O T H E R F E AT U R E S Gap Assessment of Hospitals’ Adoption of the Just Culture Principles BACKGROUND Denise M. Barger, BA, CPHRM, CPHQ, HEM Patient safety experts recognize that a healthcare organization’s culture exerts a critical Patient Safety Liaison influence on staff response to patient safety issues, as well as on staff members involved Southeast Region—Delaware Valley South in those events.1,2 Willingness to report both actual and potential adverse events can William Marella, MBA be a strong indicator of the organization’s attitude toward patient safety generally and Program Director a key to its perception and treatment of staff involved in adverse events. Organizations Franchesca J. Charney, RN, BS, MSHA, with strong safety cultures have robust reporting mechanisms to identify risks and effec- CPHRM, CPHQ, CPSO, FASHRM Director of Educational Programs tive systems for evaluating causes and taking action to address process weaknesses. They Pennsylvania Patient Safety Authority develop and reinforce the perception among staff that reporting is accepted, expected, and nonpunitive. In the alternative “blame and shame” environment, adverse events go unreported and process failures are not identified, causes go unaddressed, and the cycle of event-blame-punishment is often repeated to the detriment of patients and healthcare staff alike. Many healthcare organizations have made the transition from the punitive culture that dominated thinking in the years before the Institute of Medicine’s landmark report To Err Is Human to the nonpunitive stance that many hospitals now take toward report- ing. Some hospitals, such as those in the Department of Veterans Affairs system, have evolved to a view that does not punish individuals for reporting or committing human errors and mistakes and instead choose to identify the reasons for the error and to change the underlying process that either caused or contributed to the error.3 Recogniz- ing the inevitability of human error while still holding staff accountable for individual actions is the cornerstone of the just culture approach that has been articulated by Outcome Engineering president David Marx. Outcome Engineering has developed an algorithm for assessing the role of human behavior in individual events, as well as a methodology for evaluating an organization’s culture and commitment to a just culture that can be used by hospitals and other facilities.4 In the Pennsylvania Patient Safety Authority’s 2007 survey of Pennsylvania healthcare organizations reported in the Authority’s 2008 annual report, facilities were asked whether their internal policies and procedures related to adverse event reporting incorporated just culture principles.1 Statewide, 118 hospitals and 82 other facilities (including ambulatory surgical facilities [ASFs] and birthing centers) responded to the survey. The majority of hospitals that responded (70%) reported some level of imple- mentation of a just culture, and 59% reported that the just culture model was fully implemented hospital-wide. The remaining 30% of hospitals reported that the prin- ciples were not yet implemented. Similar results were found among responding ASFs and other facilities, with 72% reporting some or partial implementation and 28% hav- ing not adopted the just culture approach. The Authority wanted to ensure that Pennsylvania facilities fully understood the tenets of a just culture and sought out Outcome Engineering to discuss the survey results. That discussion was the genesis for the Pennsylvania Just Culture Project. The project, which began in spring 2010 and concluded with a report of gap survey results in February 2011, tested whether Pennsylvania facilities have more verbal commitment to just culture than is codified in facility policies and reflected in facility handling of adverse events and staff error. Indeed, during the process of identifying hospitals interested in participating in the project, many shared the view that they might have overstated the extent of their implementation. Page 138 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority METHODS scale and that would protect hospitals’ officers (PSOs) were engaged to lead the The Authority partnered with Outcome confidentiality while assessing their adher- assessment effort in each facility and Engineering in early 2010 to assess the ence to a just culture’s essential tenets. the gap analysis and be the conduit for degree to which a just culture was imple- Meanwhile, the Authority invited all Penn- communicating results. The hospitals mented in Pennsylvania. The Authority sylvania hospitals to consider participating represented different regions of the com- challenged Outcome Engineering to devise in the project and, ultimately, 10 hospitals monwealth and ranged from large urban a method that could be used on a larger volunteered. Hospital patient safety hospitals to smaller community hospitals. (continued on page 141) Table 1. Part 1: Patient Safety Officer Assessment of Just Culture Principles Based on Document Review HOSPITALS HOSPITALS SCORE ANSWERING ANSWERING QUESTION ACROSS ALL JUST CULTURE ATTRIBUTE QUESTION “YES” “NO” WEIGHT 10 HOSPITALS Policies A just culture organization Are the following terms 4 6 1 6 avoids using certain terms that used in your disciplinary can be misunderstood or not policies: negligent, aligned with the principles of careless, criminal conduct, the model. egregious? (Reverse worded: “No” preferred) A just culture organization Do your organization’s 1 9 1 1 makes a distinction between human resource policies values supportive discussions distinguish between with employees to influence coaching and counseling? behavior and those conversa- tions that are intended as steps in a disciplinary process. A just culture organization Do your organization’s 1 9 3 3 defines the three manageable policies define the behaviors: human error, following behaviors: at-risk behavior, and reckless human error, at-risk behavior.* behavior, reckless behavior? A just culture organization Do your organization’s 4 6 1 4 expects justifiable breaches of policies provide clear policies and procedures to examples of justifiable occur and provides clear violations of policies examples. and procedures? A just culture organization Do your organization’s 2 8 2 4 emphasizes the need to policies emphasize both improve system design while system design and the simultaneously managing management of employee human behavior. behavior? Event Investigations A just culture organization Does your event 1 9 2 2 investigates and explains reporting system require the causes of human errors. explanations for each human error identified? A just culture organization Does your event 2 8 2 4 investigates and explains the reporting system require causes of at-risk behaviors explanations for each and procedural deviations. at-risk behavior and/ or procedural deviation identified? Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 139 ©2011 Pennsylvania Patient Safety Authority O T H E R F E AT U R E S (table continued) HOSPITALS HOSPITALS SCORE ANSWERING ANSWERING QUESTION ACROSS ALL JUST CULTURE ATTRIBUTE QUESTION “YES” “NO” WEIGHT 10 HOSPITALS Human Resource Actions A just culture organization Does your organization’s 3 7 3 9 recognizes and avoids the disciplinary response to severity bias.† It is the quality employees consistently de- of the choice involved in the pend on the quality of the behavior that determines choices involved in their the level of response to an behaviors, irrespective of employee, not the actual actual harm that occurs? harm that results. Does evidence suggest 8 2 1 8 that your organization’s employees have not been disciplined for human er- rors, unless reckless choic- es were contributory? Does evidence suggest 6 4 1 6 that your organization consistently takes disciplin- ary action with employees who have made a reckless choice? A just culture organization Do managers in your orga- 3 7 1 3 consoles an employee who nization consistently con- makes a human error and sole employees who make examines both the quality of human errors and examine the choices involved in the both the choices involved behavior as well as the and the system designed design of the system around around the employee? the employee. A just culture organization Do managers in your orga- 2 8 3 6 coaches an employee who nization consistently coach makes an at-risk behavioral employees who make an choice and examines both the at-risk behavioral choice incentives for the employee’s and also examine the in- choice and the design of the centives for the employee’s system around the employee. choice and the design of the system around the em- ployee? A just culture organization Do managers in your 6 4 1 6 places an employee on notice organization consistently of disciplinary action when place employees on notice repetitive human errors or of disciplinary action when repetitive at-risk behaviors repetitive human errors or are present and not caused repetitive at-risk behav- by system performance iors are present and not shaping factors and not caused by system perfor- correctable through changes mance shaping factors and in work choices, remedial not correctable through education, or coaching. changes in work choices, remedial education, or coaching? * Human error—an inadvertent action; inadvertently doing other than what should have been done; a slip, lapse, or mistake At-risk behavior—a behavioral choice that increases risk where risk is not recognized or that is mistakenly believed to be justified Reckless behavior—a behavioral choice to consciously disregard a substantial and unjustifiable risk † The severity bias is present when the severity of the actual outcome influences how we think about the person involved or how we respond to them if we have managerial authority over them. In other words, the level of actual harm determines whether discipline or punishment is used. Page 140 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority (continued from page 139) results of the other deidentified participat- these types of errors—or the distinctions ing facilities. This report explained the management makes among them—human The just culture self-assessment tool significance of each attribute examined in resources actions may appear arbitrary. developed by Outcome Engineering was the tool and provided guidance on how Other principles of the just culture model based on two existing survey tools: a gap to improve attributes on which the facility that were not widely adopted were dis- analysis and a benchmarking survey. scored low. tinguishing between discussions aimed Outcome Engineering developed the at coaching versus counseling, requiring The survey tool is available to Pennsyl- tool specifically for this project to address explanations in event reporting systems vania PSOs on the Authority’s secure concerns that traditional methods of for human errors and at-risk behaviors, PassKey website. The Authority’s regional assessing a hospital’s culture might breach and emphasizing both system design and patient safety liaisons can assist facilities confidentiality and required a significant management of employee behavior. in the use and scoring of the assessment. time commitment. The just culture self- assessment tool comprises two parts: Part 2 involved a series of 20 statements RESULTS to be evaluated by key leaders in the — Part 1 measures organizational organization to assess their perception of culture through 13 questions about The two parts of the tool were scored the organizational culture. For each state- organizational policies, adverse event separately. Part 1, which evaluated the ment, response categories were presented investigations, and human resources hospitals policies and practices, contained on a five-point Likert scale ranging from actions. This section is completed by elements that could produce a maximum “strongly disagree” (-2) to “strongly agree” the PSO after reviewing a representa- score of 22 points for each hospital. Only (2) with a neutral value (0) for “neither tive sample of documents related to one of the participating hospitals scored agree nor disagree.” Most statements were these three areas. well—it earned 20 points, indicating worded positively, with “strongly agree” — Part 2 measures the perceptions compliance with key just culture tenets being the preferred response. Those state- of leaders about the organization’s in policies, human resources practices, ments worded negatively were scored in culture through 20 questions about and investigation documentation. Two reverse. The maximum number of points critical behavioral markers, such as hospitals met the required adherence on available for each hospital was 40. Results system design, coaching, reporting, approximately 50% of the scored items, of this section are presented in Table 2. responses to human error, responses while the majority of hospitals (seven) met to reckless behavior, severity bias, just culture expectations on fewer than The maximum score achievable was 40. equity, and transparency. This sec- 50% of the elements. Six hospitals scored No participating hospital scored well on tion is completed by 10 to 15 leaders below 5 of a possible 22 points. All 10 these elements of the survey. The aver- within each organization. Recom- participating hospitals as a group scored age score for all participating hospitals mended respondents include the 62 of a total 220 points (see Table 1). was 9.56 or only 24% of the 40 possible chief nursing and medical officers, While none of the just culture principles points. Six of the 10 participating hospi- PSOs, and directors or managers was consistently present across all 10 tals scored slightly higher than the project of human resources, quality hospitals, elements most widely adopted average; 4 had scores significantly lower assurance, and risk management included not disciplining employees for than average. The highest score from any departments. (No information iden- human errors in the absence of reck- hospital was 15.41, while the lowest was tifying individuals by name, position, less choices, taking disciplinary action 3.19 of the total 40 possible points. or title was collected.) with employees who have made reckless Based on the average scores, the aspects of Participating hospitals received their choices, and placing employees on notice their organizational culture hospital lead- survey forms in January 2011 and were of disciplinary action when repetitive ers rated most positively were investigating given three weeks to complete the survey human errors or repetitive at-risk behav- “close calls” to understand the underlying tasks. The surveys were then reviewed and iors are present and not caused by system causes, changing work practices to improve scored by Outcome Engineering working performance shaping factors and not safety when concerns are reported, and with Authority staff. Results were tabu- correctable through changes in work disciplining employees who intentionally lated and presented to the participating choices, remedial education, or coaching. endanger safety regardless of whether harm hospitals in late February 2011. After com- However, only one hospital reported that resulted. The negative aspects of orga- pleting the self-assessment, each hospital their policies define human error, at-risk nizational culture included disciplining received a confidential report presenting behavior, or reckless behavior. If staff do its results compared with the average not understand the distinctions between (continued on page 143) Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 141 ©2011 Pennsylvania Patient Safety Authority O T H E R F E AT U R E S Table 2. Part 2: Survey of Hospital Leaders LOWEST HIGHEST AVERAGE HOSPITAL HOSPITAL HOSPITAL EVALUATION STATEMENTS SCORE SCORE SCORE 1. Managers in this organization discipline employees who make mistakes that -0.79 0.09 -0.43 might impact patient safety.* 2. When a safety concern is reported, the way we work is changed to make 0.72 1.76 1.20 things safer. 3. If employees are doing something unsafe, their managers will talk to them 0.7 1.38 1.06 and explain a safer way to behave or work. 4. If employees are doing something unsafe, their coworkers will talk to them -0.22 0.84 0.26 and explain a safer way to behave or work. 5. Managers in this organization treat all employees and staff, regardless of their 0.0 1.38 1.01 position in the hospital, fairly after an event involving harm to a patient. 6. Over the past 12 months, this organization has reduced its number of safety 0.0 1.6 0.90 events resulting in harm to patients. 7. Employees and staff at this organization are reporting things they see that 0.0 1.3 0.96 could impact the safety of the patients. 8. This organization looks into “close calls”—things that could have harmed the 0.0 1.82 1.26 patients but did not—to understand the underlying causes. 9. Physicians are less likely than other staff to be disciplined in similar -1.11 0.69 -0.40 circumstances.* 10. Managers in this organization talk to employees and staff about adverse 0.53 1.31 0.95 events and lessons learned. 11. Managers in this organization discipline employees and staff who intentionally 0.8 1.43 1.16 endanger safety, whether or not harm occurs. 12. Managers in this organization address safety events only if a patient is -0.17 1.3 0.75 seriously harmed.* 13. Employees will report their own mistakes that could have resulted in -0.11 0.71 0.31 patient harm. 14. Employees will report their own mistakes that did result in patient harm. 0.21 1.17 0.83 15. Occasionally our core organizational values will be in conflict. -0.45 0.8 0.15 16. Some patient safety events are 100% preventable.* ,† -1.75 -0.5 -1.33 17. Our employees know they will be consoled if they make a human error. -0.5 1 0.24 18. Our employees know they will be coached if they engage in at-risk behavior 0.0 1 0.54 (e.g., taking shortcuts). 19. Our employees know they will be disciplined for reckless behavior regardless 0.5 1.23 0.96 of whether harm results. 20. There is never an acceptable reason for an employee to violate patient -1.54 0.17 -0.82 safety policies and procedures.* Score Sum (maximum possible = 40) 9.56 * Reverse worded and reverse scored, so that a higher score is always indicative of higher just culture alignment. † The project team determined after survey administration that this question, on which hospitals scored the lowest, would have been better worded to read, “Some human errors are 100% preventable.” The just culture model incorporates the notion that humans are fallible and will always make errors. Systems should be improved so that they are resistant to such errors without resulting in patient harm. Page 142 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority (continued from page 141) CONCLUSION self-critical and to focus on their The results supported the Authority’s shortcomings. These are among the employees for mistakes, treating physicians perception that Pennsylvania hospitals may defining characteristics of high-reliability more leniently than other staff in similar have overestimated the degree to which organizations. circumstances, and believing there is the hospital is in alignment with core Overall, the results of this project suggest never an acceptable reason for employees principles of the just culture approach. that work remains to be done to bring to violate safety policies and procedures. Some hospitals’ scores revealed significant Pennsylvania hospitals and other health- This last item, while seeming to hold gaps in multiple just culture elements, care facilities closer to achieving a just employees accountable for willful viola- while others can focus on a few key points culture in healthcare. While this project tions of procedure, is problematic because to strengthen a solid foundation. The self- focused on a small sample of the state’s it encourages following the rules for their assessment results along with the suggested hospitals, the results suggest that facilities own sake even in situations in which the improvement strategies provided by Out- may overestimate their implementation of rules do not serve the greater good or come Engineering can help participating key principles of the just culture model. when rules conflict with one another. For hospitals’ PSOs identify their organiza- With reporting a crucial feature of a example, if a patient were falling, the cor- tions’ weaknesses and set a plan for culture of patient safety and the need rect action is to prevent the fall, even if working with hospital leaders to improve to focus on process design rather than this means ignoring normal hand hygiene their culture. Despite these gaps, the 10 human error to reduce adverse events for protocols. The item on which participat- hospitals in this project voluntarily chose patients, the results suggests that there is ing hospitals scored lowest was the belief to participate, in part because the PSOs room to improve staff awareness of the that some patient safety events are 100% recognized that their culture was not as value of reporting, the need to focus on preventable, which fails to acknowledge aligned with the just culture principles as system process redesign, and the nature that human errors are inevitable. it could be. These hospitals are to be com- and cause of human error. mended for their willingness to be NOTES 1. Pennsylvania Patient Safety Authority. culture: 2009 comparative database report 4. The just culture algorithm™ [online]. 2008 annual report [online]. 2009 Apr [online]. [cited 2011 Jul 5]. Available from [cited 2011 Jul 5]. Available from [cited 2011 Jul 5]. Available from Inter- Internet: http://www.ahrq.gov/qual/ Internet: http://www.justculture.org/ net: http://patientsafetyauthority.org/ hospsurvey09/hosp09ch1.htm. algorithm.aspx. PatientSafetyAuthority/Documents/ 3. Marx D. The just culture community annual_report_2008.pdf. [online]. [cited 2011 Jul 5]. Available from 2. Agency for Healthcare Research and Internet: http://www.outcome-eng.com/ Quality. Hospital survey on patient safety justculture.html. Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 143 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 4—December 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.