JUST CULTURE. Your Organization

Transcription

1 JUST CULTURE Your Organization 1

2 Development of JUST CULTURE No-blame culture flourished in the 1990s and still endures today. Sought to replace punitive cultures. It acknowledged that a large proportion of unsafe acts were honest errors (the kinds of slips, lapses and mistakes that even the best people can make) and were not truly blameworthy, nor was there much in the way of remedial or preventative benefit to be had by punishing their perpetrators. Two serious weaknesses. 1. It ignored or, at least, failed to confront those individ willfully (and often repeatedly) engaged in dangerous behaviors that most observers would recognize as being likely to increase the risk of a bad outcome. 2. It did not properly address the crucial business of distinguishing between culpable and non-culpable unsafe acts. 4

3 LINE between unacceptable behavior and blameless unsafe acts HEALTHCARE AS A LARGELY PUNITIVE CULTURE. You re smart, you try hard, you don t make mistakes. You make mistakes, you re stupid, you didn t try hard enough NO BLAME CULTURE Honest errors, slips, lapses, no remedial benefit in punishment Prior to 1990 s 1990 s 5

4 The Progression HEALTHCARE AS A LARGELY PUNITIVE CULTURE. NO BLAME CULTURE JUST CULTURE Prior to 1990 s 1990 s 21st Century 8

5 Just Culture No Blame BALANCE Accountable for All Errors; Punitive Culture

6 INFORMED CULTURE Those who manage and operate the system have current knowledge about the human, technical, organizational and environmental factors that determine the safety of the system as a whole. REPORTING CULTURE An organizational climate in which people are prepared to report their errors and nearmisses. Safety Culture FLEXIBLE CULTURE An organization is able to reconfigure itself in the face of high tempo operations or certain kinds of danger - often shifting from the conventional hierarchical mode to A flatter mode JUST CULTURE An atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. LEARNING CULTURE An organization must possess the willingness and the competence to draw the right conclusions from its safety information system and the will to implement major reforms 11

7 WHY IS THIS IMPORTANT? To understand the scope of medical error and correct, create a climate that fosters trust Healthcare professionals are encouraged and willing to report errors and incidents, near misses or good catches Provides fair-minded treatment, creates effective structures that help people reveal their errors and help the organization learn It is NOT non-accountable, nor does it mean avoidance of critique or assessment of competence After careful collection of facts, if reckless or willful violation of policy, negligent behavior, corrective action may be appropriate 22

8 BENEFITS 1. Increased reporting 2. Trust building 3. More effective safety and operational management WHAT CHANGES? Two concepts: Human error is inevitable; system monito and improvement crucial to accommodat Individuals those errors are accountable for actions if knowingly violate safety procedures or policies 26

9 Role of the Board Lead by example and mentoring Set strategic goals related to culture Secure funding for education Select measurement tools Diagnose, Implement, Measure Bring organization into state-wide initiatives (IHI, voluntary reporting) Work with others (professional organizations, state bodies) to replace punitive strategies with ones that support culture 30

10 BOARD OVERVIEW: Key Themes Emerging NHS Lothian Report

11 Senior Leadership align the way [the Board] operates with the way it expects senior managers to operate & vice versa refocused into a strategic, transformational and creative culture...a strong system of holding people to account in a measured and balanced way expectation of all Directors.to challenge negative behavioural issues where these exist..

12 Values-Based Culture [The need for the Board to] articulate the culture to which it aspires.. [with] positive values and behaviours simply described. An approach in which values are embedded into all programmes, induction, in-house training and competencies

13 Staff Engagement The deal must be you participate and we will listen and act Simplifying and streamlining policies to make them more accessible Explaining to staff at all levels what this means for them and the part they play in the process

14 SUMMARY: the need for a culture where it is the right thing to report bad news at the soonest opportunity. The need to refocus the organisation to support challenge, learning, transformation and growth. Which is inclusive, respects and engages all staff in its agenda. Which does not seek to blame individuals for system failures, but holds to account around personal and professional responsibilities.

15 What we know is that & good team working is associated with 7.1% fewer deaths also... Higher staff engagement Higher attendance Higher staff job satisfaction Working in well structured teams predicts lower levels of near misses and errors (west 2006) Engagement with the vision and mission Positive effect on staff experience, patient experience and quality of care These tools develop and enhance team working

16 Improvement Culture Diagnostic Tool 10 Dimensions The purpose of this tool is to support teams to further develop their skills, knowledge and abilities to do improvement as their everyday normal way of working together. Continuous improvement culture is characterised by Kline (2011) as all staff to be empowered to continually improve processes and focused on providing the best possible service to all The themes captured in the questionnaire are found to be important characteristics of an improvement culture 3 questions per section

17 Improvement Culture Diagnostic Tool The Improvement Culture Tool defines the broad characteristics of improvement culture there by enabling team members to review and assess the improvement culture within their team which provides a platform for an in-depth conversation. Key strengths and potential areas for improvement are discussed and negotiated by the team with consideration given to the impact of these on the team s performance and achievement of organisational objectives.

18 Testing across NHS Tayside is at various stages 4 complete and 6 in the process over a 6 month period. Pharmacy Heads of Patient Care & Nursing Access Directorate SMT Perth & Kinross Community Health Partnership SMT Nursing Directorate AND's & Nurse Consultants Tayside Substance Misuse SMT Tayside Substance Misuse Implementation Team Learning Disabilities Psychiatry of Old Age and Community Mental Health SMT ehealth SMT

19 Shift in score across a 3 month period with OD wrap around support Improvement culture tool Mean team response to core characteristics HOPCAN Workshop 1 Workshop 2 Mean score Autonomy Engagement Ability Role modelling Blame free Innovative Characteristics Teamwork Agility Continuous learning Good practice

20 Shift in score across a 3 month period with OD wrap around support Improvement culture tool Mean team response to core characteristics Pharmacy Team Workshop 1 Workshop 2 Mean score Autonomy Engagement Ability Role modelling Blame free Innovative Characte ristic Teamwork Agility Continuous learning Good practice

21 Some Findings There was a positive shift in improvement culture in teams Participation in various courses as a result of the pilot supported team development. There is evidence of shared learning around improvement approaches, tools and techniques with other teams. Teams got a lot out of having the opportunity to have a conversation about culture and that this in itself was of great value to them in their thinking in how this impacted delivery of service and patient experience

22 Team Vitality Aim User friendly Easy to administer collate and analyse Demonstrate good psychometric properties Results shared with and owned by teams to ensure they demonstrate continual improvements in their overall team functioning Use for Improvement not Judgement

23 Progress Tests of change The practice development team 1 ward 3 wards Spread 4 wards in clinical teams in clinical teams in infection control team including admin and clerical staff 57 clinical teams in one occupational therapy-one multi disciplinary including admin and clerical staff April teams to date - clinical teams

24 Common Issues identified when undertaking either diagnostic tools Relationships values and expectations of each other Need for team values to be developed Lack of involvement in decision making Leadership and lack of senior manager visibility Recognition of team and role within the team Blame culture fear of putting head above the water or reporting for fear of retribution Modelling professional behaviour operating principles, values, organisational expectation

25 Where to next... Culture Diagnostic Tool further development of the tool is underway to ensure reliability and validity. Further testing to spread is currently being discussed following the APF event across 3 local partnership forums. The Tool is also currently used as a conversation piece with managers to enbale and support their thinking around culture and improvement

26 Where to next... Team Vitality continues to be rolled out across nursing teams within NHS Tayside Both the Improvement Culture Diagnostic Tool & Team Vitality have been recognised and adopted by the National Staff Experience Project to test nationally and develop as part of the buisness toolkit for measuring culture within and across the Boards

27 Discussion