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.

My Role

• 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

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.

Fortuitous Serendipity

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.
• Pediatrician.
• Anesthesiologist.

The Collaborative

• Prework
  • 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.

Creating Change

• Acknowledge the shift.
• Many formal communications.
• Used visible support from high-profile leaders and organizations.
• Education.
• 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.

Training

• 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.

The Algorithm

Just Culture Algorithm flowchart.

Requirements for Documentation

UNC Employee Counseling Session Form.

Sustainment Today

• Regular measurement and Focus.
• Added 5 additional questions in 2015.

1. My supervisor emphasizes learning rather than blame when staff make mistakes.
2. When staff take shortcuts that put patient safety at risk, supervisors or managers work with them to change their behavior.
3. Staff who see other staff doing something unsafe for patient care tell them it is unsafe.
4. Regardless of a person's job position, management applies the same disciplinary policy to everyone working in this hospital, including physicians.
5. 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.

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