protecting the public through disciplinary action maryann alexander, phd, rn, faan kathleen russell,...
TRANSCRIPT
Protecting the Public through Disciplinary
Action
Maryann Alexander, PhD, RN, FAAN
Kathleen Russell, JD, RN
The Board’s Duty Is To Protect The Public
NotPunish The Licensee
Criminal Justice System
Punishment does not improve behavior Emphasis is needed on examining what
happened and how can we prevent you from doing this again.
Support and resources lessen the chance of recidivating.
TERCAP Data
Individuals disciplined by their employer have a much higher chance of being disciplined by the board of nursing at
sometime in the future
2012
200,000 people die from medical errors a year (Andel, et al, 2012)
More than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month. (HHS, OIG, 2012).
When quality life adjusted years (QALYs) are applied to patients that die, the errors committed on an annual basis translates into $1 trillion dollars a year (Andel, et al, 2012)
What does all this mean?
Regulation and health care facilities need to work together.
We need to effectively prevent errors. Examine system as well as individual errors. Punishment may not be the best option for
preventing future errors or poor performance.
Remediation, counseling, supervision are tools that need to be considered as part of disciplinary action.
Punishment
People tend to hide errors Prevents fixing the system Risk to patient
Focus is on punishment Effective when used in the right way.
Questions
When do we take no action? When do we counsel, remediate and
supervise? When do we punish/remove from practice?
a system of justice (disciplinary and enforcement action) that reflects what
we now know of socio-technical system design, human free will and our
inescapable human fallibility.
Just Culture
© 2012
The Just Culture Model (simplified)
RecklessBehavior
Conscious Disregard of Substantial and
Unjustifiable Risk
Manage through: • Remedial action• Punitive action
At-RiskBehavior
A Choice: Risk Believed Insignificant or Justified
Manage through:
• Removing incentives for at-risk behaviors
• Creating incentives for healthy behaviors
• Increasing situational awareness
HumanError
Product of Our Current System Design and Behavioral Choices
Manage through changes in:
• Choices• Processes• Procedures• Training• Design• Environment
Console Coach Punish
© 2012
System versus Individual Errors
System Errors
May be due to a deficit in the institution’s policies and/or procedures
May be due to other providers in the health care system
Often a combination of factors
Human Error
Human Error
Can happen to high performers with no history of past error
Discipline may not prevent Remediation may not be needed
Risk-Taking Behavior“Justifiable Risk”
Risk-Taking Behavior
May need remediation/counseling May need discipline/supervision
Reckless
the police.
Reckless
Discipline Remediation/supervision/counseling/job
transfer
© 2012
The Just Culture Model (simplified)
RecklessBehavior
Conscious Disregard of Substantial and
Unjustifiable Risk
Manage through: • Remedial action• Punitive action
At-RiskBehavior
A Choice: Risk Believed Insignificant or Justified
Manage through:
• Removing incentives for at-risk behaviors
• Creating incentives for healthy behaviors
• Increasing situational awareness
HumanError
Product of Our Current System Design and Behavioral Choices
Manage through changes in:
• Choices• Processes• Procedures• Training• Design• Environment
Console Coach Punish
A Single Event Repetitive Events
Repetitive errors – yes, there is a process
Repetitive at-risk behaviors – yes, there is a process
Both may lead to disciplinary action…
The Just Culture Model
Alternative to Discipline Programs Only effective if the remediation is truly
directed towards preventing future occurrence.
Monitoring and mentoring. Institution must be aware and involved.
Remediation
Deliberate Behavior
Discipline May warrant permanent revocation of
license
Regulatory Action Pathway
Consistent way of evaluating BON cases Based on principles of James Reason, Just
Culture, patient safety movement Transparent Patient centered Relies on remediation Partnership with hospitals
Regulatory Action Pathway
Encourage good choices beginning with reporting and identification of errors that might lead to better systems
Identify the difference between errors that are caused by human fallibility, risk-taking behaviors and recklessness
Direct discipline according to the type of error.
Regulatory Action Pathway Patient centered Examines intention and distinguishes
between types of errors Encourages reporting of errors Encourages partnership between BON and
institution Emphasis on corrective activities Accounts for system related issues Looks at repeated occurrences Discipline when needed
