Just Culture Are Hospitals Doing What They Say?

Transcription

1 Just Culture Are Hospitals Doing What They Say? Pennsylvania Patient Safety Authority 2012 ARE HOSPITALS DOING WHAT THEY SAY? A Gap Analysis of Hospitals Adoption of the Just Culture Principles Ten volunteer hospitals in Pennsylvania Work done by PA Patient Safety Authority Fran Charney, RN, Director of Education William Marella, MBA, Program Director Denise Barger, BA, Patient Safety Liaison with Outcomes Engineering HIGHLY RELIABLE SYSTEMS Barriers Redundancy Recovery

2 HUMAN BEHAVIORS AND DEFINITIONS Human Error: inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. Consol e At-Risk Behavior behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified. Coach Reckless Behavior - behavioral choice to consciously disregard a substantial and unjustifiable risk. Censure JUST CULTURE RECOGNIZES 3 DUTIES The duty to produce an outcome. The duty to follow a procedural rule. The duty to avoid causing unjustifiable risk and harm. PSA ANNUAL SURVEY Hospitals Responded 59% fully implemented Just Culture 11% partially implemented 30% not yet implemented

3 PA JUST CULTURE PROJECT Hospitals Volunteered Different regions Different types Self-assessment survey developed by Outcomes Engineering SELF-ASSESSMENT SURVEY 13 Questions about policies reflecting culture, including RCAs and HR actions - completed by patient safety officer example: Do your policies define human error, atrisk behavior, and reckless behavior? 20 Questions about perceptions of culture - completed by organization leaders example: Physicians are less likely than others to be disciplined in similar circumstances. 13 Questions about policies (Y/N) weighted to a Maximum 22 Points Average score = 6.2 Best: No discipline unless reckless behavior (8/10) Worst: Defined human error, at-risk behavior, and reckless behavior (1/10)

4 13 Questions about policies Are the following terms used in your disciplinary policies: negligent, careless, criminal conduct,egregious? ( No preferred) 6/10 Do your organization s policies provide clear examples of justifiable violations of policies and procedures? 4/10 Do your organization s policies emphasize both system design and the management of employee behavior? 2/10 (W=2) Do your organization s human resource policies distinguish between coaching and counseling? 1/10 Do your organization s policies define the following behaviors: human error, at-risk behavior, reckless behavior? 1/10 (W=3) 13 Questions about policies (event investigation) Does your event reporting system require explanations for each at-risk behavior and/ or procedural deviation identified? 2/10 (W=2) Does your event reporting system require explanations for each human error identified? 1/10 (W=2) 13 Questions about policies (human resources 1) Does evidence suggest that your organization s employees have not been disciplined for human errors, unless reckless choices were contributory? 8/10 Does evidence suggest that your organization consistently takes disciplinary action with employees who have made a reckless choice? 6/10 Do managers in your organization consistently place employees on notice of disciplinary action when repetitive human errors or repetitive at-risk behaviors are present and not caused by system performance shaping factors and not correctable through changes in work choices, remedial education, or coaching? 6/10

5 13 Questions about policies (human resources 2) Does your organization s disciplinary response to employees consistently depend on the quality of the choices involved in their behaviors, irrespective of actual harm that occurs? 3/10 (W=3) Do managers in your organization consistently console employees who make human errors and examine both the choices involved and the system designed around the employee? 3/10 Do managers in your organization consistently coach employees who make an at-risk behavioral choice and also examine the incentives for the employee s choice and the design of the system around the employee? 2/10 (W=3) 20 Questions about perceptions of culture - average of Likert scale: Maximum 40 Points Average score = 9.6 Highest score = 15.4 Lowest score = Questions about perceptions of culture - average of Likert scale: Best: Investigate close calls (1.26) Worst: Adhere to the concept that it is never acceptable to violate policies and procedures (-0.82)* *agreement results in a negative score

6 Low High Average Low High Average PA JUST CULTURE PROJECT CONCLUSIONS Hospitals may think they have implemented Just Culture principles but they have not changed their policies and processes and have not changed the perceptions of their cultures.

7 PA PATIENT SAFETY AUTHORITY Thank You