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Just Culture in
Healthcare
Ahmad Thanin
Introduction
Just culture is an atmosphere of trust in which healthcare workers are
supported and treated fairly when something goes wrong with patient care.
Just culture is important to patient safety as it creates an environment in which
people (healthcare workers and patients) feel safe to report errors and
concerns about things that could lead to patient adverse events.
Reports of errors and patient safety hazards are important sources of
information about weaknesses in the system that need to be addressed by a
learning culture to improve patient safety.
Goal of Just Culture
The goal of a “Just Culture” environment is to design
safe systems that will reduce the opportunity for
human error and capture errors before they reach the
patient.
Safe systems should facilitate the staff to make good
decisions and should make it more difficult to make
an error. However, it is up to individuals to manage
their behaviors and choices.
Overview
• The culture of health care in the past focuses on placing blame on healthcare providers
whenever there was an error or bad outcomes occurred.
• With this kind of culture, health care providers were hesitant to report any errors due to fear of
punishment.
• As a result, such occurrences were never reported.
The Past
• To improve reporting of errors, organizations moved to blameless culture, however, this type of
culture did not succeed due to lack of accountability and the practice did not promote a
learning environment that promoted patient safety.
• Today, the focus of health care is patient safety, and “Just Culture” balances the assessment of
systems, processes and human behavior when an error or event is reported.
The Present
How would
your
organization
deal with ?
Wrong prescription from a doctor.
Ignoring the patient ring bell.
Nurse miss 2 dose antibiotics.
Giving fake lab result.
Sleeping on duty,
Pre-Documentation.
Leave duty without endorsement
is there any
possibility
for error ?
How do you describe
this behavior?
Who are we going to blame?
Do you have comment?
What is the
difference?
Key questions
Why did
these
accidents
happen?
What can
we do to
prevent
them from
happening
again?
How do we
judge the
people
involved?
A Model that Focuses on Three Duties balanced
against Organizational and Individual Values
• The duty to avoid causing unjustified risk or harm
• The duty to produce an outcome
• The duty to follow a procedural rule.
The Three Duties
• Safety
• Cost
• Effectiveness
• Equity
• Dignity
Organizational and Individual Values
Three Basic Duties
• If an individual knows the desired outcome and should be able to produce it (e.g., safe removal of an
inflamed appendix), failure to do so represents breach of this duty.
• Did the employee breach a duty to produce an outcome?
Duty to produce an outcome.
• If the individual knows the proper procedure and it is possible to follow the rule (e.g., the procedure for
inserting a central venous catheter), failure to do so represents a breach of this duty.
• Did the employee breach a duty to follow a procedural rule in a system designed by the employer?
Duty to follow a procedural rule.
• Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly.
• Did the employee put an organizational interest or value in harm’s way?
Duty to avoid causing unjustifiable risk or harm.
The Behaviors We Can Expect
Human error
• inadvertent action; inadvertently doing other that what should have been
done; slip, lapse, mistake.
At-risk behavior
• behavioral choice that increases risk where risk is not recognized or is
mistakenly believed to be justified.
Reckless behavior
• behavioral choice to consciously disregard a substantial and unjustifiable risk.
Accountability for Our Behaviors
At Risk
Behavior
• Pre-documentation
• Exceeding scope of practice .
• Nurse knowingly deviates from a
standard due to a lack of
understanding of risk to client,
organization, self, or others
Examples
• Consoling or coaching
Responses to Behavior
Human
Errors
• Failure to implement a treatment
order due to oversight
• Single medication event/error
(wrong dose, wrong route, wrong
patient, or wrong time)
Examples
• Consoling or coaching
Responses to Behavior
Reckless
Behavior
• Nurse does not intervene to protect a patient
because nurse is not assigned to patient
• Nurse abandons patients by leaving workplace
before reporting to another appropriately
licensed nurse.
• Nurse makes serious medication error, when
realized tells no one, and when questioned
denies any knowledge of reason for change in
client condition
Examples
• Report to Board for investigation
• Disciplinary action by Board
Responses to Behavior
Why should
we put just
culture into
practice?
There is a need to learn from accidents and
incidents through safety investigation so as to
take appropriate action to prevent the
repetition of such events.
The Safety Task
The Safety Task
Just Culture is
about
It’s not seeing events as
things to be fixed
It’s seeing events as
opportunities to improve
our understanding of risk
• System risk, and
• Behavioral risk
It’s About
Reinforcing the
Roles of Risk,
Quality, and HR
Risk/Quality
• Helping improve the effectiveness of the
learning process.
• Providing tools to line managers
• Helping to redesign systems
H R
• Protecting the learning culture.
• Helping with managerial competencies
• Consoling
• Coaching
• Punishing
It’s About Changing Managerial Expectations
• Investigating the source of errors and at-risk behaviors
• Turning events into an understanding of risk
Knowing my risks
Designing safe systems
• Consoling
• Coaching
• Punishing
Facilitating safe choices
It’s About Changing Staff Expectations
Looking for the risks around me
Reporting errors and hazards
Helping to design safe systems
• Following procedure
• Making choices that align with organizational values
• Never signing for something that was not done
Making safe choices
A just culture guide
This guide supports a conversation between managers about whether a staff member involved in a
patient safety incident requires specific individual support or intervention to work safely.
Action singling out an individual is rarely appropriate - most patient safety issues have deeper causes
and require wider action.
The actions of staff involved in an incident should not automatically be examined using this just
culture guide, but it can be useful if the investigation of an incident begins to suggest a concern
about an individual action.
The guide highlights important principles that need to be considered before formal management
action is directed at an individual staff member
A just culture guide
A just culture guide
A just culture guide
Just culture in healthcare
Just culture in healthcare

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Just culture in healthcare

  • 2. Introduction Just culture is an atmosphere of trust in which healthcare workers are supported and treated fairly when something goes wrong with patient care. Just culture is important to patient safety as it creates an environment in which people (healthcare workers and patients) feel safe to report errors and concerns about things that could lead to patient adverse events. Reports of errors and patient safety hazards are important sources of information about weaknesses in the system that need to be addressed by a learning culture to improve patient safety.
  • 3. Goal of Just Culture The goal of a “Just Culture” environment is to design safe systems that will reduce the opportunity for human error and capture errors before they reach the patient. Safe systems should facilitate the staff to make good decisions and should make it more difficult to make an error. However, it is up to individuals to manage their behaviors and choices.
  • 4. Overview • The culture of health care in the past focuses on placing blame on healthcare providers whenever there was an error or bad outcomes occurred. • With this kind of culture, health care providers were hesitant to report any errors due to fear of punishment. • As a result, such occurrences were never reported. The Past • To improve reporting of errors, organizations moved to blameless culture, however, this type of culture did not succeed due to lack of accountability and the practice did not promote a learning environment that promoted patient safety. • Today, the focus of health care is patient safety, and “Just Culture” balances the assessment of systems, processes and human behavior when an error or event is reported. The Present
  • 5. How would your organization deal with ? Wrong prescription from a doctor. Ignoring the patient ring bell. Nurse miss 2 dose antibiotics. Giving fake lab result. Sleeping on duty, Pre-Documentation. Leave duty without endorsement
  • 7. How do you describe this behavior?
  • 8. Who are we going to blame?
  • 9. Do you have comment?
  • 11. Key questions Why did these accidents happen? What can we do to prevent them from happening again? How do we judge the people involved?
  • 12. A Model that Focuses on Three Duties balanced against Organizational and Individual Values • The duty to avoid causing unjustified risk or harm • The duty to produce an outcome • The duty to follow a procedural rule. The Three Duties • Safety • Cost • Effectiveness • Equity • Dignity Organizational and Individual Values
  • 13. Three Basic Duties • If an individual knows the desired outcome and should be able to produce it (e.g., safe removal of an inflamed appendix), failure to do so represents breach of this duty. • Did the employee breach a duty to produce an outcome? Duty to produce an outcome. • If the individual knows the proper procedure and it is possible to follow the rule (e.g., the procedure for inserting a central venous catheter), failure to do so represents a breach of this duty. • Did the employee breach a duty to follow a procedural rule in a system designed by the employer? Duty to follow a procedural rule. • Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly. • Did the employee put an organizational interest or value in harm’s way? Duty to avoid causing unjustifiable risk or harm.
  • 14. The Behaviors We Can Expect Human error • inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. At-risk behavior • behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified. Reckless behavior • behavioral choice to consciously disregard a substantial and unjustifiable risk.
  • 16. At Risk Behavior • Pre-documentation • Exceeding scope of practice . • Nurse knowingly deviates from a standard due to a lack of understanding of risk to client, organization, self, or others Examples • Consoling or coaching Responses to Behavior
  • 17. Human Errors • Failure to implement a treatment order due to oversight • Single medication event/error (wrong dose, wrong route, wrong patient, or wrong time) Examples • Consoling or coaching Responses to Behavior
  • 18. Reckless Behavior • Nurse does not intervene to protect a patient because nurse is not assigned to patient • Nurse abandons patients by leaving workplace before reporting to another appropriately licensed nurse. • Nurse makes serious medication error, when realized tells no one, and when questioned denies any knowledge of reason for change in client condition Examples • Report to Board for investigation • Disciplinary action by Board Responses to Behavior
  • 19. Why should we put just culture into practice? There is a need to learn from accidents and incidents through safety investigation so as to take appropriate action to prevent the repetition of such events.
  • 22.
  • 23. Just Culture is about It’s not seeing events as things to be fixed It’s seeing events as opportunities to improve our understanding of risk • System risk, and • Behavioral risk
  • 24. It’s About Reinforcing the Roles of Risk, Quality, and HR Risk/Quality • Helping improve the effectiveness of the learning process. • Providing tools to line managers • Helping to redesign systems H R • Protecting the learning culture. • Helping with managerial competencies • Consoling • Coaching • Punishing
  • 25. It’s About Changing Managerial Expectations • Investigating the source of errors and at-risk behaviors • Turning events into an understanding of risk Knowing my risks Designing safe systems • Consoling • Coaching • Punishing Facilitating safe choices
  • 26. It’s About Changing Staff Expectations Looking for the risks around me Reporting errors and hazards Helping to design safe systems • Following procedure • Making choices that align with organizational values • Never signing for something that was not done Making safe choices
  • 27. A just culture guide This guide supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely. Action singling out an individual is rarely appropriate - most patient safety issues have deeper causes and require wider action. The actions of staff involved in an incident should not automatically be examined using this just culture guide, but it can be useful if the investigation of an incident begins to suggest a concern about an individual action. The guide highlights important principles that need to be considered before formal management action is directed at an individual staff member
  • 28. A just culture guide
  • 29. A just culture guide
  • 30. A just culture guide