Nursing

Learn how to hold staff accountable in a nonpunitive culture

Nurse Leader Weekly, January 17, 2003

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For years, errors were blamed on people instead of systems. People were punished and errors persisted. Now it is well-understood that errors are most often the result of problems with underlying systems, and hospitals are being encouraged to establish nonpunitive cultures that focus on processes, rather than people.

But does that mean individuals should not be held accountable for medical errors? No, said David Marx, JD, director of Outcome Engineering, LLC. "You can have learning cultures and accountable cultures at the same time," Marx said.

Establishing a just culture

So how can you establish a system that doesn't unfairly punish people for mistakes, yet still holds them accountable? First, define the objective of your disciplinary program. Marx says good disciplinary policies should

  • encourage reporting, so you can collect accurate data
  • allow employees to participate in event investigations
  • improve safety

When it comes to deciding whether an employee should be disciplined, determine whether the person made a simple error or a mistake occurred because of the employee's reckless or deliberate actions. Your facility must also decide how it will enforce the rules it puts in place. Consider whether you will punish for the following:

  • all rule violations
  • intentional rule violations
  • rule violations that deviate from the norm
  • no rule violations

Learning to manage risk

In order to manage risk within your organization, divide errors into three categories, Marx says. The first category is "normal error," which results from how your system is designed. To manage this type of error focus on making changes to the following:

  • Processes
  • Procedures
  • Training
  • Design
  • Environment

The second category is at-risk behavior. This category involves unintentional risk-taking on the part of your employees. It includes situations when employees don't follow the rules they've been taught. To help prevent errors based on this type of behavior, the following are critical:

  • Understand at-risk behaviors. Know that people will begin to drift from the rules. Anticipate these behaviors and take steps to prevent them.
  • Remove incentives for at-risk behaviors.
  • Create incentives for healthy behavior.

The third category is what Marx calls high culpability behavior, which involves intentional risk-taking. You can manage this category through disciplinary action.

Adapted from: Briefings on Patient Safety, www.hcmarketplace.com/Prod.cfm?id=234&S=ENMW.



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