Line Quality Champion 24 Medical Director 39 Residency/Fellowship Prgrm. Director 84 Chief Resident/Administrative Fellow 142 Other 114

    Leader Training Feedback

    Surveys given at 3-hour workshops; 1,107 responses

    4.0%

    2.0%

    0.6%

    0.9%

    0.1%

    0.1%

    How likely are you to recommend this class to your colleagues?

    The material and/or skills learned will be useful to my work.

    The material was presented in a logical and organized manner.

    Strongly agree Agree Disagree Strongly disagree

    67.7%

    58.6%

    53.3%

    31.4%

    39.3%

    41.8%

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    Workshop Feedback

    “Changed my mindset after an error occurs. Moving away from immediately thinking, "what level of corrective action does this fall under?”

    – Manager

    “I found the algorithm very helpful and a useful tool for further counseling. Cases were useful and helpful to apply the tool.”

    – Division Chief, Residency Program Director

    Readiness Train Sustain

    10. Embed into RCAs & Clinical Peer Review 11. Standing agenda item for leadership

    meetings 12. Future: Building resource website 13. Assess progress

    Just Culture in Action

    • S: patient was sent to wrong hospice facility • B: miscommunication between the social worker

    and the ambulance company

    • A: Human Error + System Failures • R:

    • Consoled devastated social worker • Decrease # of documentation systems • Developed new coverage plan

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    Interval Measures

    0%

    10%

    20%

    30%

    40%

    50%

    Multiple times per day

    Daily Weekly Mo