Implementing a just culture in the nursing unit

Nurse Leader Insider, April 22, 2020

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First and foremost, it goes without saying that we all want to do the right thing, at the right time, for the right patient the first time, and every time thereafter, without making a mistake or causing harm, ever. And in a perfect world, that's what would always happen-we would take good care of our patients, who in turn would always have great outcomes.

Unfortunately, it's not a perfect world and every healthcare provider will make at least one error during the course of his or her career. Whether it will actually reach a patient is irrelevant. The fact is, an error will still be made, which results in at least one of the following outcomes:

  • Actual event, with patient harm
  • Actual event, with no patient harm
  • Near miss, with no patient harm, but that has the ­potential to cause harm


We also know now that the majority of errors occur from systems failures or process problems, and we know that if we focus on and fix the process, we will have more success in achieving safer patient care conditions than if we target people problems or punish providers for making those errors. It is already well known that how an organization manages its event reporting system tells a lot about the organization's culture. It only follows that an organization with a robust event reporting database in all likelihood has a positive culture of patient safety in which staff members are very comfortable reporting, knowing that there won't be punative action taken against them. However, we do not discount accountability when an error is made, particularly in light of our understanding of the set of alogorithms that help us determine whether the behavior was human error only, at-risk behavior, or reckless behavior. We also know that those who have instituted a culture of patient safety seem to have followed several strategies to ensure successful implementation.

A healthcare organization's staff members, from leadership to frontline staff, have to understand the concept of a just culture, agree with the principles, and practice it every day. However, to ensure a hospital is operated 100% in a just culture manner, there are steps to take at the beginning of your journey. A healthcare organization would also be wise to review these steps occasionally and ensure everything is being done to support a just culture.


Step one: Leadership buy-in

If the culture of the organization is to truly be patient safety-focused, then it is absolutely critical that leadership set the example by communicating to all employees, including managers, medical staff, and board members, that patient safety is a priority organizational strategic goal. There are many steps leadership can take to ensure that they mean business when they say patient safety is an important component of success for the organization. The following is a checklist for leadership to ensure they are communicating this priority effectively:

  • Make sure patient safety issues are discussed at senior leadership and board meetings
  • Do walk-arounds and talk to staff about what they perceive as serious patient safety issues
  • Ensure senior leadership representatives are involved in performance improvement, patient safety, and risk management committees; their attendance and participation should be required
  • Ensure patient safety education is presented at new staff and medical staff orientation programs, as well as at regularly scheduled educational sessions
  • Provide a "Lesson Learned" forum where staff can present actual adverse events to their colleagues and ask them to provide to the group their plans for how these issues will be prevented from happening again
  • If a plan was successful, ask staff to share how this was accomplished with the rest of the organization and promote these successes throughout the organization
  • Make patient safety a part of competencies and ­performance evaluations for every hospital employee, the medical stall, and governing board


Step two: Formation of a patient safety ­culture committee

Form a patient safety committee, task force, or initiative composed of representatives from nursing, ancillary clinical and nonclinical departments, middle and senior leadership, and the medical staff. This team of committed individuals will eventually serve as just culture champions for the entire organization, as well as a resource for assistance and guidance to support the staff's efforts. Members of this group will also be crucial in helping to build awareness of what the staff, as well as ­leadership, perceives the current culture to be and will serve as cheerleaders during the patient safety culture assessment survey process, encouraging survey completion housewide. The results are usually an initial surprise to leadership, because their perception of the current culture will most likely differ from that of the frontline staff.


Step three: Assessing current culture

If it hasn't been done by now, it is time to assess the organization's current culture of patient safety. The best practice is to resurvey every six months, focusing on those areas most needing immediate improvement, until measurement determines that the organization has at least met its minimum target for improvement. Once improvements are identified as being more stable with respect to the rate of progress, then the survey should be conducted every year.


Step four: Education

The next step is to educate senior leadership, members of the board, and other key operating managers about the just culture workshop or other full-day session. It is at this point that an outside expert on the subject would be the most credible instructor, who can truly do justice to the topic and who can motivate attendees into action. Inviting someone outside of the hospital to speak also validates the message that the hospital's patient safety staff has been trying to communicate, usually for a long time prior to bringing an expert in to conduct the session.

Next, develop an orientation training program on patient safety and just culture for all new directors, managers, and supervisors coming on board, as well as for those who have been with the organization for some time. Include the topic of accountability as part of the program and encourage participants to work with human resources prior to utilizing a disciplinary processor before taking any action. Develop a similar program to be presented annually as a reminder of the organization's commitment to fairness and accountability.

In most cases, once senior leadership and managers have been brought on board, formal education sessions for the staff may not be necessary, depending on how comfortable mid-level managers feel about communicating to their staff what they have learned and ways in which patient safety can be improved. In fact, in many instances, educating the rest of the staff can really be incorporated into the routine and practical operations of the institution.

However, if the organization feels that formal staff training is necessary, there is no need to start from scratch. There are several programs already out there online that can be adapted to meet the organization's needs. For more information, is a great place to start looking into how education can be improved.


Step five: Policy, procedure, and protocol ­development

Revise policies, procedures, and protocols (particularly those policies relating to expectations for behavior) and continue efforts through routine orientation, during routinely scheduled competency training, and at unit-specific education programs whenever possible. Any policies that do not promote a just culture should be eliminated, specifically those relating to punishment for errors. Policies that will need to be revised include your incident reporting policy, sentinel event policy, disclosure policy, patient complaint/grievance process, job description, codes of conduct, medical staff bylaws, rules and regulations, and the like.

Any document that addresses the consequences for behavior and the management of adverse events will need to be revised to reconcile professional accountability and the need to create a safe environment to report medical errors. In other words, the staff need to know that if an event occurred because of a system failure or flaw, then the organization accepts responsibility and accountability, and the individual will not be punished for something that was out of his or her control.

Leadership will need to understand that the reasons for clinical outcomes and events should not be the focus, nor should those involved be prejudged. Any rush to blame individuals is to be avoided. Rather, there should be an attempt to understand at the time the event ­occurred the circumstances and context for the actions and decision-making. The main focus of this analysis is on system failures-with any and all subsequent analyses and proceedings conducted with fairness, within the legislative and legal frameworks, and in accordance with established hospital policy and/or bylaws. The rights of all individuals are protected, for both employees and patients, and policies and procedures should reflect language that addresses:

  • Leadership's commitment to and support of the purpose of quality improvement
  • Leadership appropriately protecting any and all quality improvement information from legal, regulatory, or other proceedings
  • The organization's intolerance of intentionally unsafe actions, reckless actions, disregard for the welfare of patients or staff, or other willful misconduct and ­misbehavior

Source: Strategies for Nurse Managers

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