Just Culture Implementation – Phase 2 Using the Just Culture Algorithm

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Just Culture Implementation – Phase 2 Using the Just Culture Algorithm. Stephanie Sobczak and Jill Hanson WHA Quality Improvement Managers. Today’s Call. Implementation –Phase 3 Event Investigation Using the Just Culture Algorithm Case Scenarios. Past 30 Days. The Purpose of the Algorithm. - PowerPoint PPT Presentation

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  • Just CultureImplementation Phase 2Using the Just Culture AlgorithmStephanie Sobczak and Jill HansonWHA Quality Improvement Managers*

  • Todays CallImplementation Phase 3Event InvestigationUsing the Just Culture AlgorithmCase Scenarios*

  • *Past 30 Days

    ACTION ITEMSReview current incident reporting process and how the data is usedContinue working on your implementation planRequest Just Culture Algorithms from WHA, if you havent done so already

  • The Purpose of the Algorithm*

  • *by Alison H. Page, MS, MHA October 2007

    We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition.

    http://webmm.ahrq.gov/perspective.aspx?perspectiveID=50

  • *by Alison H. Page, MS, MHA October 2007

    Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership.

    http://webmm.ahrq.gov/perspective.aspx?perspectiveID=50

  • *by Alison H. Page, MS, MHA October 2007

    The Just Culture concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.

    http://webmm.ahrq.gov/perspective.aspx?perspectiveID=50

  • *Purpose of the AlgorithmTo consistently determine the actions taken as a result an investigation.To provide a mechanism to better understand near misses and degree of risk (dissociated from outcome).To clearly distinguish between Human Error, At-risk Behavior, and Reckless Behavior.

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  • Event Investigation*Gathering essential information about an event or situation prior to using the algorithm is key.

    Managers must be trained to conduct a good investigation of an event.

    For learning the Just Culture Algorithm, scenarios will provide the basic elements from an event investigation.

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  • Common Traps Guessing or assuming Ive seen this before. Not doing an investigation Not talking to the people involvedNot listening actively during discussions Arriving at a conclusion early

    (much more on this next month Training Managers)

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  • Identifying Events*We need to understand the details about these two elements

  • *1. Obtain basic event investigation information. 2. Apply Duty to Avoid Causing Unjustifiable Risk or Harm and apply corresponding actions. 3. Apply either: a. Duty to Follow a Procedural Rule and apply corresponding actions. b. Duty to Produce an Outcome and apply corresponding actions. 4. Is the event repetitive? Use Repetitive Human Errors or Repetitive At-Risk Behaviors. Algorithm Steps

  • *1. Obtain basic event investigation information. 2. Apply Duty to Avoid Causing Unjustifiable Risk or Harm and apply corresponding actions. 3. Apply either: a. Duty to Follow a Procedural Rule and apply corresponding actions. b. Duty to Produce an Outcome and apply corresponding actions. 4. Is the event repetitive? Use Repetitive Human Errors or Repetitive At-Risk Behaviors. Algorithm Steps

  • The Three Duties*Putting the organizational interest or value in harms way: Potential or actual harm to persons Potential or actual harm to property

  • *1. Obtain basic event investigation information. 2. Apply Duty to Avoid Causing Unjustifiable Risk or Harm and apply corresponding actions. 3. Apply either: a. Duty to Follow a Procedural Rule and apply corresponding actions. b. Duty to Produce an Outcome and apply corresponding actions. 4. Is the event repetitive? Use Repetitive Human Errors or Repetitive At-Risk Behaviors. Algorithm Steps

  • *Determine dutyA rule, process, or procedure is in place specifying how to perform the job.(The system is largely controlled by the employer)The employee knows what the goal is (or the outcome expected) but is not told how to reach the goal or achieve the outcome.(The system is largely controlled by the employee.)

  • *1. Obtain basic event investigation information. 2. Apply Duty to Avoid Causing Unjustifiable Risk or Harm and apply corresponding actions. 3. Apply either: a. Duty to Follow a Procedural Rule and apply corresponding actions. b. Duty to Produce an Outcome and apply corresponding actions. 4. Is the event repetitive? Use Repetitive Human Errors or Repetitive At-Risk Behaviors. Algorithm Steps

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  • Case Applications using the Just Culture Algorithm*

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  • *Hand Hygiene

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  • *Repetitive At-risk Behaviors

  • *Using the algorithm You core team should be comfortable using the algorithm:

    To learn, consider using your hospitals previously encountered cases to learn the algorithm.Try it with your colleagues stories/scenariosTrial it with new situations.

  • *We can learn from each otherDo you have a case the group can learn from?

    How?Write up a paragraph similar to those we used todayEmail it to Jill HansonWe prefer that you do not identify your facility in the case description, and we will not disclose your facility. If you wish to speak to the case yourself on a call, please let us know.

  • Upcoming MonthsFebruary Training Managers and Staff

    March - Event Investigation

    April Coaching at risk behaviors* Please contribute your cases*

  • The Next 30 Days*

    ACTION ITEMSRequest Just Culture Algorithms from WHA, if you havent done so alreadyIn your core team, practice using the Just Culture Algorithm with your hospital casesRelated to your implementation plan, discuss how you will introduce the algorithm to your management staff. Who will use the algorithm? In what circumstances?

  • Thank You!Questions?

    Stephanie SobczakJill Hanson*

    **This narrative by Alison Page (who is the current CEO at Baldwin) says it the best.*Create tool for assessment

    *Mortality and morbidity**Staff Safety Assessment Ask if individuals would like to share their findings any great observations by your co-workers1.Please describe how you think the next patient in your unit/clinical area will be harmed.2.Please describe what you think can be done to prevent or minimize this harmPOTENTIAL FOR WEBEX SURVEY

    *Staff Safety Assessment Ask if individuals would like to share their findings any great observations by your co-workers1.Please describe how you think the next patient in your unit/clinical area will be harmed.2.Please describe what you think can be done to prevent or minimize this harmPOTENTIAL FOR WEBEX SURVEY

    *Staff Safety Assessment Ask if individuals would like to share their findings any great observations by your co-workers1.Please describe how you think the next patient in your unit/clinical area will be harmed.2.Please describe what you think can be done to prevent or minimize this harmPOTENTIAL FOR WEBEX SURVEY

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