Welcome to the Leadership for Safety Webinar Just Culture: What Happens When Individuals are Responsible for Safety Mishaps? The webinar will be starting momentarily… If you are having technical difficulties please contact 202-495-3356 or email@example.com Chat Box Please use the Chat Box on the webinar screen to type your question or comment at any time. NOW: Use the Chat Box to sign in. Enter your organization and names of all people in the room. Agenda for Today’s Webinar • Recent disciplinary actions against individual staff members: Accounts from your peers • Methods for determining individual culpability: Examples of Just Culture algorithms and HR protocols • Next month’s focus: Engaging doctors in safety initiatives Who is on Today’s Call? Kimberly Horton, DHA, MSN, FNP, RN, FACHE Jim Reinertsen, MD Bart Hill, MD, MPA St. Luke’s Treasure Valley St. Luke’s Regional Medical Center St. Luke’s Meridian Medical Center Jill Steinbruegge, MD, PhD Cook County Health & Hospitals System John H. Stroger, Jr. Hospital Provident Hospital Kerin Bashaw, MPH San Francisco General Hospital and Trauma Center Contra Costa Regional Med. Center Alameda County Medical Center Santa Clara Valley Health and Hospital System Truman Medical Centers TMC- Hospital Hill TMC- Lakewood San Mateo Medical Center MetroHealth Bianca Perez, PhD Regional Medical Center at Memphis Los Angeles County Department of Health Services Harbor-UCLA Med Center LAC+USC Healthcare Network Rancho Los Amigos National Rehab. Center Kimberly Horton, DHA, MSN, FNP, RN, FACHE Maricopa Medical Center UT-Health Science Center at Tyler Univ. Medical Center of El Paso Harris County Health System Ben Taub General LBJ Hospital Quentin Mease LSU-HCSD Interim Bogalusa Arielle Gorstein Leadership Summit staff Joan Spicer, RN, PhD, CCM Javier Gonzalez, MBA/HCM,BSN,CCM,CPHQ Guest speakers on today’s call A Fair and Just Culture: Why Is it Important? In-Patient Care Unit Number of Responses Nonpunitive response to error Staff feel like their mistakes are held against them. (A8R) When an event is reported, it feels like the person is being written up, not the problem. (A12R) Staff worry that mistakes they make are kept in their personnel file. (A16R) M/S M/S 1 2 ICU 24 65 31 37% 46% 61% 43% 43% 58% 46% 46% 74% 22% 49% 52% •Yes Slide 6 © 2006. Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED University Medical Center of El Paso Slide 8 Alameda Health System A Fair and Just Culture A Fair and Just Culture supports a learning culture that focuses on proactive management of system design and management of behavioral choices. The Three Behaviors Human Error Product of our current system design and behavioral choices At-Risk Behavior Reckless Behavior A choice: risk believed insignificant or justified Conscious disregard of substantial and unjustified risk Console Coach Discipline Bi-Directional Accountability ACMC Leadership ACMC Staff Systems design/maintenance Cultivate honest, fair feedback Consistent execution of just culture Behavioral choices informed by ACMC Policies Engage in honest, fair feedback TRUST – HUMANISTIC CARE A Fair and Just Culture Duty to Avoid Causing Unjustifiable Risk or Harm Was it the employee’s purpose to cause harm? No Did the employee knowingly cause harm? Yes Yes Consider punitive action Was the harm justified as the lesser of two evils? Yes No Did the behavior represent a substantial and unjustifiable risk? No Do not consider employee action Yes No Consider punitive action Did the employee consciously disregard this substantial and justifiable risk? Yes Support employee in decision Actions No Should the employee have known they were taking a substantial and unjustifiable risk? Console employee and conduct human error investigation Did the employee choose the behavior? Consider Punitive action Yes HE RB At all times, an employee will be subject to the duty to avoid causing unjustifiable risk or harm to himself, to fellow employees, customers, visitors, and to the organization. Under this duty, an employee will be subject to disciplinary action when they have acted with reckless disregard toward the potential harm to themselves or others. No Do not consider employee action Coach Employee and conduct atrisk behavior investigation ARB Next Month: Tuesday March 12th 8am PT/9am MT/10am CT/ 11am ET Engaging Doctors in Safety Initiatives 1. Ask your staff: Who is the most engaged physician in your collaborative? 2. Talk to him or her and be prepared to tell the rest of the group A. B. C. How s/he became engaged What continues to drive engagement What s/he thinks would work to engage other physicians SAVE THE DATES! Monthly webinars extended to September 2013 June 19, 2013 Leadership for Safety: Yes, It’s Personal A Workshop for Boards, C-Suite, and Senior Leaders THANK YOU FOR JOINING US Feedback survey can be accessed in chat box.