Using Just Culture To Improve Hospital SOPS (Presentation)
Celeste Mayer, PhD
University of North Carolina Health Care System, Chapel Hill, NC
UNC Medical Center
- Public Academic Medical Center.
- Memorial, Children's, Neurosciences, Women's and Cancer Hospital.
- ~850 beds.
- Chapel Hill, NC.
- Patient Safety Officer since 2003.
- At UNC since 1988.
- Reporting structure
- VP for Quality –2003 - 2007.
- Chief of Staff –2007 - 2014.
- General Counsel –2014 - present.
Non-punitive Response to Error Survey Results over Time
|Survey Administration Period||UNC Medical Center Average % Positive||Database Teaching Hospitals Average % Positive|
|2006 July||36%||41% (2007)|
|2008 June||39%||42% (2009)|
|2009 December||46%||42% (2011)|
|2011 October||48%||41% (2012)|
|2013 December||51%||42% (2014)|
|2015 October||53%||43% (2016)|
North Carolina Just Culture Collaborative 2006/2007
- What it was –Partnership between the NC Quality Center and Outcome Engineering.
- How I got involved –saw the opportunity.
- Proposed the idea for participation to the Chief of Staff.
- 10 NC Hospitals participated in a year-long learning and sharing experience - July 2006 to April 2007.
How I pitched this to my boss
- Inexpensive consulting.
- We were measuring.
- Foundational, next step work.
Two people playing catch with the baseball under a large tree.
The UNC Collaborative Team
- Patient Safety Officer.
- Director for Risk Management.
- Attorney from the Legal Department.
- Director for Employee Relations.
- Human Resources Associate.
- Director for Nursing Education.
- Two Nurse Managers.
- RCA Event documentation.
- Employee Corrective Action Reports.
- Patient Safety Activity Documentation.
- Policies; Corrective Action, Sentinel Events, Adverse Event Reporting.
- Patient Safety Plan.
- Code of Conduct, Employee Handbook, Medical Staff By laws.
- In-Person Learning/Sharing – 3 Days.
- Monthly conference calls.
- Acknowledge the shift.
- Many formal communications.
- Used visible support from high-profile leaders and organizations.
- Weaving into the fabric of the organization.
- Policy Change.
Practice into Policy
Two years to change the Corrective Action Policy.
Policy into Practice
- Clear expectation for use of the Just Culture Algorithm.
- Mandatory training for new managers.
- Visibility to all staff.
- Requirements for documentation.
- Employee Relations involvement.
- Manager and all comer training near the end of the collaborative (Feb/March 2007).
- David Marx lead training for leadership and managers (May 2007)
- Serendipity again –Organizational "Commitment to Caring" kickoff and folding Just Culture into the strategic plan.
- Offered Continuing Nurse Education credit for managers.
- Created a "cascade learning" document for managers to guide the sharing with staff.
- And since then Employee Relations leads training for all new managers
- 1 hour concepts.
- Application practice using a case.
- Frontline staff experience Just Culture.
Visibility to Staff
- The algorithm – can be found displayed in most managers' offices.
Just Culture Algorithm flowchart.
Requirements for Documentation
UNC Employee Counseling Session Form.
- Regular measurement and Focus.
- Added 5 additional questions in 2015.
- My supervisor emphasizes learning rather than blame when staff make mistakes.
- When staff take shortcuts that put patient safety at risk, supervisors or managers work with them to change their behavior.
- Staff who see other staff doing something unsafe for patient care tell them it is unsafe.
- Regardless of a person's job position, management applies the same disciplinary policy to everyone working in this hospital, including physicians.
- When a patient safety event happens, hospital management looks at more than staff actions to determine what led to the event.
What Was and Is Most Important
- Supportive and influential leader.
- The perfect learning collaborative opportunity.
- Incorporating Just Culture Principles into the Corrective Action policy.
- Incorporating Just Culture Principles into Counseling/Corrective action documentation.
- Regular measurement and sharing.