Session 49AB Effective Governance of Executive Compensation

Prepared for the Foundation of the American College of Healthcare Executives

Session 49AB Examining the Just Culture Model:

20 Years Later

Presented by: Anne Pedersen, MSN, RN, NEA-BC

Joanne L. Sorensen, DNP, RN, FACHE

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Examining the Just Culture Model: 20 Years Later

Disclosure of RelevantFinancial Relationships

The following faculty of this continuing education activity has no relevant financial relationships with commercial interests to disclose:

• Joanne Sorensen, DNP, RN, FACHE

• Anne Pedersen, MSN, RN, NEA-BC

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FacultyJoanne L. Sorensen DNP, RN, FACHE

CNO, VP Patient Care Services

UPMC Northwest

Anne Pedersen MSN, RN, NEA-BC

Director of Nursing

UPMC Hamot

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Learning Objectives

#1 Following this session, attendees will be able to discuss the concept of Just Culture and application of a structured Just Culture Decision-Tree.

#2 Following this session, attendees will be able to assess their organization for challenges, barriers and strategies to overcome obstacles related to enhancing and strengthening a Just Culture.

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Agenda 1.Thought leaders: a historical perspective

• Reason, Marx, Donabedian, & Leape• 20 Year challenges and learning• The impact of a limited focus

2. Current research3. A Model for the Future

• Culture is local• Concepts which support Just Culture

4. Case Studies5. Outcomes6. Conclusions

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Patient Safety in America

• 200,000 people die from medical errors/year (Andel, et al, 2012)

• OVER 130,000 Medicare beneficiaries experienced 1 or more adverse events in hospitals in a single month (HHS, OIC, 2012)

• In 2014, 56% of hospital employees did not report any medical errors over a 12 month period (AHRQ, 2014)

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A Just Culture Historical Underpinnings

• James Reason-seminal work 1990’s in human factors and safe environments of care - author of Human Error

• Avedis Donabedian-Links Quality Outcomes to Structure, Process, and Love

• David Marx-thought leader and author of Patient Safety and the Just Culture: A Primer for Health Care Executives (2001)

• Lucian Leape-Applied Human Factors research within the Medical Model- author of Error in Medicine (1994)

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A Just Culture Historical Underpinnings

AHRQ Culture of Safety recognizes essentials:

– High risk nature of the work being done

– Determination to achieve consistent safe operations

– A safe and fair environment for reporting error that is blame-free

– Collaboration across ranks and disciplines

– Organizational commitment of resources toward the elimination of safety concerns

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James Reason

“Swiss Cheese Model”Worked with 3 Risk Industries

• Military• Air Traffic Control• Nuclear

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David Marx“Just Culture” was first used in a 2001 report by David Marx the report which popularized the term in the patient safety lexicon

The Three Duties

• The duty to avoid causing unjustified risk or harm

• The duty to produce an outcome

• The duty to follow a procedural rule

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Avedis Donabedian

The Father of Quality AssuranceThe Donabedian Model

Structures of Care

Processesof Care

Outcomes

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Donabedian understood health care as a system…

“Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system”.

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Lucian Leape MD

Punishment of Individuals instead

of changing systems provides

strong incentives for under-reporting.

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Lucian LeapeProfessional Response to Human Error

Physician Values

• Physicians are socialized to strive for error-free

• Error is viewed as a failure of character

• Medical responsibility= infallibility

• Emotional devastation

• Learn from error in a vacuum

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Lucian LeapeProfessional Response to Human Error

Nursing Values• Rigid adherence to

protocols

• Social and peer disapproval is viewed as punishment

• Emotional devastation

• Learn from error in a vacuum

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Lucian Leape Human Factors Research-Health Care Industry

• Mental functioning is automatic-Schematic mode

• Skill-based efforts

• Attentional Control Mode-conscious, used in problem-solving, takes effort

• Rule and Knowledge-based

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Just Culture

Single greatest impediment to error prevention in the medical industry is

“that we punish people for making mistakes”

Lucian Leape, Professor, Harvard School of Public Health

Testimony before Congress on Health Care Quality Improvement

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In Fact …..The IOM has identifiedsafety as a property of ahealth care system ratherthan of an individual,noting that moving from aculture of blame to one oflearning and improving isone of the majorchallenges in creating asafer health care system.

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Punitive culture creates fear, destroys creativity, builds barriers, and DRIVES ERROR UNDERGROUND.

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TOO MANY ABANDON THE “SECOND VICTIMS” OF MEDICAL ERRORS

July 14, 2011 issue

It was with immeasurable sadness that we learned a veteran pediatric nurse had taken her own life in the aftermath of a fatal medication error. The nurse, Kimberly, 50, committed suicide on April 3, 2011, just 7 months after making a mathematical error that led to an overdose of calcium chloride and the subsequent death of a critically ill infant.

The Second Victim

Institute for Safe Medication Practice accessed on January 2, 2015 at https://www.ismp.org/newsletters/acutecare/articles/20110714.asp

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Just Culture Theoretical Underpinnings

• Believing that a culture is fair and just is a lived reality– Dignity and Respect

– Psychological Safety

• The system has effective structures and processes

• Safety is institutionalized

• Values: Honesty and Integrity

• Communication openness

• Understanding of human factors

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Just Culture: Giving Staff a Voice

An environment of trust and fairness where:

– it is safe to report and learn from mistakes and system flaws to ensure patient safety;

– consistent clarity and distinction exist between human error in unreliable systems and intentional unsafe acts;

– leaders, physicians, and staff work collaboratively to build a thriving healthcare culture.

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Blame-Free vs. Punitive Cultures

A Just Culture finds the middle ground between a blame-free culture and an overly punitive culture

ORGANIZATIONAL CULTURES

All errors are faults of the ‘system,’ not individuals

All errors are blamed on mistakes made by individuals

PunitiveBlame-Free

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Just Culture Simplified

Product of our current system design and behavioral choices

Manage through:

• Choices• Processes• Procedures• Training• Design• Environment

Human Error

Risk Behavior

Careless Behavior

A Choice: Risk believed insignificant or justified

Manage through :

• Removing incentives for at‐risk behaviors

• Creating incentives for healthy behaviors

• Increasing situational awareness

Conscious disregard of substantial and unjustifiable risk

Manage through :

• Remedial action• Punitive action

Console Coach Punish

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• Organizational commitment

• Poor teamwork

• Communication

• Culture of low expectations

• Pronounced authority gradients

Barriers to a Safety Culture

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Just Culture Current Research

Efforts to develop a strong safety culture produce spillover effects. Abrahamson, et al. 2016

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ANCC Magnet

• Structural Empowerment • Exemplary Professional

Practice• Transformational

Leadership• New Knowledge,

Innovation • Empirical Outcomes

Engagement

• Local culture drives safety culture

• Synergy -- employee engagement & safety

• Link to unit culture, LOS, morbidity & mortality

• Clear safety policies, safety training

Just Culture Current Research

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Patient Experience

• Open Communication

• Collaboration

• Commitment

Patient Outcomes

Mortality

Readmissions

AHRQ PSI

HAPU

Just Culture Current Research:Key Relationships

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Just Culture Current Research: Systematic Review of Safety Culture Associations

• Hospital level versus unit level research

• Composite score for AHRQ Patient Safety Indicators

• Mortality

• Patient outcomes

• Patient experience

Margaret DiCuccio. 2015 J Patient Safety

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What if we could measure how “Just” a Culture really is …..

The Development of the JCAT

1. Feedback and communication

2. Openness of communication

3. Balance

4. Quality of event-reporting process

5. Continuous improvement

6. Trust

Petschonek, S. et. Al (2013) J. of Patient Safety

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Current Research Summary

Emerging recognition that

a Safety Culture is

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• “Inadvertently doing other than what should have been done.”

• Identification of system risk is critically important. It is about designing safe systems, structures, and processes of care.

Definitions: ANA Position Statement Just Culture

Human Error

System Risk

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• “Reckless behavior is action taken with conscious disregard for a substantial and unjustifiable risk.”

• “At-risk behavior occurs when a behavioral choice is made that increases risk where risk is not recognized or is mistakenly believed to be justified.”

Definitions: ANA Position Statement Just Culture

Reckless

Risk Behavior

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Let’s Give It a Try!

Small Group Application Exercise

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System Situational Awareness:

• Policies & Procedures in place

• Dedicated Vascular Access Team

• Active CLABSI Champions

• HWST

• Zero CLABSI x 5 months

1: Case of the Expired Tubing

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Case 1: Evaluate the care by the nursing staff

• Situation: Patient went to Interventional Radiology to have a PICC (Peripherally Inserted Central Catheter) line inserted.

• Background: A 38-year-old female was admitted with multiple comorbidities. After three days in hospital, she went to Interventional Radiology for PICC line placement related to multiple IV antibiotics ordered.

• Assessment: Upon return to her room, the nurse connected the old tubing to the new PICC line. For the next 3 days and over the course of 5 assigned nurses, no one changed the tubing.

• Recommendation: ???

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Select the outcome category of this case from the options listed below:......

1. Human Error

2. Risky Behavior

3. Careless Behavior

4. System Error

5. Human Error + System Error

6. Risky Behavior + System Error

Answer Now

Audience Polling

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System Situational Awareness

• Suicide Precautions and Psyche Care Attendants part of Mandatory Madness Fairs

• Nursing M&Ms

• 18 inservices offered

• Bright green sitters placed on name tags, to identify staff as “Psych Care Attendants"

• The "Safe Room Checklist" revised

• Unit Directors engaged in oversight of Suicide Precautions – incorporated into all nursing unit shift huddles

Case 2: It’s Raining Pills!

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Case 2: Evaluate care provided by the staff

• Situation: A patient was admitted for fractured long bones. She was placed under suicide watch for her hospital stay per comments she made to staff and Psychiatrist.

• Background: A 59 year old female fell off a ladder at home. She sustained a broken tib/fib requiring surgery to repair the fracture; an external fixator was applied. Several days into her hospitalization, she began to voice suicidal ideations (with a plan). The Psyche eval was completed with the recommendation to petition for involuntary commitment. Psych Care Attendants (PCAs) were ordered until discharge

• Assessment: It came to the attention of leaders that the PCAs and RNs were departing from policy (allowing luggage and belongings in the room. Upon search found over 100 different pills (Oxycodone, etc.), 5 fentanyl patches, razor, cell phone w/charger cord etc.


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1. Human Error

2. Risky Behavior


4. System Error



Answer Now

Audience Polling

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System Situational Awareness

– Policy & Procedure

• Counts

• Critical moments

• Role clarity

– Sophisticated OR Safety Triad

• Measured and monitored Safety Triad

• Practiced in Sim Lab

– Tenured team

– Strong working relationships

3: Case of the Missing Screw

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Case 1: Evaluate the care by the Surgical Team

• Situation: Patient went to OR for removal of hardware in knee. Six of seven screws removed.

• Background: A 59 year-old female was admitted fore removal of surgical hardware in her knew related to infection. The attending surgeon started the case removing the plate and then went to a second procedure. The chief resident to removed six screws, closed the incision, dressed the wound as the patient was awakened. The surgeon returned to the room and asked if all seven screws were removed. Upon confirming that one screw remained, the patient was re-sedated, re-opened and the final screw removed.

• Assessment: Only the attending surgeon knew that 7 screws were to be removed.


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1. Human Error

2. Risky Behavior


4. System Error



Answer Now

Audience Polling

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HOW DOES THE OUTCOME IMPACT OUR PERCEPTION OF

THE EVENT?

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Strategic Implications: 20 years later

A comprehensive patient safety strategy is multifaceted:

• It depends on a fair and just response to error-leadership matters

• Recognizes the local nature of safety culture and the benefit of front-line staff engagement

• Incorporates the creation of safer systems of care

• Psychological safety matters

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Just Culture Response to

Error


Error


Error

1

CRMStandardize

Systems Focus

CRMStandardize

Systems Focus

CRMStandardize

Systems Focus

2

SimulationPractice

Communication & Teamwork

SimulationPractice


SimulationPractice


3Superior Outcomes

StrategicImplications

Safety Culture

Local Culture with Patient Safety Focus



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Local Leadership

Local Leadership

Local Leadership

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Outcomes

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Tools & Concepts

Magnet NDNQIJCAT JC Concepts My Voice Survey

12 Domains6 Concepts 42 Questions

Feedback & CommunicationOpenness of CommunicationQuality of event‐reporting Continuous improvementTrustBalance

Open Communication Error Feedback Reporting FrequencySupport for SafetyNon‐punitive ResponseOrg Learning Overall Perception of SafetyStaffingSupervisor ActionsTeamwork AcrossTeamwork WithinFacility Handoffs

I can speak openlyThe people I work with help each otherWe deliver quality care & servicesA commitment to patient care is clearMy supervisor acknowledges me for doing good workMy leaders treats me with dignity & respect

AHRQ COS Tool

Foundations for quality of care Nurse manager ability, leadership & supportPerceived qualityStaffing & resource adequacyCollegial Nurse MD relationshipsLast shift descriptionRecommend hospital, orientation, in‐services

Scales

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Outcomes UPMC Hamot

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63

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64

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56

54

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20 30 40 50 60 70

Frequency of EventReporting

Facility Management Supportfor Safety

Nonpunitive Response toError

Overall Perception of Safety

Staffing

20122014

1.00

1.50

2.00

2.50

3.00

3.50

2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 2015 2016

NurseParticipation

Hospital Affairs

NursingFoundations forQuality of Care

Nurse ManagerAbility,

Leadership, andSupport

Staffing andResourceAdequacy

Collegial Nurse-Physician

Relationship

Mean PES

AHRQ COS MAGNET NDNQI

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Outcomes: Unit A vs B AHRQ Culture of Safety

63

70

76

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45

40 50 60 70 80

CommunicationOpenness

Management SupportFor Safety

Overall Perception ofSafety

Unit A v Unit B: 2014

Unit A Unit B

• COS is local

• Unit A & B are next door

• Report up to the same leaders

• Different managers, issues & challenges

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Outcomes: PACU

40% 50% 60% 70% 80% 90% 100%

Communication Openness

Frequency of Event Reporting

Supervisor Actions Promoting Safety

Teamwork Across Hospital Units

Teamwork within Hospital Unit

2012 2014

ARHQ Survey

My Voice

Magnet NDNQI

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Outcomes: The OR

• Large unit

• Tenured staff

• Leadership changes

• New leader, new values

• OR changed greatly between the 2 surveys

• Structure, staffing, leadership

My Voice Survey

Magnet NDNQI Survey

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NICU: An Exemplar → AHRQ COS

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%NICU AHRQ COS Overall Results

2012

2014

AHRQ 50%

Director in role for 15 years – hospital 43 yearsDeep commitment to patients and staffExciting culture, evidence based, and research oriented

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The NICU: An Exemplar → Magnet

2012 2013 2015 2012 2013 2015 2012 2013 2015 2012 2013 2015 2012 2013 2015

Nurse ParticipationHospital Affairs

Nursing Foundations forQuality of Care

Nurse Manager Ability,Leadership, and Support

Staffing and ResourceAdequacy

Collegial Nurse-PhysicianRelationship

NICU 3.2 3.17 3.26 3.41 3.4 3.45 3.4 3.44 3.38 3.27 2.84 3.15 3.35 3.37 3.36

Mean of Hospitals Bedsize 300-399 2.89 2.87 2.87 3.14 3.11 3.08 2.92 2.91 2.9 2.92 2.91 2.87 3.17 3.14 3.18

1

1.5

2

2.5

3

3.5

Magnet NDNQI Practice Environment Scale

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COMMENTS

• Strong leadership at all levels

• Commitment to patient safety and quality

• Drive to succeed to provide the best care in the region

• Caring, compassion

• Teamwork

• Allowing nurses to be part of making the changes

• I am lucky to work here

• Commitment to quality care

• Great people who work here

• The staff of the hospital are wonderful

My Voice Survey █ NICU █ Hospital █ System

The NICU: An Exemplar → My Voice

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Just Culture response to

error


error


error

1

CRMStandardize

Systems Focus

CRMStandardize

Systems Focus

CRMStandardize

Systems Focus

2

SimulationPractice

Communication and Teamwork

SimulationPractice


SimulationPractice


3Superior Outcomes

StrategicImplications

Safety Culture




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Local Leadership

Local Leadership

Local Leadership

4

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The NICU: An Exemplar → Outcomes

Beating Benchmarks on:

– Mortality

– Morbidity

– Readmission Rates

– Complications

• Retinopathy of prematurity

• Necrotizing enterocolitis

• Intraventricular hemorrhage

• Nosocomial infections

• Chronic lung disease

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My Voice Survey

12 Domains 42 Questions

Open Communication Error Feedback Reporting FrequencySupport for SafetyNon‐punitive ResponseOrg Learning Overall Perception of SafetyStaffingSupervisor ActionsTeamwork AcrossTeamwork WithinFacility Handoffs

I can speak openlyThe people I work with help each otherWe deliver quality care & servicesA commitment to patient care is clearMy supervisor acknowledges me for doing good workMy leaders treats me with dignity & respect

AHRQ COS Tool

Data• Sample: surgical units across

the system• Sources:

– 2016 MyVoice Engagement Index (≥ 10 respondents per unit)

– 2015 Culture of Safety (≥ 10 respondents per unit)

Analysis• Calculated Spearman rank

correlations between the Engagement Index and 12 Culture of Safety Domains

Data and Analysis: The System ORs

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• Bolded correlations are statistically significant

• As the proportion of engagement increases in a unit, the culture of safety domains tend to improve as well

Culture of Safety Domain Engagement Index

Communication Openness .40*

Feedback & Communication About Error .33*

Frequency of Event Reporting .15

Facility Management Support For Safety .44*

Nonpunitive Response to Error .18

Organizational Learning & Continuous

Improvement .45*

Overall Perceptions of Safety .53*

Staffing .27

Supervisor Actions Promoting Safety .48*

Teamwork Across Facility Units .65*

Teamwork Within Hospital Units .66*

Facility Handoffs & Transitions .35*

*p<.05, Spearman’s rank correlation

Data

• Sample: surgical units across system

Sources:

• 2016 My Voice Engagement Index (≥ 10 respondents per unit)

• 2015 Culture of Safety (≥ 10 respondents per unit)

Analysis

• Calculated Spearman rank correlations between the Engagement Index and 12 Culture of Safety Domains

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Conclusions

C-Suite Backing

HR Alignment

Internal vs. External Resources

Must Have Physician

buy in

Staff Readiness

Shared Governance Model

May Have

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• Consider that culture is a local phenomena and engage front-line staff in owning their safety culture

• Incorporate principles of CRM and Simulation Training to identify local risk behaviors

• Celebrate success with stories and data!

Conclusions

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PresentersJoanne L. Sorensen DNP, RN, FACHE Anne Pedersen MSN, RN, NEA-BC

Chief Nursing Officer and Vice President of Patient Care Services at UPMC Northwest

[email protected]

814-877-6875

Director of Nursing, Emergency,

Critical, and Operative Services at UPMC Hamot

[email protected]

814-877-2928

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Joanne Sorensen BiographyJoanne Sorensen has been a nurse leader for 33years in a variety of settings and roles and is currentlythe VP of Patient Care Services/CNO at UPMCNorthwest. Previously she served as Clinical Director:Regulatory Readiness/ Women’s Hospital at UPMCHamot. She earned her DNP from WaynesburgUniversity in 2011 where she is adjunct faculty. Shewas a member of the Pennsylvania State Board ofNursing from 2003-2015, chairing the board in 2006.Sorensen co-chaired the UPMC Health Systemimplementation of a Just Culture. She is also acertified LifeWings instructor teaching the principlesof CRM. Sorensen, the recipient of the 2015 Cameosof Caring Quality and Safety Nursing Award, hasextensive process improvement experience and hasdeveloped and implemented nursing peer reviewincorporating a “Just Culture”. Sorensen haspresented nationally and internationally on theconcepts of Patient Safety and Safety Cultures.

Joanne L. Sorensen DNP, RN, FACHECNO, VP Patient ServicesUPMC Northwest100 Fairfield DriveSeneca, PA 16346

Office: 814-676-7147Email: [email protected]

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Anne Pedersen Biography

Anne Pedersen MSN, RN, NEA-BC has been anurse leader in a variety of settings for over 20years. She earned her BSN at the University ofPittsburgh and MSN at UNC-Chapel Hill. Shehas published extensively in journals rangingfrom Nursing Management to the Journal ofNursing Administration. She has spokennationally and internationally on a variety oftopics including patient satisfaction, peer review,and the qualities of effective leadership. She iscurrently the Director of Nursing at UPMCHamot in Erie, Pennsylvania. She has nurseexecutive oversight of implementing crewresource management in the ICUs, ED andtrauma service lines.

Anne Pedersen MSN, RN, NEA-BCDirector of Nursing, UPMC Hamot201 State StreetErie, PA 16550

Office: 814-877-2928Email: [email protected]

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Bibliography/References• Abrahamson, K., Hass, Z., Morgan, K., Fulton, B., & Ramanujam, R.

(2016). The Relationship Between Nurse-Reported Safety Culture and the Patient Experience. The Journal Of Nursing Administration, 46(12), 662-668.

• Agency for Healthcare Research and Quality. (2004) Safety culture dimensions and reliabilities: user’s guide: hospital survey on patient safety culture. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html. Accessed January 2, 2017.

• Albrecht, R. M. (2015). Patient safety: the what, how, and when. American Journal Of Surgery, 210(6), 978-982. doi:10.1016/j.amjsurg.2015.09.003

• Bashaw, E. S., & Lounsbury, K. (2012). Forging a new culture: blending Magnet® principles with Just Culture. Nursing Management, 43(10), 49-53.

• Best, M., & Neuhauser, D. (2004). Avedis Donabedian: father of quality assurance and poet. Quality & Safety In Health Care, 13(6), 472-473.

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Bibliography/References• Boysen II, P. G. (2013). Just Culture: A Foundation for Balanced Accountability

and Patient Safety. Ochsner Journal, 13(3), 400-406.

• DiCuccio, M. H. (2015). The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic Review. Journal Of Patient Safety, 11(3), 135-142. doi:10.1097/PTS.0000000000000058

• Helbling, N., & Huve, J. (2015). Finding the balance for a culture of safety. Nursing2015, 45(12). Pp. 56-68 doi: 10.1097/01.NURSE.0000473405.04919.10

• Leape L. (1994) Error in Medicine. JAMA, 272(23):1851-1857. doi:10.1001/jama.1994.03520230061039

• Marx, D. (2001). Patient Safety and the Just Culture: A Primer for Health Care Executives, New York: Columbia University

• Miranda, S. J., & Olexa, G. A. (2013). Creating a just culture: recalibrating our culture of patient safety. The Pennsylvania Nurse, 68(4), 4-9.

• Petschonek, S., Burlison, J., Cross, C., Martin, K., Laver, J., Landis, R. S., & Hoffman, J. M. (2013). Development of the just culture assessment tool: measuring the perceptions of health-care professionals in hospitals. Journal Of Patient Safety, 9(4), 190-197. doi:10.1097/PTS.0b013e31828fff34

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Documents

Session 49AB Effective Governance of Executive Compensation