creating a just culture of accountability in long term care a just... · safety blame-free culture...

© 2016 MMIC. All rights reserved

Outcome Engineering, LLC

Curators of the Just Culture Community

Executive Briefing Presented by

MMIC

The transformation to a

Kristi EldredgeRN, JD, CPHRM

Senior resident Safety Consultant

MMIC

Culture of resident Safety

Creating a Just

Culture of

Accountability in

Long Term Care

Kristi EldredgeR.N., J.D., CPHRMSenior Risk and resident Safety Consultant


Advisory

This presentation has been abridged from a variety of

sources and is intended for informational and advisory

purposes only. MMIC does not undertake to establish

any standards of medical practice. This presentation is

has been provided as guidance relating to risk

management and claim prevention. Specific legal

advice should be obtained from a qualified attorney,

when necessary.

If you have any questions please contact MMIC.


The single greatest impediment to error prevention in

the medical industry is “that we punish people for making

mistakes.”


Accountability Spectrum

“There are activities in which the degree of professional

skill which must be required is so high, and the potential

consequences of the smallest departure from that high

standard are so serious, that one failure to perform in

accordance with those standards is enough to justify

dismissal.”

Lord Denning

English Judge


The problem statement

Support

of system

safety

Blame-free

culture

Punitive

culture

What system of accountability best

supports system safety?

As applied to:

•Operators

•Managers

• Institutions

•Regulators


System

design

Behavioral

choices

Adverse

events

Human

errors

Working it here (80%) Before it leads to here (20%)

Supporting a proactive culture

http://www16.brinkster.com/shipwrecks/post1950_hofe3.jpg


What we must believe about the

management of risk


Our beliefs about risk management

• To err is human

• To drift is human

• Risk is everywhere

• We must manage in support of our values

• We are all accountable

• Success can be measured


To err is human


MMIC Apology and Communication Position

Statement…To Err is Human

To err is human. That is, mistakes are an inevitable reality of the human

condition. It is critical to keep in mind that health care providers are human

too — and they make mistakes. The way in which they approach their mistakes

is what matters the most.

The importance of trust and communication

Timely and meaningful communication between health care providers and

their residents is imperative when an adverse outcome* occurs. This includes

an apology of regret,** which is fundamental to maintaining a respectful,

trusting and open relationship. An apology is a powerful and essential

component in the healing process for residents, families and clinicians alike.


To drift is human


Risk is everywhere

• Risk = severity x likelihood

– Risk can be a perception

– Risk can be an absolute

– Risk is not inherently bad


We must manage in support of our values

• Risk = Severity x Likelihood

• Safety ~ Reasonableness of Risk


Our values

Overlapping values?

Yes

Conflicting duties?

Yes

Still, we must prioritize and balance our duties in

support of our values

Public

access

Privacy

Health, safety

and comfort

Fiscal responsibility


Success can be measured

adverse events

(iatrogenic harm)

self-reports, audits,

observations,

interviews,

investigations

near misses

OutcomesError

ratesCulture

Safe systems

Behavioral

choices

Periodic gap

analysis


Managing system design


Managing system reliability

Factors affecting system performance

Poor Good

System

failure

Successful

operation

100%

0%• Human factors design to reduce the rate of error

• Barriers to prevent failure

• Recovery to capture failures before they become critical

• Redundancy to limit the effects of failure

Design for

system reliability…

… knowing that systems will never be perfect

System reliability


Managing human reliability

Factors affecting human performance

Poor Good

Human

error

Successful

operation

100%

0%

Design for human reliability…

… knowing humans will never be perfect

Human reliability

• Information

• Equipment/Tools

• Design/Configuration

• Job/Task

• Qualifications/Skills

• Perception of Risk

• Individual Factors

• Environment/Facilities

• Organizational Environment

• Supervision

• Communication


Seven design strategies

important to managing risk

• “Make no mistakes”

• Knowledge and skill

• Performance shaping factors

• Barriers

• Redundancy

• Recovery

• Perception of high risk


Managing behavior


The behaviors we can expect

• Human error – an inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.

• At-risk behavior – a behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.

• Reckless behavior – a behavioral choice to consciously disregard a substantial and unjustifiable risk.


Managing human error

• Two questions:

– Did the employee make the correct behavioral choices in

their task?

– Is the employee effectively managing their own

performance shaping factors?

• If yes, the only answer is to console the employee –

the error happened to them.


Managing multiple human errors

• What is the source of a pattern of human errors

– In the system? If yes, address the system.

– If no, can the repetitive errors be addressed through non-

disciplinary means?

– If no, how will disciplinary sanction reduce the rate of

human error?


Managing at-risk behaviors

"The best car safety device is a

rear-view mirror with a cop in it."

Dudley Moore



• A behavioral choice

– Driven by perception of consequences

• Immediate and certain consequences are strong

• Delayed and uncertain consequences are weak

• Rules are generally weak



• A behavioral choice

– Managed by adding forcing functions (barriers to prevent

non-compliance)

– Managed by changing perceptions of risk

– Managed by changing

– consequences


Managing reckless behavior

• Reckless behavior

– Conscious disregard of substantial and unjustifiable risk

• Manage through:

– Disciplinary action


The Three Behaviors

Reckless

behavior

Intentional Risk-Taking

Manage through:

• Remedial action

• Disciplinary action

At-risk

behavior

Unintentional Risk-Taking

Manage through:

• Removing incentives for

At-Risk Behaviors

• Creating incentives for

healthy behaviors• Increasing situational

awareness

Human

error

Product of our current

system design

Manage through

changes in:

• Processes

• Procedures

• Training• Design

• Environment

Console Coach Punish


Learning through events

• Learning

Learning through events


what happened?

why did it happen?

how were we managing it?

Increasing

value

The basics of event investigation


• Its not seeing events as

things to be fixed

• Its seeing events as

opportunities to inform

our risk model– System risk

– Behavioral risk

Where management decisions are

based upon where our limited

resources can be applied to

minimize the risk of harm,

knowing our system is comprised

of sometimes faulty equipment,

imperfect processes, and fallible

human beings

It’s about a proactive learning culture


The Just Culture algorithm


The Three Duties


The duty to avoid

causing unjustified risk

or harm

The duty to follow a

procedural rule

The duty to produce

an outcome

The Three Duties


Unacceptable rate of

undesired outcome

Product of Employee’s

System and Behaviors

Intervene in

employee’s system,

- or -

Consider:

• Remedial action

• Corrective action

Acceptable rate of

undesired outcome

Product of Employee’s

System and Behaviors

Continue to allow employee

to manage rate

Accept Punitive

The duty to produce an outcome


Reckless

behavior

Conscious disregard of

unjustifiable risk

Manage through:

• Remedial action

• Disciplinary action

At-Risk

behavior

A choice: risk believed

insignificant or justified

Manage through:

• Removing incentives

for at-risk behaviors


healthy behaviors• Increasing situational

awareness

Human

error


system design

Manage through

changes in:

• Processes

• Procedures


• Environment

Console Coach Punitive

The duty to follow a procedural rule


Reckless

violation

Intentional Risk-Taking

Manage through:

• Remedial action

• Corrective action

At-Risk

violation

Unintentional Risk-Taking

Manage through:

• Removing incentives for

At-Risk Violations


compliance• Increasing situational

awareness

Inadvertent

violation


system design

Manage through

changes in:

• Processes

• Procedures


• Environment

Console Coach Punitive

The duty to avoid causing

unjustifiable risk or harm


One physician’s view

“Education about Just Culture has aided my understanding and acceptance of our innate human frailty, the ubiquity of human error and how we are continuously surrounded by risk. Without better understanding of human error and risk, continuous learning and growth as leaders and mentors is limited.

In addition, Just Culture prepares us to understand and appropriately respond to unexpected outcomes, events and behaviors in fair, respectful and professional manners.

I believe that education in Just Culture should be mandatory in all disciplines of medical education. Serious consideration should be given for age-appropriate Just Culture curricula for elementary and secondary school children. The knowledge and application of Just Culture principles will become an important and critical building block for our communities and society.”

John W. Overton, Jr., M.D.

Cardiothoracic Surgeon and Board of Directors, Commission on Accreditation of Medical Transport Systems


Facility implementation steps

• Educate senior leadership

• Identify and mentor champions

• Gap analysis– Policy alignment

– Event reviews

– Cultural survey

• Educate managers

• Educate staff

• Measure success

• Continue improvement cycles


The culture change cycle

Oe product summary

Just Culture

training for

managers

Safe choices

training for

Management

accountabilities

Coaching

and

mentoring

System

design

Event

investigation

Management

benchmarking

Staff

benchmarking

Peer

review

Quarterly

coaching and

mentoring

Baseline

gap

analysis

Additional

tools and

training

Post

gap analysis

First cycle tools

Subsequent cycle tools

Multi-cycle Just Culture implementation

Base

line c

ulture

Culture

chang

e


It’s about reinforcing your

expectations of managers

• Knowing the risks

– Investigating the source of errors and at-risk behaviors

– Turning events into an understanding of risk

• Designing safe systems

• Facilitating safe choices

– Consoling

– Coaching

– Punitive


It’s about reinforcing your

expectations of staff

• Looking for the risks around them

• Reporting errors and hazards

• Helping to design safe systems

• Making safe choices

– Following procedure

– Making choices that align with organizational values


Just Culture - what’s it about?

• It’s about both error and drift

• It’s both pre- and post-event

• It’s about executive commitment

• It’s about values and expectations

• It’s about system design and behavioral choices

• It’s for all employees

• It’s partnership with the regulator

• It’s about doing the right thing


Our journey to a Just Culture…

What is a culture?

Your culture is what your

people are doing when

you are not looking!

What is a Just Culture?

Your Just Culture is KNOWING

what your people are doing

when you are not looking!

Sentinel Event Alert

Issue 40, July 9, 2008

Behaviors that undermine a culture of safety

47

Disruptive Behavior

48


Disruptive Behavior

49

Examples:

• Personal conduct that affects or may

affect resident care negatively

• Inappropriate language or behavior

• Non-constructive criticism

• Impertinent, inappropriate, and

jousting comments

Any behavior that shows disrespect for

others, or any interpersonal interaction

that impedes the delivery of resident

care.

Lucian Leape, adjunct professor of health policy at the Harvard School of Public Health, was cited in a recent articlesaying disrespect is the reason why so many residents leave the emergency room, why staff is "demoralized" and why medical errors persist.

Consequences of Disruptive Behavior

50

http://www.psmag.com/health/why-patients-leave-hospitals-with-a-bad-taste-in-their-mouth-47831/


Policies & Procedures

Zero tolerance

Medical staff

Non-retaliation clauses

resident and/or family

Response

Disciplinary

action


Effects of Disruptive Behavior

Contributes to

poor

resident/family

satisfaction

Fosters

medical

error

Contributes to

preventable

adverse outcomes

Increases cost of care

Causes qualified staff

to seek positions in

more professional

environments


Joint Commission Suggestions

Educate

Organizational Process

• Addresses intimidatingand disruptive behavior

• Solicits and integrates input from multi-disciplinary team

Accountability

• All team members must model desirable behavior

• Enforce code of conduct consistently and equitably

training & coaching

• All leaders, managers in relationship building and collaborative practice

• Feedback on unprofessional behavior and conflict resolution

• Skills for giving feedback on unprofessional behavior and conflict resolution

• Cultural assessment tools

Reporting/surveillance

system

Assessment

• Staff perceptions of seriousness and extent of unprofessional behavior and risk of harm to residents

• Code of conduct• Entire organization• Emphasize respect• Basic business etiquette &

people skills

Skill Based Training

• Detecting unprofessional behavior

• Possibly anonymous• resident advocates

Skills Based Training


Doves or hawks? Who are we?


Contact us

Kristi.Eldredge

@MMICgroup.com

952.838.6735

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