Friday, November 28, 2008

A Just Culture

“Curmudge, when one thinks about a ‘just culture’ as the opposite of a punitive culture, its meaning is pretty obvious; but I know that there’s a lot more that you intend to say about it.”

“That’s for sure, Jaded Julie. The ‘just culture’ approach to patient safety is so important that even screaming from the top of the parking ramp, ‘Read what I write!’ is not sufficient. We both must shout in unison, ‘Read what I write about!’ That means that this blog will only scratch the surface, and that one should read the publications referenced below.”

“Sounds like fun, Curmudge. I’d wear my high school cheerleading uniform, but it probably wouldn’t fit. Anyway, after we have finished screaming, maybe you can give me a more complete definition of ‘just culture’? And while you are at it, you might also tell me what this has to do with Lean.”

“As you know, Julie, a Lean culture is one in which we continuously learn to do our work better. In a just culture, we learn to do things more safely. Both are learning cultures. That is this blog’s raison d’ĂȘtre.”

“(’Raisin debt?’ Oh well, sometimes the Old Guy talks funny. I guess it’s a justification for the blog’s existence.) So what is a ‘just culture’?”

“A just culture is one ‘that is supportive of system safety by facilitating open communication within the organization, while working with a system of accountability that supports safe behavior choices among staff.’(1) In health care, this boils down to being able to safely report errors and near misses so that their root cause can be discovered and the system improved to avoid the error’s recurrence. But there is more to it than that; a culture that is free of blame is not necessarily a culture that is free of responsibility. We’ll talk more about that in a moment.”

“Here’s another question. Sometimes I see ‘Just Culture’ capitalized, and it’s not in a title. Is that different from ‘just culture’?”

“Good catch, Julie. The Just Culture Community was formed by representatives from high-risk industries like aviation and health care to control the hazards of human and organizational error. Their website,
http://www.justculture.org, is moderated by the firm, Outcome Engineering. The site is an extremely valuable resource.”

“As I understand it, Just Culture classifies errors and the organization’s response to them in terms of personal responsibility. They use a tool called the Just Culture Algorithm.” (2)

“Now aren’t you glad, Julie, that we explained algorithms on October 23? In this algorithm, error-producing behaviors are classified as Human Error, At-Risk Behavior, and Reckless Behavior. Human Error reflects the fact that no one is perfect and that some errors are truly inadvertent. The appropriate organizational response is to console the person and to manage the system to minimize the risk that human errors will harm the patient.”

“I’ll bet that the other classifications are more serious. Right?”

“Right. At-Risk Behavior is unintentional risk-taking, such as taking a shortcut to get necessary work done on time. The organization needs to establish whether the employee had a good faith but mistaken belief that the violation was insignificant or justified. If so, the employee should be coached and the incentives for at-risk behavior removed.”

“And finally we get to a situation where punishment may be justified.”

“That’s called Reckless Behavior. In this case, the employee consciously disregarded a known substantial and unjustified risk. So if an investigation has established that there has been reckless behavior, punishment can occur in a just culture.”

“Well, it’s a relief to learn that there is a system out there in which the organization’s response is not totally dependent on how serious the error was.”

“There is a similar but less complex algorithm available from IHI; it’s called the Decision Tree for Determining Culpability of Unsafe Acts.(3) A critical element of this algorithm is the substitution test: ‘Would three other individuals with similar experience and in a similar situation and environment act in the same manner as the person being evaluated?’ It should be very helpful to an organization working toward a non-punitive approach to errors and patient safety.”

“Curmudge, I’ve had enough ‘raisin debt’ for one day. Will we continue the discussion next week?”

“We sure will, Julie. And bring your French dictionary.”

Affinity’s Kaizen Curmudgeon

(1)
http://www.jutculture.org/faq.aspx

(2)
http://www.mocps.org/resources/Marx%20Presentation%20Handouts%201.JC%201Day%20Training%20Slides%20PrintV2.pdf

(3)
http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Decision+Tree+for+Unsafe+Acts+Culpability.htm

Thursday, November 20, 2008

Clashing Cultures in Patient Safety: the "Blame Game" vs. the "Just Culture"

“Jaded Julie, you look very stylish in your coveralls, hard hat, safety glasses, and steel-toed shoes. What’s the event?”

“Well, Curmudge, you said that we were going to lay a foundation, so I felt that I should wear the appropriate personal protective equipment.”

“The foundation will be for our discussion of patient safety, Julie, and our computer shouldn’t be much of a hazard. But I’m delighted that your heart is in the right place. Let’s begin with a quotation from Dr. Lucian Leape, a well known guru of patient safety, ‘The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.’(1) He seems to be saying that in a punitive culture, organizations try to punish people into not making mistakes.“(2)

“I presume that Dr. Leape is referring to the so-called ‘blame game’ in which every adverse event is considered a personal failure and triggers the ‘name, blame, and shame’ response. In that sort of atmosphere, it’s not surprising that people will hide any error that can be hidden. They’re not going to look for the root cause of the error, and it will probably happen again with a possibly more serious outcome.”

“Regrettably, Julie, in our society the ‘blame game’ seems like the natural thing to do. Professionals aren’t supposed to make mistakes, and it is assumed that when a mistake is made it’s because the person wasn’t good enough. Even the person making the mistake often feels that way. Our legal system compounds the problem with the threat of civil penalties (from malpractice suits) and in rare cases criminal penalties as well. It’s not surprising that if somebody makes a mistake, we either cover it up, refuse to admit it, or punish the person instead of asking, ’What gave rise to that mistake?’”(3)

“Curmudge, I have read that IHI uses a technique called the Global Trigger Tool to count mistakes. It’s used because only about 10 to 20 percent of errors are ever reported. Can you tell me more about it?”

“The Global Trigger Tool (4) uses retrospective reviews of randomly selected patient charts to locate and count adverse events (AEs). An AE is an injury or harm related to the delivery of care; it does not have to be the result of an error. A ‘near miss’ does not count because it, by definition, does not cause harm. Lists of ‘triggers’ are provided to serve as clues that an adverse event, from the viewpoint of the patient, has occurred.”

“This doesn’t sound much like Lean, Curmudge. Do you have an inexpert opinion?”

“You’re right as usual, Julie. Use of the trigger tool does not require a change of culture, identification of root cause, and use of the Deming cycle to develop countermeasures. Because it identifies AEs after the fact, there is no such thing as ‘stop the line.’ However, it does provide useful metrics to indicate if changes being made are improving the safety of care processes.”

“Okay, Curmudge. We have the metric, so how can we make the changes in patient care processes that it is going to measure?”

“The most effective change—yet the most difficult to achieve—is to abandon the punitive culture, i.e., the ‘blame game,’ and adopt the ‘just culture.’ We’ll start talking about that next week. I hope you’ll be here, Julie.”

“With bells on, Curmudge. I guess I won’t need the hard hat.”

Affinity’s Kaizen Curmudgeon

(1)
http://www.mocps.org/resources/Marx%20Presentation%20Handouts%201.JC%201Day%20Training%20Slides%20PrintV2.pdf

(2)
http://justculture.org Summer Edition, 2007

(3)
http://www.webmm.ahrq.gov/perspectives.aspx November 2006. Conversation with Donald A. Norman

(4)
http://ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/IHIGlobalTriggerToolforMeasuringAEs.htm

Thursday, November 13, 2008

Resources for Learning about Patient Safety

“Hey, Curmudge, where should I go to do a quick study on patient safety?”

“Right here.”

“No, no. If I couldn’t wait until we finished our discussions on the topic, where should I go?”

“As you know Jaded Julie, you can always start with Google; but you can save a few clicks by starting at
http://www.ihi.org/IHI/Topics/PatientSafety/. You can peel the Institute for Healthcare Improvement website like an onion to dive more and more deeply into your topic of choice.”

“I suspect that there are other sites that you monitor, Curmudge.”

“Here are two more: (1) Morbidity and Mortality Rounds on the Web (
http://www.webmm.ahrq.gov). Topics on this site are not nearly as ominous as they sound. Perspectives on Safety provides two full-text articles per month. (2) Patient Safety Network (http://psnet.ahrq.gov). One may access this site directly, via webmm, or as a free e-mail newsletter. The site’s archives may be browsed by safety target, approach to improving safety, error types, clinical area, target audience, and setting of care. One may also view their Patient Safety Classics, a collection of the most influential, frequently cited articles, books, and resources on patient safety.”

“And in addition…”

“In addition, I recommend that you play detective and follow leads on the net that look interesting. Don’t ignore the health care blogs that—unlike this one—are written by hands-on practitioners. There’s a ton of information out there.”

“Back to IHI, Curmudge. What’s on their Patient Safety menu? Is there a specialty of the house, or as you would say, a plat du jour?”

“We’ll talk about some examples later, Julie. It’s critical for you to know that all of the topics covered by IHI—not just Patient Safety—pertain to health care quality, and quality in health care is virtually synonymous with patient safety. So when you explore the IHI site, don’t limit yourself to Patient Safety. For example, last week we talked about standard work and reliability, and IHI was our principal resource.”

“So now can we discuss specific threats to patient safety?”

“Not so fast, Julie. This is a big topic, and there’s a lot of groundwork that we must do first. So wear your coveralls next week and be ready to build the foundation for our further discussions.”

Affinity’s Kaizen Curmudgeon

Thursday, November 6, 2008

Reliability and Patient Safety

”Curmudge, if you could foresee that you would be run over by a giant turtle while you are jogging tonight, what words of wisdom about patient safety would you gasp with your final breath?”

“Turtle? Don’t you mean Beetle? There may still be a few that haven’t rusted away.”

“No, I really mean turtle. I know how slowly you jog. So, Speedy, what would be your final words?”

“Well, if you must know: ‘We must be serious about patient safety and do the right thing right the first time every time. That requires know-how, systems designed for safety, and a safety culture exhibited by everyone involved.’”

“Okay, Curmudge, let’s assume you survived your 22-minute mile unscathed and can discuss patient safety at your leisure. What’s our first topic?”

“Let’s start with the need to address patient safety. Regrettably, the story about Stan that I related last week is not a once-in-100-years event. Most patients approach a medical procedure with confidence in achieving a favorable outcome. An informed patient will approach the same procedure with trepidation. ‘In health care delivery, a defect—an error, omission, or other failure to accomplish an intended action—occurs, on average, 10 to 20 percent of the time, compared to 0.0001 percent of the time for airlines and nuclear power plants.’(1) It is evident that health care has a reliability problem.”

“Hey, that’s pretty scary, Curmudge. But how about this: The 100 thousand deaths per year in hospitals purported to result from medical errors would be equivalent to the lives lost in four jumbo jet crashes per week.(2) Maybe I should give those numbers to my hypochondriac mother-in-law. She’s afraid to fly, but she thinks a hospital is just like a hotel with room service providing all the meals.”

“Julie, the Institute for Healthcare Improvement (IHI) has developed a framework for improved reliability based on industrial principles of standardization.(3) It begins with protocols of care that are evidence based and widely agreed upon. As IHI says, ‘Standardization is crucial to improvement, because that’s what promotes reliability.’”

“I see now, Curmudge, why we talked about standard work a few weeks ago.”

“The IHI framework employs a three-tiered strategy:
· Prevent failure using guidelines, checklists, and other techniques for best-practice treatment of specific conditions.
· Identify and mitigate failure by using standing orders for best-practice treatments, warnings when an undesirable event is approaching, and independent double-checking of required actions.
· Redesign for success after root cause analysis of persistent failure reveals a flaw in the system design.”

“I presume that IHI’s ‘bundles’ that we discussed two weeks ago were a product of this effort. So we know the importance of standardization; what else must a hospital do to keep its patients safe?”

“Let’s continue this next week, Julie. We’ve got lots to talk about, so you’d better ask your husband to fix supper for the kids.”

“Sure…and supper will be potato chips and toasted Pop-Tarts.”

Affinity’s Kaizen Curmudgeon

(1)
http://www.ihi.org/IHI/Topics/Reliability/ReliabilityGeneral/ImprovementStories/WhenGoodEnoughIsntGoodEnoughTheCaseforReliability.htm

(2)Karl, R.C., Staying Safe: Simple tools for safe surgery. Bulletin of the American College of Surgeons 92 (4):16-22 (April, 2007).
(3)
http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliabilityofHealthCare.htm