Discussion Forum Evaluation DF#2
Each area will look at the following 5 components:
• Awareness of the students’ personal thinking.
• Openness to adopting alternative perspectives.
• Ability to analyze differing perspectives.
• Ability to construct support.
• Effective interpretation of information.
• Effective synthesis of information.
Discussion Forum #2
1. The “Just Culture” movement in healthcare has required significant changes in institutions as it has been implemented across the country . You have been appointed as the group leader to a team in your place of employment that has been assigned the task of implementing the principles of just culture across the organization. Identify theories/coneepts from economic, organizational change and leadership, and systems science that you will utilize to plan and implement this program. Use references to support your points.
2. Reply to at least 2 of your peers, offering objective and constructive critique to their ideas for implementation of just culture. (What was clearly and accurately explained, what was unclear or inaccurate, and Suggestions for improvement). Peer responses must also be posted by the assignment due date.
Evaluation
• You will receive points based on your response being outstanding, proficient or basic.
• You can receive up to 2 points for responses to your peers.
Discussion Board Evaluation Rubric
Level/grade Criteria for evaluation
Outstanding 8 points • Response reflects an awareness of the students’ personal thinking. Explains in detail the sequence of thought they used when evaluating the topic. Provides a detailed analysis of how an awareness of their own thinking has enhanced or will enhance their performance, • Response reflects openness to adopting alternative perspectives. Identifies and articulates differing points of views, flexibility and objectivity. • Response reflects the ability to analyze differing perspectives. Explains the reasoning behind differing points of view. Considers and articulates alternative views rationally and impartially. • Response reflects the ability to construct support. Determines when it is appropriate to take a position on an issue and dan justify the position by providing rational explanations without emotion or judgment.
• Response reflects an effective interpretation of information, Accurately and insightfully interprets information. Cites readings and prior experiences and explains how these references extend and refine insights. • Response reflects an effective synthesis of information. Clearly identifies and explains the social, political, and/or professional implications of the information and insight,
Proficient • Response somewhat reflects an awareness of the students’ personal thinking.
6 points Provides a vague or incomplete description of how the student may think through the topic. Provides on a few ideas about how new information could influence performance. • Response reflects difficulty with adopting alternative perspectives. Identifies and articulates differing points of views as points of opposition. Articulates a somewhat inflexible position and is biased in discussing alternative points of view, • Response reflects development toward analyzing differing perspectives. Identifies and articulates issues that are not points of disagreement: as important issues of disagreement, • Response reflects development toward constructing support. Takes a strong position on an issue that does not necessarily warrant defense. Articulates a position but fails to articulate a clear line of reasoning to advance that perspective, • Response reflects an interpretation of information. Refers to other readings or experiences, but references and explanations about how the information provides insights that are underdeveloped or awkward. • Response reflects a synthesis of information. Inconsistent or incomplete explanations of how the information will affect his/her own thought and that of others.
Level/grade Criteria
Basic 4 points • Response reflects an emerging awareness of the students' personal thinking. Provides confusing, little, or no explanation of the thinking used in evaluating the topic. Poor explanation of how the new information will influence the current thought. • Response reflects difficulty with adopting alternative perspectives. Demonstrates an inability to understand or discuss alternative points of view objectively. Often disagrees without explanation. • Response reflects an emerging ability to analyze differing perspectives. Defends persona! dominant and privileged beliefs, expectations, and values without sufficiently considering alternative points of view. Ignores explicit and implicit points of disagreement. • Response reflects an emerging ability to construct support. Identifies and defends information that does not require support. • Response reflects an emerging ability to interpret information. Reflections and statements are descriptive or reiterate what happened or what was said previously. Lack of interpretation of the information. Comments are generally shallow and vague.
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OchsnerJ. 2013 Fall; 13(3): 400-406, PMCID: PMC3776518
PMlD:24052772
Just Culture: A Foundation for Balanced Accountability and
Patient Safety
Philip G. Boysen.. II. MD, MBA, FACP, FCCP, FCCM
Department of Anesthesiology, OchsnerClinic Foundation, New Orleans, LA, Emeritus Professor, University of North Carolina at Chapel Hill, Chapel Hili, NC
Address correspondence to Philip G. Boysen II, MD, MBA, FACP, FCCP, FCCM, Deportment of Anesthesiology, Ochsner Clinic Foundation; 1514 Jefferson Hwy., New Orleans, LA 70121, Tel: (504) 842-0796, Fax: (504) 842-2036, Email: pbovsen(&oclisner.org
Copyright © Academic Division of Ochsner Clinic Foundation
Abstract
Background
The framework of a just culture ensures balanced accountability for both individuals and: the organization responsible for designing and improving systems in the workplace. Engineering principles and human factors analysis influence the design of these systems so they are safe and reliable.
Methods
Approaches for improving patient safety introduced here are (1) analysis of error, (2) specific tools to enhance safety, and (3) outcome engineering.
Conclusion
The just culture is a learning culture that is constantly improving and oriented toward patient safety.
Keywords: Behavior, medical errors, patient Safety
INTRODUCTION
People make errors. Errors can cause accidents. In healthcare, errors and accidents result in morbidity and adverse outcomes and sometimes in mortality.
One organizational approach has been to seek out errors and identify the responsible individual. Individual punishment follows. This punitive approach does: not solve the problem. People function within systems designed by an organization. An individual may be at fault, but frequently the system is
also at fault. Punishing people without changing the system only perpetuates the problem rather than solving it.
A patient care system is obligated to collect productive investigative data that can be analyzed and: acted upon to improve patient safety. This process is not possible unless members of the organization remain vigilant and mindful and maintain continuous surveillance. Similarly, people within the organization must believe that they are obligated to report errors. However, medicalinstitutions cannot afford a blame-free culture: Some errors do warrant disciplinary action. Finding a balance between the extremes of punishment and blamelessness is the goal of developing a just culture.™
JUST CULTURE: CONCEPT AND PHILOSOPHY
A just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture. While the organization has a duty and responsibility to employees (and ultimately to patients), all employees are held responsible for the quality of their choices. Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees
Consider the following situations:
• Two nurses select the (same) wrong vial of intravenous medication from the dispensing system. One nurse administers the drug, causing cardiac arrest. The other nurse realizes the switch when drawing the solution from the vial into the syringe at the bedside. How do we approach the nurses and investigate the situation?
• The attending physician tells a resident physician to obtain a specific blood test. The resident forgets. Fearing the wrath of the supervising physician, the resident reports that the result is normal. How do we deal with this breach?
• A surgical team does not perform a surgical time out on the grounds that no adverse events have occurred in the past. How do we handle this violation?
• The night nurse supervisor reports to a medical director thatthe lead respiratory therapist was in the hospital at 4:00 am with alcohol on his breath. At a later date, the physician confronts the employee who vehemently denies alcohol abuse. Should the matter be dropped?
In only one of these scenarios does an adverse event occur, yet a just culture, with its insistence on a value-based culture and shared accountability, demands that all of these situations be addressed. However, individuarpractitioners should not be held accountable for mistakes made in a system they cannot control.-
In the first example, further investigation showed that the 2 vials of entirely different medications looked alike in shape, size, color, and print. This accident waiting to happen did happen to the first nurse and her patient. Human error was involved, but this nurse should be consoled and supported rather than punished.
The resident physician falsified patient data, which cannot be condoned and must be addressed. Honest disclosure without fear of retribution is an important characteristic of a just culture.
The surgical team cannot function outside of the value-based principles designed by the: organization. Although this surgical team has never been involved in an adverse event, one may occur in the future.
As for the respiratory therapist, in a just culture we are concerned for the safety of our patients and we are concerned for and care about each other. Further nonpunitive investigation is necessary.
These examples address an aspect of just culture that goes beyond ensuring that employees feel free to report errors. Highly reliable organizations and industries: foster mindfulness in their workers. Weick and Sutcliffe- describe mindfulness in terms of 5 components:
1 A constant concern about the possibility of failure
2 Deference to expertise regardless of rank or status
3 Ability to adapt when the unexpected occurs
4 Ability to concentrate on a task while having a sense of the big picture
5 Ability to alter and flatten the hierarchy to fit a specific situation
Mindfulness throughout an organization considers, but moves beyond, events and occurrences. Everyone in the organization is continually learning, adjusting, and redesigning systems for safety and managing behavioral choices.
INDUSTRIES OUTSIDE OF HEALTHCARE
While the concepts of developing a just culture arid supporting team function may be new to healthcare —spurred by publication of Errors in Medicine in 2000—the just culture environment has been imbedded in other industries for many years.-The industries of aviation, train transportation, and nuclear power have been accepted as highly reliable and safe,- For aviation, frequently compared to healthcare, these principles and their foundation span 45 years.- Nonetheless, within these just culture industries are examples of errors , failures, and accidents that are insightful and address human behavior in complex systems.-
Chatsworth Train Collision, 2008
The Chatsworth train collision occurred on the afternoon of Friday, September 12, 2008 at the beginning of the everting commute in a high-density travel corridor - This mass casualty accident brought a massive emergency response by the city and county of Los Angeles, taxing resources to the breaking point. Twenty-five people died, and many survivors were hospitalized for an extended period. The Metrolink train company was exposed to more than S200 million in liability judgments.
Investigations revealed that the train engineer did not obey a signal to not enter a single-track segment (designated as such because of oncoming train traffic) . The Metrolink passenger train and a freight train were headed toward one other, both moving at a speed of 40 miles per hour. The engineer of the freight train engaged his air brake 2 seconds before impact, while the engineer of the passenger train did not engage his brake. Further investigation revealed that the engineer in the commuter train had a habit Of text messaging while operating the train and had been warned about this policy violation. Nevertheless, his cell phone history (delivered under subpoena) showed 2 text messages sent shortly before impact. A spokeswoman for the train company admitted the strong likelihood of operator error and was chastised by the firm as a result. She resigned.
U.S. Airways Flight 1549, 2009
Flight 1549, an Airbus A-3 20, departed LaGuardia Airport in New York City bound for Seattle-Tacoma International Airport with a stopover at the Charlotte-Douglas International Airport. The aircraft carried 150 passengers and a flight crew of 5. Three minutes into the flight, while still on the initial climb out of New York, the airplane encountered a flock of Canadian geese. A multiple bird strike with a total loss of power in both engines is a highly improbable occurrence, but this event is exactly what occurred “ Within seconds, the crew determined that the plane would be unable to reach an airfield;
the captain turned south alpng the Hudson River in a glide mode and ditched the aircraft in the river near the C.S.S. Intrepid Museum within 3 minutes of losing power. All 155 persons aboard the aircraft were rescued while the aircraft was still sinking, and only minor injuries resulted. The accident investigation revealed crew management at its finest, with the pilot communicating and the copilot audibly reading aloud procedures to ditch the aircraft. Captain Sullenberger and his crew were widely acclaimed for their performance underpressure. A former Air Force pilot with a graduate degree from Purdue University in human factors, the captain asserted that his highest duty and obligation have been to safety, A pilot colleague commented “If an unlikely tragedy like this had to occur, I can think of no other pilot 1 would pick to handle it other than Sully!”
The Chernobyl Accident, 1986
The Chernobyl accident in the Ukraine is the only accident in the history of nuclear power that resulted in fatalities from radiation.™ An explosion and fires released the contents of the reactor core into the atmosphere, and radioactive material moved downwind. The 2 plant operators died immediately; another 28 people died of acute radiation poisoning. The disaster provides insight into the serious Consequences of ignoring safety issues. Investigation after the event revealed a flawed reactor design compounded by inadequately trained personnel operatingthe facility. Twenty years later, the only resulting public health issue is an increased incidence of thyroid cancer.
Applications in Healthcare
These anecdotes and exhaustive investigationalmaterial from other industries indicate several points that apply to the healthcare environment.
1 As in aviation, aspects of medical care (anesthesiology, surgery, emergency medicine, intensive care medicine) are event driven and dynamic, complex and tightly coupled, and uncertain and risky.-
2 Written checklists help prevent crises.
3 Established written procedures are vital in crises.
4 Training in decisionmaking and crew resource management are valuable,
5 Systematic drills and practice using simulation technology address the ability to handle crisis situations.
•ANALYSIS OF ERROR
In a landmark publication, Reason presented a detailed analysis of human error.^ Reason introduced his text by referring to the 1928 studies of Spearman but asserted that the decade prior to the publication of his book was characterized by public concern about the terrible cost of human error. He lists the Tenerife runway collision in 1977, the Three Mile Island crisis in 1979, the Bhopal methyl isocyanate disaster in 1984, the Challenger and Chernobyl explosions of 1986, the capsize of the Herald of Free Enterprise, the King’s Cross tube station fire in 1987, and the Piper Alpha oil platform explosion in 1988 as causes for a collective impetus to address error. Furthermore, this decade made clear that the nature and scale of such tragedies impacted wide geographic areas and generations pf humans.
Perhaps the most significant contribution of Reason's work was his development of a model for the dynamics of accident causation, sometimes referred to as the Swiss cheese model (Figure 1). The author identified what he describes as latent failures at the managerial level before the possibility for human error is even involved. As described by Reason, latent errors are those
Local triggers Intrinsic defects Atypical conditions
Latent failures at the managerial levels
Defence-in-depth
Trajectory of accident opportunity
Psychological Unsafe acts
precursors
Oner, in a separate window
Figure 1.
Reason's model of accident causation, Accident opportunity and possible adverse outcomes stem from a combination of latent, tail tires. psy olio logical .precursors, event triggers, and: fadmv of ibc system's defenses. (From. Reason— with permission.;)
... whose adverse consequences may lie dormant within the system for a longtime, only becoming evident when they combine with other factors to breach the: system's defences ... Latent errors ... are most likely to be spawned by those whose activities are removed in both time and space from the direct control interface: designers, high-level decision makers, construction workers, managers and maintenance personnel,
Latent errors exist in complex systems. Reason uses a medical metaphor, describing them as resident pathogens, much like microorganisms, that can exist in an organism only to emerge and proliferate when defenses are inadequate.
Reason's model of accident causation begins with latent failures, and the Swiss cheese plates represent psychological precursors and unsafe acts, local triggers, and failures of other defenses. The trajectory of error opportunity results from the alignment of the holes in the slices of Swiss cheese.
Gaba and colleagues-^ adapted this model to the practice Of anesthesiology. Some of the latent failures in this specialty include machine and process design flaws, manufacturing defects, maintenance failure, underlying disease, production pressure, fatigue, and environmental factors. With a triggering event
and the failure of preventive measures (preoperative evaluation, checklists, etc), an event occurs. The clinician must respond with dynamic decisionmaking to detect and correct the critical incident before; it results in an adverse outcome.
THE MILITARY AND THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
Safety-—fostered by teamwork, leadership, and communication—has been a major focus of military efforts. Historical events illustrate this focus.
Lord Nelson
Admiral Lord Nelson was renowned as a leader, military strategist, and communicator. His communication skills extended beyond interpersonal relationships. Communicating from his command ship through a flag system, he was able to instruct his entire fleet to come about as one to achieve unorthodox strategies. With fewer and smaller ships, but through precision ship positioning and gunnery training, he defeated the Spanish Armada (once thought invincible) and the allied French navy;— Lord Nelson understood leadership and communication in a way that applies to medicine. His communication to his sailors was safe, timely, effective, and always oriented to the task at hand.
World War II
Officers on U.S, Navy warships during World War II had an established means of verbal communication duringmaneuvers:
CAPTAIN: Come right to 190, all ahead one-third.
BOSUN: Aye sir, right to 190, all ahead one-third.
The call out, Check backhand Other scripting techniques ensured that orders were received, confirmed, understood, and executed.
Military Aviation
Military aviation develops effective team leaders on the ground, at sea, and in the air. Whether on land or at sea, pilots assemble in a ready room to review the mission, understand objectives, and unify the team. Events are described, recorded, visually confirmed, and processed. After flying the mission, a second assembly of the pilots focuses on a thorough debriefing. What went well? What went wrong? Were objectives accomplished? What areas can be improved? What is the next step?
Coast Guard
The U.S. Coast Guard Academy has a unique method of emphasizing and developing teamwork and team leaders. All cadets .serve aboard the Eagle,a square-rigger sailing: ship with an intricate system of masts, stays, halyards, and sheets. Effective and coordinated teamwork is essentialwhen underway, and the cadets learn not only seamanship but ‘‘team-man ship” on a 30-60 day cruise. The training emphasizes safety, as expressed in the published command philosophy of a recent captain of the Eagle15:
Safety. Above all, Safety. We leafn safe practices and procedures. We follow them onboard and ashore. We watch our shipmates to ensure they do too. We immediately speak up when we think we see an unsafe practice developing. We listen. We care about the safety of our shipmates and ourselves. If any situation tests our commitment to safety, safety comes first.
Strategies and Tools to Enhance Performance and Patient Safety
These same leadership arid communication skills can be successfully applied to healthcare. The U.S. Congress commissioned the Department of Defense arid the Agency for Healthcare Research and Quality (AHRQ) to translate the principles of a just culture into a format applicable to the delivery of healthcare™ The result of this collaboration was the TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety) approach to patient safety. Consistent with the principles demonstrated in the above: military examples, TeamSTEPPS focuses on leadership and communication skills (with scripting), mutual support of team members, and situation monitoring. It identifies barriers, suggests observation tools, and focuses on outcomes. TeamSTEPPS also helps participants assess whether the safety culture is being sustained.
The goal of TeamSTEPPS is the establishment, nurturing, and preservation of a just culture in which - '- ¦ ’17
“we immediately speak up when we think we see an unsafe practice developing
CREATING A JUST CULTURE
Functional issues must be addressed in a just culture.—’—While encouraging personnel to report mistakes, identify the potential for error, and even stop work in acute situations, a just culture cannot be a blame-free enterprise. Competency is one issue, but even competent professionals make mistakes. In complex, dynamic, and inherently risky environments, society has an expectation for human performance.
After identifying an adverse event or near miss, the investigation procedure technique becomes paramount (Figure 2). Two approaches have been successfully implemented in hospitals.
t.Gtiooselhe column thatmsi describes the caregiver's action, Read down the column for recommend ad responses
Tho caregivers ibinkiiig. was impaired by sieg-it nr legal sutisianccs. cognitive mspalrmertl, Of sever ot’syc.nosoda! stressors The cmegw warned.lo. tat.se harm The c.vedvct k.-icmnc; ly :: . ¦Zoiatwl 3 rule-snd'or ¦ madea.dangerousor tins ale. choice. The decision appears to have been ma do with little or no .concern obourrisk. The caregiver made a potentially unsafe choice. Faulty or self-serving decision-making may be ¦oviccnt, ¦ The ca regiver makeso-punclpatecin an e.-icr wnito working approprl atety and in the pallet!Is'best imerasls .-. . ... '.. J...
IMPAIRED JUDGMENT MALICIOUS ACTION RECKLESS ACTION RI5KY.ACTI0N ..UNINTENTIONAL ERROR
• Oisclpiuta is warranted it illeg al substanc cs were used: •The caregiver's performance, should bo evaluated la determine whether a temporary work s uspsfi ssorv would: tw helpful. • Help should lie actively offered to he caregiver sbiscsphne: ana'cr.legal proceedings are, warranted, The carogwvrV duties should be suspended. . immediately.’ . ¦Discipline may iso warranted. ¦ The carcp.ver is accouNablo uoc ncyCs. . re-traliwi'g, • IJw categtoyshouifj. ¦pnttidpaie in teaching • others Iho.iessoni ¦ teamed. ..•TrA caregiver is • • ¦ .aeppun tab'ea nd. should r&whe coaching. ¦Tto caregiver shoUd :¦ pwticip ate in leaching:..: -outers the lessons . learned. /•tTbe-rareghrerisnot accountable, ' • nio cmegiver should participate In investigating wliy me occurred, and teach :¦¦¦¦: ' oihorsabiiiitttie.resuits •• . ctlheinvasligailon.l
2, If three other caregivers with similar skills and knowledge would do the same i In similar circumstances:
The system supports reckless action and requires fixing. The ; caregiver is probably le ss ?-iomouM bte' fortlw action, landsystem leddere .sharpy m u-.o accoumab.luy. The system supports' r|$ky' action and. requires fixings -. ¦ The ca regiver is probably -.¦¦: less a-cotir.inblc for ihe fictWi, pud system, terriers share In iho accountability.. The systemsiipporls error ¦.and e quire s 1 fxiri g.. Tno system's loaders are ¦.-; accduniafeo an d should. m i'.-apply emit-p roofing, Improvements, ''
3, If the caregiver has a history of repeatedly making mistakes, the caregiver may be In hie wrong position Evaluation is warranted, and coaching, transfer or termination shaul d be con Sider nd. The corrective actions above should bo modtfind accordingly.
Open in a separate window
Figure 2,
Caregivers' actions and lecununctided responses for analyzing risks ctynstructed from mtieo.me engineering principles and analysis of human, factors. (From Leonard and Frankel-^ with permisswnd
Outcome Engineering Algorithm
Marx-coined the term outcome engineering that is applicable to healthcare and other industries.His algorithm lists 3 basic duties:
1 Duty to produce an outcome
2 Duty to follow a procedural role
3 Duty to avoid unjustifiable risk
Consequently, with breach of duty, the mechanism of the breach is categorized into one of the following:
1 Human error
2 At-risk behavior (a conscious drift from safe behavior)
3 Reckless behavior (conscious of conduct and risk)
Reason— highlights the notion of intent when considering the nature of error. Slips (eg,. Freudian slips) lack intention; that is, the actions are not carried out as intended or planned. Lapses are missed actions or omissions, with the perpetrator often conscious of the action and believing that it will hot lead to harm.
Mistakes involve error, ie, faulty planning or intention; the individual involved believes the action to be correct. Corrective action and coaching, not punishment, are indicated for improving the system.
At-risk behavior includes both intention and the violation of rules, policies, and procedures and makes a system vulnerable, increasing risk. The individual should be coached to understand the risks resulting from his or her action.
Reckless behavior may be grounds for disciplinary action, and civil or criminal charges may be filed against the individual. Punishment, including termination, may be the appropriate consequence.
Repetitive patient safety problems must be addressed, whether caused by individual error or system weakness.”
United Kingdom National Health Service Algorithm
The National Health Service in the United Kingdom and the National Patient Safety Agency published an incident decision tree and a guide for its use.” The algorithm on which the decision tree is based identifies the role of an individual and the given specific outcome. The decision tree has 4 main elements:
• The deliberate harm test: a conscious and deliberate breach of duty resulting in patient harm. The goal of the institution or system is to establish or refute this violation immediately as a first step.
• The physical/mental health test: a provider is impaired for any reason, including substance abuse. The impact of impairment or the patient outcome must be established.
• The foresight test: once the deliberate intent to harm and physical/mental health tests have been discounted, this analysis establishes whether protocols, policies, and procedures have been followed.
• The substitution test: this test asks the question, “Would another provider put in the same circumstances in the same systems environment make the same error?”
Combination of Models
Because both algorithms have merits, Leonard and Frankel— schematically integrated them into a single format that involves a 3-step process. The first step analyzes the individual caregiver's actions via 5 measures: impaired judgment, malicious action, reckless action, risky action, and unintentional error. The second step determines if other caregivers with similar skills and knowledge would react the same way in similar circumstances. The final step is the important determination of whether the present system supports reckless or risky behavior and thus requires redesign.
CONCLUSION..............
A fair and just culture improves patient safety by empowering employees to proactively monitor the workplace and participate in safety efforts in the work environment. Improving patient safety reduces risk by its focus on managing human behavior (or helping others to manage their own behavior) and redesigning systems. In a just culture, employees are not only accountable for their actions and choices, but they are also accountable to each other, which may help some overcome the inherent resistance to dealing with impaired or incompetent colleagues —
Secondary benefits of a just culture include the ability to develop a positive patient safety profile to respond to outside auditors such as The Joint Commission.^ When implemented, a just culture fosters innovation and cross-departmental communication. An example is tile opportunity to revitalize: the morbidity and mortality conference to cross specialty lines and develop a patient-centered focus.—
In a just culture, both the organization and its people are held accountable while focusing on risk, systems: design, human behavior, and patient safety.
Safety. Above all, Safety.
Footnotes........................
The author has no financial or proprietary interest in the subject matter of this article.
This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care and Professionalism.
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