A Regulatory Model/Decision Tree for Collaboration

and Practice Accountability

Maryann Alexander, PhD, RN

Nancy Spector, PhD, RN

Maureen Cahill, MS, RN

Kathy Russell, JD, RN

© 2012

The Just Culture Model (simplified)

Reckless

Behavior

Conscious Disregard of

Substantial and

Unjustifiable Risk

Manage through:

• Remedial action

• Punitive action

At-Risk

Behavior

A Choice: Risk Believed

Insignificant or Justified

Manage through:

• Removing incentives

for at-risk behaviors

• Creating incentives

for healthy behaviors

• Increasing situational

awareness

Human

Error

Product of Our Current

System Design and

Behavioral Choices

Manage through

changes in:

• Choices

• Processes

• Procedures

• Training

• Design

• Environment

Console Coach Punish

A Single Event Repetitive Events

• Repetitive errors – yes, there is a process

• Repetitive at-risk behaviors – yes, there is a process

• Both may lead to disciplinary action…

The Just Culture Model

Just Culture

Examines the fallibility of the system as well as inevitable human error and flawed behavioral choices

• System

• Human Error

• Flawed decisions

Regulation

• Public Protection

• Holding systems and individuals accountable for their actions

• Safer care for Patients

Regulatory Model

– Encourage reporting of errors so that systems, processes and behaviors can be improved

– Collaborative/Partnership (Facility and BON and Nurse and Facility)

– Centers around the patient

– Focus is on ethical behavior

– Encourages remediation

– Employs discipline where needed

Accountability of Nurse

Recognize Contributions of System Errors

Patient Outcome Not Primary to BON Decision

Boards and Employers Collaborate

Use Reliable Tools to Evaluate Behaviors and

Systems

Regulatory Decision Model

Next Steps

• Volunteers

• Try out the decision tree

• Send us your feedback/comments

• Feedback from Outcomengenuity

• Develop a resource kit

• Pilot the model/algorithm once completed

Our Goal

Help BONs make consistent decisions that protect the public and lead to safer systems and competent practitioners.