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Just Culture Application Consoling Employees
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Just Culture Application Consoling Employees Stephanie Sobczak & Jill Hanson Quality Improvement Managers WHA 1
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Just Culture Application Consoling Employees. Stephanie Sobczak & Jill Hanson Quality Improvement Managers WHA. Today’s Call. Guest Speaker Chris Baker, St. Mary’s Hospital Application – Consoling Case examples using the Just Culture algorithm Next 30 days. Courtesy Reminders: - PowerPoint PPT Presentation
Transcript of Just Culture Application Consoling Employees
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Just CultureApplication
Consoling Employees
Stephanie Sobczak & Jill HansonQuality Improvement Managers
WHA
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Today’s Call
• Guest Speaker Chris Baker, St. Mary’s Hospital• Application – Consoling• Case examples using the Just Culture algorithm• Next 30 days
Courtesy Reminders: •Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) •Please do not take calls and place the phone on HOLD during the presentation.
Saint Mary’s HospitalMadison
Guest Presenter
Chris Baker, RN, PhD, MBAAdministrative Director
Quality and Safety Systems
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Q & A with Chris Baker• Could you briefly review St. Mary’s Just Culture
journey for us?
• Perhaps the biggest shift in Just Culture is treating near misses with similar importance and attention that we give to harmful outcomes. How have you done this at St. Marys?
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Q & A with Chris Baker
• How do you encourage front-line staff to report near misses?
• Can you describe your process for handling near misses?
Reviewing Past 30 DaysACTION ITEMS
Modify your existing event investigation processes (if needed)Use the Just Culture Algorithm to walk through a recent employee discipline scenarioBe prepared to discuss how the algorithm walk thru went during June’s webinar
Sharing Your Scenario Examples (choose one):• Send in a safety scenario example• Schedule a Just Culture scenario interview with WHA
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Group Discussion on Action Item
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Hands On Practice - JC Algorithm•Use the algorithm to walk through a recent employee discipline scenario
•Share what insights you discovered as a result
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Managing Human Error and Consoling Employees
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Human Error• Inadvertent action; inadvertently doing other
that what should have been done; slip, lapse, mistake
Just Culture Model• Console the person who has made the error• Address the system design
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Consoling ConversationIs one that acknowledges...• The event • The employee’s emotions
It also… • Provides an appropriate, comforting response• Helps to understand why the human error
occurred • Identifies how it can be managed in the future.
Scenario One
Group Discussion
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A lab tech is running a complete blood count for an emergency department patient.
When entering the values into the computer she transposes the red blood cell count value and the white blood cell count value.
The emergency department physician reads the incorrect white blood cell count and orders a large dose of broad spectrum antibiotics.
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Scenario One Questions• What would you need to know from the event
investigation?• Were any duties breached in this scenario? If yes,
which?
Now walk this scenario through the Just Culture Algorithm
• What is you assessment using the algorithm?• What action would you take based on your
assessment?
Scenario Two
Group Discussion
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An accountant working for a hospital is asked to give the lab manager a sense of how much budget they have left over at the end of the fiscal year.
This extra budget would be transferred to the mobile medical office – an under-funded service to support homeless people in the city.
When year-end spending was announced, the lab had overspent roughly $25,000, base in part on the accountant who incorrectly failed to account for some supply purchases made by the lab.
The lab manager was told in his performance review that he needed to maintain better control of his budget.
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Scenario Two Questions• What would you need to know from the event
investigation?• Were any duties breached in this scenario? If yes,
which?
Now walk this scenario through the Just Culture Algorithm
• What is you assessment using the algorithm?• What action would you take based on your
assessment?
Scenario Three
Group Discussion
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The nurse goes to the medication room to retrieve Demerol for her patient. She reaches into the bin and grabs the vial in the bottom right corner of the drawer. Next, she draws up the medication and administers it to the patient.
The pharmacy had made a change and placed Morphine in the slot where the Demerol used to be kept. The nurse actually gave the patient Morphine.
The patient had an allergic reaction and coded. Although they were able to revive him, he suffered anoxic injuries that resulted in right-sided paralysis.
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Scenario Three Questions• What would you need to know from the event
investigation?• Were any duties breached in this scenario? If yes,
which?
Now walk this scenario through the Just Culture Algorithm
• What is you assessment using the algorithm?• What action would you take based on your
assessment?
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The Next 30 DaysACTION ITEMSAssess current risk/event reporting system as it relates to Just Culture. Does it allow for reporting of good catches/near misses?
Determine if event reporting/near miss process is sufficient
Develop/modify process to routinely assess risk as it relates to a fair and just culture, if not done currently.
Thank You!Questions?
July 3rd Just Culture Webinar10-11 am
Case Studies – High Risk Clinical Processes
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