creating a just culture of accountability in long term care a just... · safety blame-free culture...
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© 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
© 2016 MMIC. All rights reserved
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.
© 2016 MMIC. All rights reserved
The single greatest impediment to error prevention in
the medical industry is “that we punish people for making
mistakes.”
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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
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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
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System
design
Behavioral
choices
Adverse
events
Human
errors
Working it here (80%) Before it leads to here (20%)
Supporting a proactive culture
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What we must believe about the
management of risk
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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
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To err is human
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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.
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To drift is human
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Risk is everywhere
• Risk = severity x likelihood
– Risk can be a perception
– Risk can be an absolute
– Risk is not inherently bad
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We must manage in support of our values
• Risk = Severity x Likelihood
• Safety ~ Reasonableness of Risk
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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
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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
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Managing system design
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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
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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
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Seven design strategies
important to managing risk
• “Make no mistakes”
• Knowledge and skill
• Performance shaping factors
• Barriers
• Redundancy
• Recovery
• Perception of high risk
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Managing behavior
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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.
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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.
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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?
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Managing at-risk behaviors
"The best car safety device is a
rear-view mirror with a cop in it."
Dudley Moore
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Managing at-risk behaviors
• A behavioral choice
– Driven by perception of consequences
• Immediate and certain consequences are strong
• Delayed and uncertain consequences are weak
• Rules are generally weak
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Managing at-risk behaviors
• A behavioral choice
– Managed by adding forcing functions (barriers to prevent
non-compliance)
– Managed by changing perceptions of risk
– Managed by changing
– consequences
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Managing reckless behavior
• Reckless behavior
– Conscious disregard of substantial and unjustifiable risk
• Manage through:
– Disciplinary action
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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
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Learning through events
• Learning
Learning through events
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what happened?
why did it happen?
how were we managing it?
Increasing
value
The basics of event investigation
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• 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
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The Just Culture algorithm
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The Three Duties
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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
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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
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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
• 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 Punitive
The duty to follow a procedural rule
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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
• Creating incentives for
compliance• Increasing situational
awareness
Inadvertent
violation
Product of our current
system design
Manage through
changes in:
• Processes
• Procedures
• Training• Design
• Environment
Console Coach Punitive
The duty to avoid causing
unjustifiable risk or harm
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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
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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
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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
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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
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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
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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
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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
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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
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Policies & Procedures
Zero tolerance
Medical staff
Non-retaliation clauses
resident and/or family
Response
Disciplinary
action
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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
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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
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Doves or hawks? Who are we?
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Contact us
Kristi.Eldredge
@MMICgroup.com
952.838.6735